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Bleiziffer S, Appleby C, Delgado V, Eltchaninoff H, Gebhard C, Hengstenberg C, Wojakowski W, Petersen N, Kurucova J, Bramlage P, Rudolph TK. Patterns of aortic valve replacement in Europe and adoption by sex. Int J Cardiol 2024; 406:131996. [PMID: 38555056 DOI: 10.1016/j.ijcard.2024.131996] [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: 01/23/2024] [Revised: 03/20/2024] [Accepted: 03/27/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE Management of patients with severe aortic stenosis (AS) may differ according to the patient sex. This study aimed to describe patterns of aortic valve replacement (AVR) for severe AS across Europe, including stratification by sex. METHODS Procedure volume data for surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) for six years (2015-2020) were extracted from national databases for Austria, Czech Republic, Denmark, England, Finland, France, Germany, Norway, Poland, Spain, Sweden, and Switzerland and stratified by sex. Patients per million population (PPM) undergoing AVR per year were calculated using population estimates from Eurostat. RESULTS Between 2015 and 2019, AVR procedures grew at an average annual rate of 3.9%. In 2020, the average total PPM undergoing AVR across all countries was 339, with 51% of procedures being TAVI and 49% SAVR. AVR PPM varied widely between countries, with the highest and lowest in Germany and Poland, respectively. The average total PPM was higher for men than women (423 vs. 258), but a higher proportion of women (62%) than men (44%) received TAVI. The proportion of TAVI among total AVR procedures increased with age, with an overall average of 96% of men and 98% of women aged ≥85 years receiving TAVI; however, adoption of TAVI varied by country. CONCLUSIONS The analysis of temporal trends in the adoption of TAVI vs. SAVR across Europe showed significant variations. Despite the higher use of TAVI vs. SAVR in women, overall rates of AV intervention in women were lower compared to men.
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Affiliation(s)
- Sabine Bleiziffer
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Centre, North Rhine-Westphalia, University Hospital, Ruhr-University Bochum, Bad Oeynhausen, Germany.
| | - Clare Appleby
- Department of Cardiology, Liverpool Heart and Chest Hospital, Thomas Dr, Liverpool L14 3PE, UK.
| | - Victoria Delgado
- Heart Institute, Department of Cardiology, Hospital University Germans Trias i Pujol Barcelona, Spain.
| | - Helene Eltchaninoff
- Department of Cardiology, Normandie Univ, UNIROUEN, U1096, CHU Rouen, F-76000 Rouen, France.
| | - Catherine Gebhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland.
| | - Christian Hengstenberg
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Wojtek Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Ziolowa 45/47, Katowice 40-635, Poland.
| | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany.
| | - Tanja K Rudolph
- General and Interventional Cardiology/Angiology, Heart and Diabetes Centre, North Rhine-Westphalia, Bad Oeynhausen, Ruhr-University, Germany.
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Troger F, Kremser C, Pamminger M, Reinstadler SJ, Thurner GC, Henninger B, Klug G, Metzler B, Mayr A. Functional aortic valve area differs significantly between sexes: A phase-contrast cardiac MRI study in patients with severe aortic stenosis. IJC HEART & VASCULATURE 2024; 51:101357. [PMID: 38356930 PMCID: PMC10863308 DOI: 10.1016/j.ijcha.2024.101357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/16/2024]
Abstract
Background Aortic stenosis (AS) is one of the most prevalent valvular heart-diseases in Europe. Currently, diagnosis and classification are not sex-sensitive; however, due to a distinctly different natural history of AS, further investigations of sex-differences in AS-patients are needed. Thus, this study aimed to detect sex-differences in severe AS, especially concerning flow-patterns, via phase-contrast cardiac magnetic resonance imaging (PC-CMR). Methods Forty-four severe AS-patients (20 women, 45 % vs. 24 men, 55 %) with a median age of 72 years underwent transthoracic echocardiography (TTE), cardiac catheterization (CC) and CMR. Aortic valve area (AVA) and stroke volume (SV) were determined in all modalities, with CMR yielding geometrical AVA via cine-planimetry and functional AVA via PC-CMR, the latter being also used to examine flow-properties. Results Geometrical AVA showed no sex-differences (0.91 cm2, IQR: 0.61-1.14 vs. 0.94 cm2, IQR: 0.77-1.22, p = 0.322). However, functional AVA differed significantly between sexes in all three modalities (TTE: p = 0.044; CC/PC-CMR: p < 0.001). In men, no significant intermethodical biases in functional AVA-measurements between modalities were found (p = 0.278); yet, in women the particular measurements differed significantly (p < 0.001). Momentary flowrate showed sex-differences depending on momentary opening-degree (at 50 %, 75 % and 90 % of peak-AVA, all p < 0.001), with men showing higher flowrates with increasing opening-area. In women, flowrate did not differ between 75 % and 90 % of peak-AVA (p = 0.191). Conclusions In severe AS-patients, functional AVA showed marked sex-differences in all modalities, whilst geometrical AVA did not differ. Inter-methodical biases were negligible in men, but not in women. Lastly, significant sex-differences in flow-patterns fit in with the different pathogenesis of AS.
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Affiliation(s)
- Felix Troger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Gudrun C Thurner
- Institute of Pathology, Neuropathology and Molecular Pathology, Medical University of Innsbruck, Müllerstraße 44 6020, Innsbruck, Austria
| | - Benjamin Henninger
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Gert Klug
- Department of Internal Medicine, County Hospital Bruck an der Mur, Tragoesser Strasse 1 8600, Bruck an der Mur, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35 6020, Innsbruck, Austria
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Abumoawad A, Afify H, Saleh M, Obaed N, Jneid H, Khalife WI, Kumbhani DJ, Elbadawi A. Outcomes of Transcatheter Aortic Valve Implant Among Patients With A Previous Coronary Artery Bypass Graft: A Nationwide Analysis. Am J Cardiol 2023; 202:210-217. [PMID: 37473670 DOI: 10.1016/j.amjcard.2023.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 06/07/2023] [Accepted: 06/18/2023] [Indexed: 07/22/2023]
Abstract
There is a paucity of data regarding the temporal trends and outcomes of transcatheter aortic valve implant (TAVI) among patients with a previous coronary artery bypass graft (CABG) surgery. We queried the Nationwide Readmissions Database (2016 to 2019) for hospitalized patients who underwent TAVI using the appropriate International Classification of Diseases, Tenth Revision procedural codes. A multivariable regression analysis was used to adjust for the patients' and hospitals' characteristics in comparing the study groups. The primary outcome was in-hospital mortality. The final analysis included 237,829 patients who underwent TAVI, of whom 42,671 (17.9%) had a previous CABG. During the study period, there was a decrease in the proportion of patients with previous CABG who underwent TAVI (21.0% in 2016 vs 15.5% in 2019, ptrend = 0.01), although there was no change in their in-hospital mortality rate (1.08% in 2016 vs 1.25% in 2019, ptrend = 0.43). Patients with a previous CABG were younger and less likely to be women than those without a previous CABG. TAVI among those with a previous CABG was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.79, 95% confidence interval [CI] 0.69 to 0.91), similar rate of ischemic stroke (aOR 0.81, 95% CI 0.71 to 0.93) and permanent pacemaker implant (aOR 1.00, 95% CI 0.93 to 1.05). Patients with a previous CABG had a lower all-cause 90-day readmission (odds ratio 0.95, 95% CI 0.94 to 1.06) but higher readmission for transient ischemic attack. Among those with a previous CABG, female gender and chronic kidney disease stage ≥3 were independently associated with a higher in-hospital mortality, whereas obesity was associated with a lower in-hospital mortality. In conclusion, there was a decrease in the proportion of patients with a previous CABG among those who underwent TAVI. TAVI among those with a previous CABG was not associated with increased in-hospital adverse events or 90-day all-cause readmissions.
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Affiliation(s)
- Abdelrhman Abumoawad
- Division of Cardiovascular Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Hesham Afify
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky
| | - Mohamed Saleh
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Nadia Obaed
- Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Hani Jneid
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Wissam I Khalife
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Dharam J Kumbhani
- Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ayman Elbadawi
- Division of Cardiovascular Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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Mehran R, Spirito A, Jin J, Chen C, Seeger J, Mascherbauer J, Vranckx P, Moreno R, Lang IM, Duggal A, Watanabe Y, Capranzano P, Kini AS, Veulemans V, Tessitore E, Hayashida K, Unverdorben M, Van Mieghem NM, Hengstenberg C, Dangas GD. Sex Differences Among Patients Receiving Edoxaban vs Vitamin K Antagonist for Atrial Fibrillation After TAVR. JACC. ADVANCES 2023; 2:100259. [PMID: 38938310 PMCID: PMC11198645 DOI: 10.1016/j.jacadv.2023.100259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/27/2022] [Accepted: 01/04/2023] [Indexed: 06/29/2024]
Abstract
Background In the ENVISAGE-TAVI AF (Edoxaban vs Standard of Care and Their Effects on Clinical Outcomes in Patients Having Undergone Transcatheter Aortic Valve Implantation-Atrial Fibrillation) trial, edoxaban was noninferior to vitamin K antagonists (VKA) for a composite outcome of ischemic and bleeding complications but increased major bleeding in patients with atrial fibrillation after successful transcatheter aortic valve replacement. Women are at higher risk of bleeding and stroke than men after transcatheter aortic valve replacement. It is unclear whether the effect of edoxaban on these complications varies in relation to sex. Objectives This study was to assess the effect of edoxaban vs VKA according to sex in the ENVISAGE-TAVI AF trial. Methods The primary outcomes were net adverse cardiovascular events (NACE) and major bleeding, assessed considering the effective time on study medication (safety analysis). Results Out of 1,377 patients, 658 (47.8%) were women. Risks for ischemic and major bleeding outcomes were similar between women and men. Edoxaban compared to VKA was associated with a similar risk of NACE in women (HR: 1.16; 95% CI: 0.81-1.65) and men (HR: 1.08; 95% CI: 0.76-1.53; P for interaction = 0.820) and a higher risk of major bleeding in both sexes (P for interaction = 0.170). The risk increase of major bleeding was attenuated in women (HR: 1.11; 95% CI: 0.69-1.79) as compared to men (HR: 1.75; 95% CI: 1.07-2.85). There were no treatment-related differences for ischemic complications in both sexes. Conclusions Edoxaban compared to VKA was associated with a similar risk of NACE and higher risk of major bleeding in both sexes. The increase in bleeding complications with edoxaban was attenuated in women.
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Affiliation(s)
- Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Jin
- Daiichi Sankyo, Basking Ridge, New Jersey, USA
| | - Cathy Chen
- Daiichi Sankyo, Basking Ridge, New Jersey, USA
| | - Julia Seeger
- Department of Cardiology and Intensive Care, Medical Campus Lake Constance, Friedrichshafen, Germany
| | - Julia Mascherbauer
- Department of Internal Medicine 3, Karl Landsteiner University of Health Sciences, University Hospital St. Pölten, Krems, Austria
| | - Pascal Vranckx
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Raul Moreno
- Department of Cardiology, University Hospital La Paz, Madrid, Spain
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University, Vienna, Austria
| | - Anil Duggal
- Daiichi Sankyo, Basking Ridge, New Jersey, USA
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Piera Capranzano
- Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy
| | - Annapoorna S. Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Verena Veulemans
- Department of Cardiology, Pulmonology, and Angiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | - Nicolas M. Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, the Netherlands
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University, Vienna, Austria
| | - George D. Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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5
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Rubens FD, Clarke AE, Lee DS, Wells GA, Sun LY. Population study of sex-based outcomes after surgical aortic valve replacement. CJC Open 2022; 5:220-229. [PMID: 37013069 PMCID: PMC10066438 DOI: 10.1016/j.cjco.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Background Surgical aortic valve replacement (SAVR) is a key strategy for the treatment of aortic valve disease. However, studies have involved primarily male patients, and whether the benefits of this approach can be extrapolated to female patients is unclear. Methods Clinical and administrative datasets for 12,207 patients undergoing isolated SAVR in Ontario from 2008 to 2019 were linked. Male and female patients were balanced using inverse probability treatment weighting. Mortality, endocarditis, and major hemorrhagic and thrombotic events, as well as 2 composite outcomes-major adverse cerebral and cardiovascular events (MACCE) and patient-derived adverse cardiovascular and noncardiovascular events (PACE)-and their component events, were compared in the weighted groups with a stratified log-rank test. Results A total of 7485 male patients and 4722 female patients were included in the study. Median follow-up was 5.2 years in both sexes. All-cause mortality did not differ between sexes (hazard ratio [HR] 0.949 [95% confidence interval {CI} 0.851-1.059]). Male sex was associated with an increased risk of new-onset dialysis (HR 0.689 [95% CI 0.488-0.974]). Female sex was associated with a significantly increased risk of both new-onset heart failure (HR 1.211 [95% CI 1.051-1.394], P = 0.0081) and heart failure hospitalization (HR 1.200 [95% CI 1.036-1.390], P = 0.015). No statistically significant differences were seen in any of the other secondary outcomes between sexes. Conclusions This population health study demonstrated that survival did not differ between male and female patients undergoing SAVR. Significant sex-related differences were found in the risk of heart failure and new-onset dialysis, but these findings should be considered exploratory and require further study.
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Masiero G, Paradies V, Franzone A, Bellini B, De Biase C, Karam N, Sanguineti F, Mamas MA, Eltchaninoff H, Fraccaro C, Castiglioni B, Attisano T, Esposito G, Chieffo A. Sex-Specific Considerations in Degenerative Aortic Stenosis for Female-Tailored Transfemoral Aortic Valve Implantation Management. J Am Heart Assoc 2022; 11:e025944. [PMID: 36172929 DOI: 10.1161/jaha.121.025944] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The impact of sex on pathophysiological processes, clinical presentation, treatment options, as well as outcomes of degenerative aortic stenosis remain poorly understood. Female patients are well represented in transfemoral aortic valve implantation (TAVI) trials and appear to derive favorable outcomes with TAVI. However, higher incidences of major bleeding, vascular complications, and stroke have been reported in women following TAVI. The anatomical characteristics and pathophysiological features of aortic stenosis in women might guide a tailored planning of the percutaneous approach. We highlight whether a sex-based TAVI management strategy might impact on clinical outcomes. This review aimed to evaluate the impact of sex from diagnosis to treatment of degenerative aortic stenosis, discussing the latest evidence on epidemiology, pathophysiology, clinical presentation, therapeutic options, and outcomes. Furthermore, we focused on technical sex-oriented considerations in TAVI including the preprocedural screening, device selection, implantation strategy, and postprocedural management.
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Affiliation(s)
- Giulia Masiero
- Department of Cardiac, Thoracic Vascular Science and Public Health, University of Padova Italy
| | - Valeria Paradies
- Department of Cardiology Maasstad Hospital Rotterdam The Netherlands
| | - Anna Franzone
- Department of Advanced Biomedical Sciences Federico II University of Naples Italy
| | - Barbara Bellini
- Interventional Cardiology Unit IRCCS San Raffaele Scientific Institute Milan Italy
| | - Chiara De Biase
- Groupe CardioVasculaire Interventionnel Clinique Pasteur Toulouse France
| | - Nicole Karam
- Cardiology Department European Hospital Georges Pompidou Paris France
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group School of Medicine, Keele University Stoke-on-Trent United Kingdom.,Department of Cardiology Royal Stoke University Hospital Stoke-on-Trent United Kingdom.,Department of Medicine Thomas Jefferson University Philadelphia PA
| | | | - Chiara Fraccaro
- Department of Cardiac, Thoracic Vascular Science and Public Health, University of Padova Italy
| | | | - Tiziana Attisano
- Division of Interventional Cardiology Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi Salerno Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences Federico II University of Naples Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit IRCCS San Raffaele Scientific Institute Milan Italy
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Iribarren AC, AlBadri A, Wei J, Nelson MD, Li D, Makkar R, Merz CNB. Sex differences in aortic stenosis: Identification of knowledge gaps for sex-specific personalized medicine. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 21:100197. [PMID: 36330169 PMCID: PMC9629620 DOI: 10.1016/j.ahjo.2022.100197] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/18/2022] [Accepted: 08/20/2022] [Indexed: 06/16/2023]
Abstract
Objectives This review summarizes sex-based differences in aortic stenosis (AS) and identifies knowledge gaps that should be addressed by future studies. Background AS is the most common valvular heart disease in developed countries. Sex-specific differences have not been fully appreciated, as a result of widespread under diagnosis of AS in women. Summary Studies including sex-stratified analyses have shown differences in pathophysiology with less calcification and more fibrosis in women's aortic valve. Women have impaired myocardial perfusion reserve and different compensatory response of the left ventricle (LV) to pressure overload, with concentric remodeling and more diffuse fibrosis, in contrast to men with more focal fibrosis and more dilated/eccentrically remodeled LV. There is sex difference in clinical presentation and anatomical characteristics, with women having more paradoxical low-flow/low-gradient AS, under-diagnosis and severity underestimated, with less referral to aortic valve replacement (AVR) compared to men. The response to therapies is also different: women have more adverse events with surgical AVR and greater survival benefit with transcatheter AVR. After AVR, women would have more favorable LV remodeling, but sex-related differences in changes in myocardial reserve flow need future research. Conclusions Investigation into these described sex-related differences in AS offers potential utility for improving prevention and treatment of AS in women and men. To better understand sex-based differences in pathophysiology, clinical presentation, and response to therapies, sex-specific critical knowledge gaps should be addressed in future research for sex-specific personalized medicine.
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Affiliation(s)
- Ana C. Iribarren
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Ahmed AlBadri
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Michael D. Nelson
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
| | - Debiao Li
- Cedars-Sinai Biomedical Imaging Research Institute, Los Angeles, CA, United States of America
| | - Raj Makkar
- Cedars-Sinai Cardiovascular Intervention Center, Smidt Heart Institute, Los Angeles, CA, United States of America
| | - C. Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States of America
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8
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Hartley A, Hammond-Haley M, Marshall DC, Salciccioli JD, Malik IS, Khamis RY, Shalhoub J. Trends in Mortality From Aortic Stenosis in Europe: 2000-2017. Front Cardiovasc Med 2021; 8:748137. [PMID: 34708094 PMCID: PMC8542896 DOI: 10.3389/fcvm.2021.748137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/15/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Trends in mortality from aortic stenosis across European countries are not well-understood, especially given the significant growth in transcatheter aortic valve implantation (TAVI) in the last 10 years. Methods: Age-standardised death rates were extracted from the World Health Organisation Mortality Database, using the International Classification of Diseases 10th edition code for non-rheumatic aortic stenosis for those aged > 45 years between 2000 and 2017. The UK and countries from the European Union with at least 1,000,000 inhabitants and at least 50% available datapoints over the study period were included: a total of 23 countries. Trends were described using Joinpoint regression analysis. Results: No reductions in mortality were demonstrated across all countries 2000-2017. Large increases in mortality were found for Croatia, Poland and Slovakia for both sexes (>300% change). Mortality plateaued in Germany from 2008 in females and 2012 in males, whilst mortality in the Netherlands declined for both sexes from 2007. Mortality differences between the sexes were observed, with greater mortality for males than females across most countries. Conclusions: Mortality from aortic stenosis has increased across Europe from 2000 to 2017. There are, however, sizable differences in mortality trends between Eastern and Western European countries. The need for health resource planning strategies to specifically target AS, particularly given the expected increase with ageing populations, is highlighted.
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Affiliation(s)
- Adam Hartley
- National Heart and Lung Institute, Imperial College London, London, United Kingdom,Imperial College Healthcare NHS Trust, London, United Kingdom,Department of Cardiology, Hammersmith Hospital, London, United Kingdom,*Correspondence: Adam Hartley
| | - Matthew Hammond-Haley
- British Heart Foundation Centre of Excellence, King's College London, London, United Kingdom
| | - Dominic C. Marshall
- National Heart and Lung Institute, Imperial College London, London, United Kingdom,Imperial College Healthcare NHS Trust, London, United Kingdom,Department of Respiratory Medicine, St Mary's Hospital, London, United Kingdom
| | - Justin D. Salciccioli
- Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Iqbal S. Malik
- Imperial College Healthcare NHS Trust, London, United Kingdom,Department of Cardiology, Hammersmith Hospital, London, United Kingdom
| | - Ramzi Y. Khamis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom,Imperial College Healthcare NHS Trust, London, United Kingdom,Department of Cardiology, Hammersmith Hospital, London, United Kingdom
| | - Joseph Shalhoub
- Imperial College Healthcare NHS Trust, London, United Kingdom,Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom,Department of Vascular Surgery, St Mary's Hospital, London, United Kingdom
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9
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Transcatheter aortic valve implantation in patients with a small aortic annulus: performance of supra-, intra- and infra-annular transcatheter heart valves. Clin Res Cardiol 2021; 110:1957-1966. [PMID: 34387736 PMCID: PMC8639544 DOI: 10.1007/s00392-021-01918-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND A small aortic annulus is associated with increased risk of prosthesis-patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI). Whether specific transcatheter heart valve (THV) designs yield superior hemodynamic performance in these small anatomies remains unclear. METHODS Data from 8411 consecutive patients treated with TAVI from May 2012 to April 2019 at four German centers were retrospectively evaluated. A small aortic annulus was defined as multidetector computed tomography-derived annulus area < 400 mm2. TAVI was performed with a balloon-expanding intra-annular (Sapien-3, n = 288), self-expanding intra-annular (Portico, n = 110), self-expanding supra-annular (Evolut, n = 179 and Acurate-Neo, n = 428) and mechanically expanding infra-annular (Lotus, n = 64) THV according to local practice. PPM was defined as indexed effective orifice area ≤ 0.85cm2/m2. RESULTS A small annulus was found in 1069 (12.7%) patients. PPM was detected in 38.3% overall with a higher prevalence after implantation of a balloon-expanding intra-annular or mechanically expanding infra-annular THV compared to self-expanding intra- and supra-annular THV. Multivariable analysis linked self-expanding THV (Evolut: Odds ratio [OR] 0.341, Acurate-Neo: OR 0.436, Portico: OR 0.291), postdilatation (OR 0.648) and age (OR 0.968) to lower rates of PPM, while aortic valve calcification was associated with an increased risk (OR 1.001). Paravalvular regurgitation > mild was more frequent after TAVI with self-expanding THV (p = 0.04). CONCLUSION In this large contemporary multicenter patient population, a substantial number of patients with a small aortic anatomy were left with PPM after TAVI. Self-expanding supra- and intra-annular THV demonstrated superior hemodynamics in these patients at risk, however at the cost of higher rates of residual paravalvular regurgitation.
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10
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Sarajlic P, Plunde O, Franco-Cereceda A, Bäck M. Artificial Intelligence Models Reveal Sex-Specific Gene Expression in Aortic Valve Calcification. JACC Basic Transl Sci 2021; 6:403-412. [PMID: 34095631 PMCID: PMC8165113 DOI: 10.1016/j.jacbts.2021.02.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/03/2021] [Accepted: 02/03/2021] [Indexed: 12/13/2022]
Abstract
Differences in the clinical presentation and physiology of aortic stenosis in men and women complicate the management of the condition. By combining traditional inferential statistics, artificial intelligence predictive modeling, and genetic pathway analysis, one can gain further insight into sex-specific gene expression patterns, potentially driving the valvular phenotype differences between the sexes. Results from this study, implementing a mixed and comprehensive methodological approach, offer a foundation for further exploration of potential drug targets.
Male and female aortic stenosis patients have distinct valvular phenotypes, increasing the complexities in the evaluation of valvular pathophysiology. In this study, we present cutting-edge artificial intelligence analyses of transcriptome-wide array data from stenotic aortic valves to highlight differences in gene expression patterns between the sexes, using both sex-differentiated transcripts and unbiased gene selections. This approach enabled the development of efficient models with high predictive ability and determining the most significant sex-dependent contributors to calcification. In addition, analyses of function-related gene groups revealed enriched fibrotic pathways among female patients. Ultimately, we demonstrate that artificial intelligence models can be used to accurately predict aortic valve calcification by carefully analyzing sex-specific gene transcripts.
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Affiliation(s)
- Philip Sarajlic
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Oscar Plunde
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Theme Heart and Vessels, Division of Valvular and Coronary Disease, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Bäck
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Theme Heart and Vessels, Division of Valvular and Coronary Disease, Karolinska University Hospital, Stockholm, Sweden
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11
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Guzzetti E, Poulin A, Annabi MS, Zhang B, Kalavrouziotis D, Couture C, Dagenais F, Pibarot P, Clavel MA. Transvalvular Flow, Sex, and Survival After Valve Replacement Surgery in Patients With Severe Aortic Stenosis. J Am Coll Cardiol 2021; 75:1897-1909. [PMID: 32327100 DOI: 10.1016/j.jacc.2020.02.065] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/21/2020] [Accepted: 02/24/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The respective impacts of transvalvular flow, gradient, sex, and their interactions on mortality in patients with severe aortic stenosis undergoing surgical aortic valve replacement (AVR) are unknown. OBJECTIVES This study sought to compare the impact of pre-operative flow-gradient patterns on mortality after AVR and to examine whether there are sex differences. METHODS This study analyzed clinical, echocardiographic, and outcome data prospectively collected in 1,490 patients (544 women [37%]), with severe aortic stenosis and preserved left ventricular ejection fraction who underwent AVR. RESULTS In this cohort, 601 patients (40%) had normal flow (NF) with high gradient (HG), 405 (27%) NF with low gradient (LG), 246 (17%) paradoxical low flow (LF)/HG, and 238 (16%) LF/LG. During a median follow-up of 2.42 years (interquartile range: 1.04 to 4.29 years), 167 patients died. Patients with LF/HG exhibited the highest mortality after AVR (hazard ratio [HR]: 2.01; 95% confidence interval [CI]: 1.33 to 3.03; p < 0.01), which remained significant after multivariate adjustment (HR: 1.96; 95% CI: 1.29 to 2.98; p < 0.01). Both LF/LG and NF/LG patients had comparable outcome to NF/HG (p ≥ 0.47). Optimal thresholds of stroke volume index were obtained for men (40 ml/m2) and women (32 ml/m2). Using these sex-specific cutpoints, paradoxical LF was independently associated with increased mortality in both women (adjusted HR: 2.05; 95% CI: 1.21 to 3.47; p < 0.01) and men (adjusted HR: 1.54; 95% CI: 1.02 to 2.32; p = 0.042), whereas guidelines' threshold (35 ml/m2) does not. CONCLUSIONS Paradoxical LF/HG was associated with higher mortality following AVR, suggesting that a reduced flow is a marker of disease severity even in patients with HG aortic stenosis. Early surgical AVR (i.e., before gradient attains 40 mm Hg) might be preferable in these patients. Furthermore, the use of sex-specific thresholds (<40 ml/m2 for men and <32 ml/m2 for women) to define low-flow outperforms the guidelines' threshold of 35 ml/m2 in risk stratification after AVR.
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Affiliation(s)
- Ezequiel Guzzetti
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Anthony Poulin
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Mohamed-Salah Annabi
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Bin Zhang
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Christian Couture
- Department of Anatomo-Pathology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - François Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | - Philippe Pibarot
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada. https://twitter.com/PPibarot
| | - Marie-Annick Clavel
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada.
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12
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Namasivayam M, He W, Churchill TW, Capoulade R, Liu S, Lee H, Danik JS, Picard MH, Pibarot P, Levine RA, Hung J. Transvalvular Flow Rate Determines Prognostic Value of Aortic Valve Area in Aortic Stenosis. J Am Coll Cardiol 2020; 75:1758-1769. [PMID: 32299587 DOI: 10.1016/j.jacc.2020.02.046] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/01/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aortic valve area (AVA) ≤1.0 cm2 is a defining characteristic of severe aortic stenosis (AS). AVA can be underestimated at low transvalvular flow rate. Yet, the impact of flow rate on prognostic value of AVA ≤1.0 cm2 is unknown and is not incorporated into AS assessment. OBJECTIVES This study aimed to evaluate the effect of flow rate on prognostic value of AVA in AS. METHODS In total, 1,131 patients with moderate or severe AS and complete clinical follow-up were included as part of a longitudinal database. The effect of flow rate (ratio of stroke volume to ejection time) on prognostic value of AVA ≤1.0 cm2 for time to death was evaluated, adjusting for confounders. Sensitivity analysis was performed to identify the optimal cutoff for prognostic threshold of AVA. The findings were validated in a separate external longitudinal cohort of 939 patients. RESULTS Flow rate had a significant effect on prognostic value of AVA. AVA ≤1.0 cm2 was not prognostic for mortality (p = 0.15) if AVA was measured at flow rates below median (≤242 ml/s). In contrast, AVA ≤1.0 cm2 was highly prognostic for mortality (p = 0.003) if AVA was measured at flow rates above median (>242 ml/s). Findings were irrespective of multivariable adjustment for age, sex, and surgical/transcatheter aortic valve replacement (as time-dependent covariates); comorbidities; medications; and echocardiographic features. AVA ≤1.0 cm2 was also not an independent predictor of mortality below median flow rate in the validation cohort. The optimal flow rate cutoff for prognostic threshold was 210 ml/s. CONCLUSIONS Transvalvular flow rate determines prognostic value of AVA in AS. AVA measured at low flow rate is not a good prognostic marker and therefore not a good diagnostic marker for truly severe AS. Flow rate assessment should be incorporated into clinical diagnosis, classification, and prognosis of AS.
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Affiliation(s)
- Mayooran Namasivayam
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/MayoNamasivayam
| | - Wei He
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy W Churchill
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Romain Capoulade
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000, Nantes, France; Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Shiying Liu
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hang Lee
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jacqueline S Danik
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael H Picard
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Robert A Levine
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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13
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Mohadjer A, Brown G, Shah SR, Nallapati C, Waheed N, Bavry AA, Park K. Sex-Based Differences in Coronary and Structural Percutaneous Interventions. Cardiol Ther 2020; 9:257-273. [PMID: 32440761 PMCID: PMC7584690 DOI: 10.1007/s40119-020-00176-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Indexed: 02/06/2023] Open
Abstract
In the current state of interventional cardiology, the ability to offer advanced therapies to patients who historically were not surgical candidates has grown exponentially in the last few decades. As therapies have expanded in complex coronary and structural interventions, the nuances of treating certain populations have emerged. In particular, the role of sex-based anatomic and outcome differences has been increasingly recognized. As guidelines for cardiovascular prevention and treatment for certain conditions may vary by sex, therapeutic interventions in the structural and percutaneous coronary areas may also vary. In this review, we aim to discuss these differences, the current literature available on these topics, and areas of focus for the future.
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Affiliation(s)
- Ashley Mohadjer
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Garrett Brown
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
- Division of Cardiovascular Medicine, University of South Florida, Tampa, FL, USA
| | - Syed R Shah
- Department of Internal Medicine, North Florida Regional Medical Center, University of Central Florida (Gainesville), Gainesville, FL, USA
| | - Charishma Nallapati
- Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Nida Waheed
- Department of Internal Medicine, University of Florida, Gainesville, FL, USA
| | - Anthony A Bavry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA.
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14
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Updates to a Modern Dilemma: a Practical Approach to the Workup and Management of Low-Gradient Severe Aortic Stenosis Using Transvalvular Flow Rate. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00865-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Caponcello MG, Banderas LM, Ferrero C, Bramlage C, Thoenes M, Bramlage P. Gender differences in aortic valve replacement: is surgical aortic valve replacement riskier and transcatheter aortic valve replacement safer in women than in men? J Thorac Dis 2020; 12:3737-3746. [PMID: 32802453 PMCID: PMC7399394 DOI: 10.21037/jtd-20-700] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Aortic stenosis (AS) is a progressive and degenerative disease that necessitates valve replacement through either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). Various studies have shown that, unlike for TAVR, SAVR is associated with an elevated risk for women as compared to men. The aim of this review is to better understand the risks and their possible causes, associated with the use of both TAVR and SAVR in female patients. Our systematic review included studies published between 2012 and 2020, identified through specific searches of PubMed. Compatibility of publications, determined by the use of pre-defined inclusion/exclusion criteria, resulted in 15 articles being used in our review. Overall, more men than women undergo SAVR, but our findings confirmed that SAVR is associated with worse outcomes in women in the short-term. Reasons for a higher 30-day mortality post-SAVR in women include an increased age, higher in-hospital mortality and, possibly baseline comorbidities and anatomical differences. There was no difference observed in 30-day mortality between men and women undergoing TAVR. Female patients appear to have a better longer-term survival post-TAVR than their male counterparts. Understanding the reasons why women have worse outcomes post-SAVR is essential for ensuring appropriate treatment selection for patients with AS, as well as for achieving the best possible long-term and safety outcomes for these patients.
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Affiliation(s)
- Maria Giulia Caponcello
- Departamento Farmacia y Tecnología Farmacéutica, Universidad de Sevilla, Sevilla, Spain.,Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Lucia M Banderas
- Departamento Farmacia y Tecnología Farmacéutica, Universidad de Sevilla, Sevilla, Spain
| | - Carmen Ferrero
- Departamento Farmacia y Tecnología Farmacéutica, Universidad de Sevilla, Sevilla, Spain
| | - Carsten Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Martin Thoenes
- Departamento Farmacia y Tecnología Farmacéutica, Universidad de Sevilla, Sevilla, Spain.,Leman Research Institute, Switzerland
| | - Peter Bramlage
- Departamento Farmacia y Tecnología Farmacéutica, Universidad de Sevilla, Sevilla, Spain.,Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
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