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Felbel D, Fattom A, Fechter I, Paukovitsch M, Stephan T, Gröger M, Keßler M, Schneider L, Mörike J, Gonska B, Imhof A, Rottbauer W, Buckert D, Markovic S. Kidney disease, diabetes, and diameter stenosis predict Rotablation bailout in modified balloon application for severely calcified coronary lesions. Catheter Cardiovasc Interv 2024; 104:676-687. [PMID: 39219464 DOI: 10.1002/ccd.31181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 07/19/2024] [Accepted: 07/31/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Modified balloon (MB) treatment in severely calcified coronary artery lesions is an established technique. However, some lesions require Rotablation (RA) as bailout strategy. AIMS This study aimed to assess predictors of switch from MB to RA and its impact on procedural and midterm outcomes. METHODS Four hundred and eighty-three consecutive patients were included undergoing MB treatment (n = 204) with a scoring or cutting balloon, or upfront RA treatment (n = 279) serving as control cohort. Strategy switch from MB to RA was performed in 19 of 204 patients. Procedural success was defined as successful stent implantation and TIMI III flow. RESULTS In the MB cohort, median age was 72 [63-78] years, 75.5% were male and 42.1% had acute coronary syndrome. Procedure success was achieved in 89.4% of the switch group versus 98.4% of the MB only group (p < 0.001) and in 96.4% of the RA cohort. In the switch group, periprocedural complications (31.6% vs. 8.1% vs. 11.8%, p = 0.007), radiation dose (149 [126-252] vs. 59 [30-97] vs. 102 [59-156] Gcm2; p < 0.001) and contrast volume (250 [190-250] vs. 190 [150-250] vs. 195 [190--250] mL; p < 0.001) were significantly higher. Diabetes (OR 3.8, 95% CI 1.1-13.9, p = 0.042), chronic kidney disease stage 4 or 5 (OR 19.0, 95% CI 3.3-108.6, p < 0.001) and pronounced calcification resulting in higher angiographic diameter stenosis (OR 1.13, 95% CI 1.1-1.2, p = 0.001) independently predicted strategy switch. Midterm results were not affected by strategy switch regarding 1-year target lesion revascularization rates (86% vs. 89% vs. 89%; log-rank p = 0.95). CONCLUSION Primary RA strategy might be considered in patients with severely calcified coronary artery lesions with high angiographic diameter stenosis, diabetes or impaired renal function due to increased periprocedural complication rates, radiation dose, and contrast volume following strategy switch.
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Affiliation(s)
- Dominik Felbel
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Ali Fattom
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Isabella Fechter
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Michael Paukovitsch
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Tilman Stephan
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Matthias Gröger
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Mirjam Keßler
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Leonhard Schneider
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Johannes Mörike
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Birgid Gonska
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Armin Imhof
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Wolfgang Rottbauer
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Dominik Buckert
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
| | - Sinisa Markovic
- Department of Cardiology, Angiology, Pneumology and Intensive Care, Ulm University Heart Center, Ulm, Germany
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Takagi K, Yoshida R, Fujita T, Noguchi T. Bail-Out Techniques in Percutaneous Intervention for Ellis Grade III Coronary Perforation in Left Main Distal Bifurcation Lesions. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100609. [PMID: 39130718 PMCID: PMC11307895 DOI: 10.1016/j.jscai.2023.100609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 08/13/2024]
Abstract
The left main (LM) coronary artery stenosis is associated with high morbidity and mortality and has traditionally been treated with coronary artery bypass grafting. However, in recent years, advancements in device technology and adjunctive pharmacotherapy have led to the widespread use of percutaneous coronary intervention (PCI) as a treatment for unprotected LM lesions. Despite this, LM lesions are often complex, involving distal bifurcation and heavy calcification, which increases the risk of coronary perforation (CP) during PCI. In addition, the use of rotational or orbital atherectomy in severely calcified LM bifurcation lesions carries a higher risk of complications and in-hospital mortality than that in non-LM lesions. CP is a rare but potentially fatal complication of PCI, particularly in cases of Ellis grade III (CP-G3), with a high rate of cardiac tamponade and mortality. The management of CP-G3 in LM distal bifurcation lesions is challenging and requires specialized techniques. This article presents a flowchart of bail-out strategies for CP-G3 in LM distal bifurcation lesions and provides detailed procedures for each technique. Furthermore, we highlight the challenges and limitations of each technique, requiring careful management when CP-G3 occurs in LM distal bifurcation lesions.
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Affiliation(s)
- Kensuke Takagi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Ruka Yoshida
- Department of Cardiology, Japanese Red Cross Society Nagoya Daini Hospital, Nagoya, Japan
| | - Tomoyuki Fujita
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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3
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Dumitrascu S, Bartos D, Ungureanu C. Outcomes after Percutaneous Coronary Intervention in Patients with Extremely Calcified Left Main Lesions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050825. [PMID: 37241057 DOI: 10.3390/medicina59050825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Available data with regard to the outcomes of patients with severely calcified left main (LM) lesions after revascularization by percutaneous coronary intervention (PCI) when compared to non-calcified LM lesions is unclear. Materials and Methods: The present study sought to retrospectively investigate in hospital and 1 year post-intervention outcomes of patients with extremely calcified LM lesions after PCI facilitated by calcium-dedicated devices (CdD). Seventy consecutive patients with LM PCI were included. CdD requirement was based on suboptimal results after balloon angioplasty. Results: Twenty-two patients (31.4%) required at least one CdD, while nine patients (12.8%) required at least two. Intravascular lithotripsy and rotational atherectomy were the predominantly used methods(59.1% and 40.9% respectively, for in-group ratios), while ultra-high pressure and scoring balloons contributed the least to lesion preparation (9%). In 20 patients (28.5%), severe or moderate calcifications were angiographically identified, but non-compliant balloon predilation was adequate and CdD were not necessary. Total procedural time was significantly higher in CdD group (p-value 0.02). Procedural and clinical success were obtained in 100% of cases. There were no major adverse cardiac and cerebrovascular events (MACCE) recorded during hospitalization. MACCE at 1 year post-procedure were recorded in three patients (4.2% overall). All three events were documented in the control group (6.2%), and no events were recorded in CdD group (p-value 0.23). There was one cardiac death at 10 months and two target lesion revascularizations for side-branch restenosis. Conclusions: Patients with extremely calcified LM lesions treated by PCI present a favorable prognosis if angioplasty is facilitated by more aggressive lesion debulking using calcium-dedicated devices.
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Affiliation(s)
- Silviu Dumitrascu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bvd. Eroii Sanitari 8, 050474 Bucharest, Romania
- Cardiovascular Department, Jolimont Hospital, Ferrer St. 159, 7100 La Louviere, Belgium
| | - Daniela Bartos
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bvd. Eroii Sanitari 8, 050474 Bucharest, Romania
| | - Claudiu Ungureanu
- Cardiovascular Department, Jolimont Hospital, Ferrer St. 159, 7100 La Louviere, Belgium
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Bouisset F, Ribichini F, Bataille V, Reczuch K, Lhermusier T, Dobrzycki S, Meyer-Gessner M, Bressollette E, Zajdel W, Faurie B, Mezilis N, Palazuelos J, Vaquerizo B, Ferenc M, Cayla G, Barbato E, Carrié D. Clinical Outcomes of Left Main Coronary Artery PCI With Rotational Atherectomy. Am J Cardiol 2023; 186:36-42. [PMID: 36343444 DOI: 10.1016/j.amjcard.2022.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/10/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
Data regarding rotational atherectomy percutaneous coronary intervention (RA PCI) angioplasty in the left main (LM) coronary artery are scarce, and mostly outdated. We aimed to describe clinical outcomes of RA PCI in LM. Patients requiring RA in 8 European countries and 19 centers were prospectively and consecutively included in the European registry of Cardiac Care of Calcified and Complex patients registry. In-hospital data collection and 1-year follow-up were performed for each patient. Between October 2016 and July 2018, 966 patients with complete data were included. Among them, 241 presented with an LM lesion, and 171 required an LM lesion preparation by RA. The latter, allocated to the LM-RA group, were compared with the 725 patients in the non-LM-RA group. Clinical success of the RA procedure was comparable in both groups, but in-hospital major adverse cardiac events were higher in the RA-LM group (7.6% vs 3.2%, adjusted p = 0.04), mainly driven by a higher in-hospital mortality rate (5.3 vs 0.3%, adjusted p = 0.005). At 1-year follow-up, mortality and major adverse cardiac event rates were comparable in both groups (12.9% vs 8.0%, adjusted p value: 0.821, and 15.8% vs 10.9%, adjusted p value: 0.329, respectively), but the rate of target vessel revascularization remained higher in the RA-LM group (5.3% vs 3.2%, adjusted p = 0.021). In conclusion, RA PCI is an efficient option for calcified LM lesions, providing acceptable outcomes regarding this population with high risk at 1 year, and yields comparable outcomes with RA PCI performed on non-LM lesions.
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Affiliation(s)
- Frédéric Bouisset
- Department of Cardiology, Rangueil Toulouse University Hospital, University Paul Sabatier, Toulouse, France.
| | | | - Vincent Bataille
- Department of Cardiology, Rangueil Toulouse University Hospital, University Paul Sabatier, Toulouse, France; Association pour la Diffusion de la Médecine de Prévention (ADIMEP), Toulouse, France
| | - Krzysztof Reczuch
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Thibault Lhermusier
- Department of Cardiology, Rangueil Toulouse University Hospital, University Paul Sabatier, Toulouse, France
| | | | | | | | - Wojciech Zajdel
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Kraków, Poland
| | - Benjamin Faurie
- Cardiovascular Institute, Groupe Hospitalier Mutualiste, Grenoble, France
| | - Nikolaos Mezilis
- Department of Cardiology, St Luke's Hospital, Thessaloniki, Greece
| | - Jorge Palazuelos
- Department of Cardiology, Interventional Cardiology Unit, Hospital La Luz, Madrid, Spain
| | - Beatriz Vaquerizo
- Department of Cardiology, Hospital del Mar, Barcelona, Spain; Heart Diseases Biomedical Research Group (GREC), IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Department of Medicine, School of Medicine, Universitat Pompeu Fabra, Barcelona, Spain
| | - Miroslaw Ferenc
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Guillaume Cayla
- Department of Cardiology, Centre Hospitalier Universitaire de Nîmes, Université de Montpellier, Nîmes, France
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Didier Carrié
- Department of Cardiology, Rangueil Toulouse University Hospital, University Paul Sabatier, Toulouse, France
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Chen YW, Lai CH, Su CS, Chang WC, Wang CY, Chen WJ, Lin TH, Liang KW, Liu TJ, Lee WL. The Procedural and Clinical Outcomes of Rotational Atherectomy in Patients Presenting With Acute Myocardial Infarction. Front Cardiovasc Med 2022; 9:846564. [PMID: 35369302 PMCID: PMC8971549 DOI: 10.3389/fcvm.2022.846564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Rotational atherectomy (RA) is an indispensable tool used for calcified lesion preparation in percutaneous coronary intervention (PCI). However, use of RA in the setting of acute myocardial infarction (AMI) is challenged with limited clinical data. Objectives This study aims to retrospectively investigate the procedural results, periprocedural complications, and clinical outcomes of RA in patients with AMI. Methods All possible consecutive patients who received RA in AMI from January 2009 to March 2018 in a single tertiary center were analyzed retrospectively. Patients without AMI during the study period were also enrolled for comparison. Results A total of 121 patients with AMI (76.0 ± 10.8 years, 63.6% males) and 290 patients without AMI were recruited. Among the AMI group, 81% of patients had non-ST-elevation myocardial infarction (NSTEMI) and 14% presented with cardiogenic shock. RA could be completed in 98.8% of patients in the AMI group and 98.3% in the non-AMI group (p = 1.00). The periprocedural complication rates were comparable between the AMI and non-AMI groups. The risks of in-hospital, 30-day, 90-day, and 1-year cardiovascular major adverse cardiac events (CV MACE) were significantly higher in the AMI group compared with the non-AMI group (in-hospital 13.2 vs. 2.8%, p < 0.001; 30-day 14.2 vs. 4.5%, p < 0.001; 90-day 20.8 vs. 6.9%, p < 0.001; 1-year 30.8 vs. 19.1%, p = 0.01). AMI at initial presentation and cardiogenic shock were predictors for both in-hospital CV MACE and 1-year CV MACE in multivariable binary logistic regression analysis. Other predictors for 1-year CV MACE included serum creatinine level and triple vessel disease. Conclusion RA in patients with AMI is feasible with a high procedural completion rate and acceptable periprocedural complications. Given unstable hemodynamics and complex coronary anatomy, the in-hospital and 1-year MACE rates remained higher in patients with AMI compared with patients without AMI.
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Affiliation(s)
- Yu-Wei Chen
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chieh-Shou Su
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Chun Chang
- Department of Cardiology, Feng Yuan Hospital, Ministry of Health and Welfare, Taichung, Taiwan
- Department of Life Science, Tunghai University, Taichung, Taiwan
| | - Chi-Yen Wang
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Wei-Jhong Chen
- Department of Cardiology, Taipei Veterans General Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Tzu-Hsiang Lin
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kae-Woei Liang
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tsun-Jui Liu
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Wen-Lieng Lee
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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6
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Kawashima H, Serruys PW, Hara H, Ono M, Gao C, Wang R, Garg S, Sharif F, de Winter RJ, Mack MJ, Holmes DR, Morice MC, Kappetein AP, Thuijs DJFM, Milojevic M, Noack T, Mohr FW, Davierwala PM, Onuma Y. 10-Year All-Cause Mortality Following Percutaneous or Surgical Revascularization in Patients With Heavy Calcification. JACC Cardiovasc Interv 2022; 15:193-204. [PMID: 34973904 DOI: 10.1016/j.jcin.2021.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 09/27/2021] [Accepted: 10/19/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The aim of this study was to assess 10-year all-cause mortality in patients with heavily calcified lesions (HCLs) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). BACKGROUND Limited data are available on very long term outcomes in patients with HCLs according to the mode of revascularization. METHODS This substudy of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study assessed 10-year all-cause mortality according to the presence of HCLs within lesions with >50% diameter stenosis and identified during the calculation of the anatomical SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score among 1,800 patients with the 3-vessel disease and/or left main disease randomized to PCI or CABG in the SYNTAX trial. Patients with HCLs were further stratified according to disease type (3-vessel disease or left main disease) and assigned treatment (PCI or CABG). RESULTS The 532 patients with ≥1 HCL had a higher crude mortality rate at 10 years than those without (36.4% vs 22.3%; HR: 1.79; 95% CI: 1.49-2.16; P < 0.001). After adjustment, an HCL remained an independent predictor of 10-year mortality (HR: 1.36; 95% CI: 1.09-1.69; P = 0.006). There was a significant interaction in mortality between treatment effect (PCI and CABG) and the presence or absence of HCLs (Pinteraction = 0.005). In patients without HCLs, mortality was significantly higher after PCI than after CABG (26.0% vs 18.8%; HR: 1.44; 95% CI: 0.97-1.41; P = 0.003), whereas in those with HCLs, there was no significant difference (34.0% vs 39.0%; HR: 0.85; 95% CI: 0.64-1.13; P = 0.264). CONCLUSIONS At 10 years, the presence of an HCL was an independent predictor of mortality, with a similar prognosis following PCI or CABG. Whether HCLs require special consideration when deciding the mode of revascularization beyond their current contribution to the anatomical SYNTAX score deserves further evaluation. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).
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Affiliation(s)
- Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; National Heart and Lung Institute, Imperial College London, London, United Kingdom.
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Chao Gao
- Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; Department of Cardiology, Radboud University, Nijmegen, the Netherlands
| | - Rutao Wang
- Department of Cardiology, National University of Ireland, Galway, Galway, Ireland; Department of Cardiology, Radboud University, Nijmegen, the Netherlands
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Faisal Sharif
- Department of Cardiology, National University of Ireland, Galway, Galway, Ireland
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - David R Holmes
- Department of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Marie-Claude Morice
- Département of Cardiologie, Hôpital privé Jacques Cartier, Générale de Santé Massy, Massy, France
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Daniel J F M Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Thilo Noack
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | | | - Piroze M Davierwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Canada
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway, Galway, Ireland
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