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Medranda GA, Rogers T, Case BC, Zhang C, Shea C, Satler LF, Ben-Dor I, Waksman R. Sex Disparities in Hemodynamics and Outcomes in Patients Who Underwent Contemporary Transcatheter Aortic Valve Implantation. Am J Cardiol 2022; 174:101-106. [PMID: 35550824 DOI: 10.1016/j.amjcard.2022.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 11/01/2022]
Abstract
Studies have reported worse outcomes after transcatheter aortic valve implantation (TAVI) in women receiving early generation transcatheter heart valves (THVs). They have smaller aortic annuli, which could result in higher gradients and more patient-prosthesis mismatch (PPM) after TAVI. We investigated the interactions between contemporary THV hemodynamics and outcomes in women who underwent TAVI. We conducted a retrospective, observational study of patients who underwent contemporary TAVI from 2015 to 2020. We compared baseline characteristics, in-hospital outcomes, and hemodynamics according to sex. We then dichotomized women according to aortic annular area (<430 or ≥430 mm2). Included were 869 patients who underwent TAVI with the SAPIEN 3 or CoreValve Evolut PRO/PRO+. Most patients with small annuli were female (82.5%). They had nonsignificantly higher mortality (30-day: 1.5% vs 0.6%, p = 0.313; 1-year: 4.1% vs 2.7%, p = 0.265). Those who received self-expanding THVs had lower gradients (8.0 mm Hg vs 13.8 mm Hg, p <0.001), resulting in less moderate PPM (21.2% vs 73.6%, p <0.001), similar severe PPM (19.5% vs 15.3%, p = 0.454), and higher rates of pacemaker implantation (14.4% vs 4.2%, p = 0.009). Women with small annuli who received a balloon-expandable THV had nonsignificantly higher mortality (30-day: 2.1% vs 0.8%, p = 0.631; 1-year: 6.3% vs 1.7%, p = 0.118). In conclusion, women who underwent contemporary TAVI had nonsignificantly higher mortality, which could be due to higher PPM rates. These findings were more pronounced in the subset of women with small annuli, in whom those who received self-expanding THVs demonstrated superior hemodynamics at the cost of increased rates of pacemaker implantation.
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Pivato CA, Cao D, Spirito A, Sartori S, Nicolas J, Chiarito M, Snyder C, Mehilli J, Lefèvre T, Stefanini GG, Presbitero P, Capranzano P, Tchetche D, Iadanza A, Vogel B, Sardella G, Van Mieghem NM, Nardin M, Tavenier AH, Meliga E, Dumonteil N, Fraccaro C, Trabattoni D, Mikhail G, Sharma S, Ferrer MC, Naber C, Kievit P, Baber U, Petronio AS, Morice MC, Chieffo A, Dangas G, Mehran R. Impact of Small Valve Size on 1-Year Outcomes After Transcatheter Aortic Valve Implantation in Women (from the WIN-TAVI Registry). Am J Cardiol 2022; 172:73-80. [PMID: 35461697 DOI: 10.1016/j.amjcard.2022.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
Abstract
Although most patients with small aortic annulus are women, there is paucity of data on the prognostic impact of small aortic prosthesis in women who underwent transcatheter aortic valve implantation (TAVI). Therefore, we aimed to evaluate the impact of small valve size on 1-year clinical outcomes after TAVI in women. The Women's INternational Transcatheter Aortic Valve Implantation is an all-women registry evaluating patients with severe aortic stenosis who underwent TAVI. Based on the size of the aortic bioprosthesis implanted, women were stratified into small (≤23 mm) and nonsmall (>23 mm) valve. The primary efficacy endpoint was the Valve Academic Research Consortium-2 composite of all-cause death, stroke, myocardial infarction, hospitalization for valve-related symptoms or heart failure or valve-related dysfunction at 1-year follow-up. Of 934 women who underwent TAVI, 388 (41.5%) received a small valve. Women with a small valve size had a lower body mass index, lower surgical risk scores, were less likely to suffer from atrial fibrillation, less often required postdilation and had a lower rate of residual aortic regurgitation grade ≥2. The occurrence of the Valve Academic Research Consortium-2 efficacy endpoint was similar between women treated with small and nonsmall valve (16.0% vs 16.3%, p = 0.881; adjusted hazard ratio 1.34, 95% confidence interval 0.90 to 2.00). Likewise, there were no significant differences in the occurrence of other secondary endpoints after multivariable adjustment. In conclusion, women with severe aortic stenosis who underwent TAVI with the implantation of a small valve bioprosthesis had similar 1-year outcomes as those receiving a nonsmall bioprosthesis.
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Affiliation(s)
- Carlo A Pivato
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Cardio Center, Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Cardiovascular Department, Humanitas Gavazzeni, Bergamo, Italy
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | - Clayton Snyder
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Julinda Mehilli
- Department of Cardiology, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Thierry Lefèvre
- Department of Cardiology, Institut Hospitalier Jacques Cartier, Ramsay Générale de Santé, Massy, France
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; Cardio Center, Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | | | | | - Didier Tchetche
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Alessandro Iadanza
- Department of Cardiology, Azienda Ospedaliera Universitaria Senese, Policlinico Le Scotte, Siena, Italy
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gennaro Sardella
- Department of Cardiology, Policlinico "Umberto I," Sapienza University of Rome, Rome, Italy
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Matteo Nardin
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anne H Tavenier
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Nicholas Dumonteil
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | - Chiara Fraccaro
- Department of Cardiology, University of Padova, Padova, Italy
| | - Daniela Trabattoni
- Department of Invasive Cardiology, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Ghada Mikhail
- Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maria Cruz Ferrer
- Department of Cardiology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Christoph Naber
- Department of Cardiology, Contilia Heart and Vascular Centre, Elisabeth Krankenhaus, Essen, Germany
| | - Peter Kievit
- Department of Cardiology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anna S Petronio
- Department of Cardiology, AOUP Cisanello, University Hospital, Pisa, Italy
| | - Marie C Morice
- Department of Cardiology, Institut Hospitalier Jacques Cartier, Ramsay Générale de Santé, Massy, France
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Okamura H, Kusadokoro S, Mieno M, Kimura N, Yamaguchi A. Long-term outcomes after aortic valve replacement using a 19-mm bioprosthesis. Eur J Cardiothorac Surg 2021; 61:625-634. [PMID: 34431991 DOI: 10.1093/ejcts/ezab379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/01/2021] [Accepted: 07/22/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Transcatheter aortic valve replacement is known to be associated with improved haemodynamics in patients with aortic stenosis and a small aortic annulus. However, limited benchmark data are available regarding the long-term outcomes in patients treated with surgical aortic valve replacement (SAVR). We investigated the long-term outcomes of SAVR using a 19-mm bioprosthesis. METHODS This study included consecutive patients who underwent SAVR using a 19-mm bioprosthesis at our hospital between 2008 and 2012. RESULTS In a total of 132 patients, moderate and severe prosthesis-patient mismatch occurred in 36 (27.3%) and 7 patients (5.3%), respectively. The median follow-up period was 7.7 years. The overall 5- and 10-year survival rates were 79.4% and 52.9%, respectively. The 5- and 10-year freedom from major adverse valve-related events rates were 89.6% and 74.2%, respectively. Neither moderate nor severe prosthesis-patient mismatch was associated with late mortality, major adverse valve-related events or heart failure. Follow-up echocardiographic data were obtained at a median interval of 4.8 years in 80% of patients who survived ≥6 months postoperatively. Follow-up echocardiographic data showed a significantly increased left ventricular ejection fraction, decreased mean transvalvular/transprosthetic pressure gradients and a decreased mean left ventricular mass. At follow-up, we observed moderate or severe haemodynamic structural valve deterioration in 17 patients; however, structural valve deterioration did not affect late survival or freedom from major adverse valve-related events rates, or heart failure. CONCLUSIONS SAVR using the 19-mm bioprosthesis was associated with satisfactory long-term clinical and haemodynamic outcomes.
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Affiliation(s)
- Homare Okamura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Sho Kusadokoro
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Makiko Mieno
- Department of Medical Informatics, Center for Information, Jichi Medical University, Tochigi, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Long-Term Results (up to 20 Years) of 19 mm or Smaller Prostheses in the Aortic Position. Does Size Matter? A Propensity-Matched Survival Analysis. J Clin Med 2021; 10:jcm10102055. [PMID: 34064845 PMCID: PMC8151595 DOI: 10.3390/jcm10102055] [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: 03/02/2021] [Revised: 04/19/2021] [Accepted: 05/07/2021] [Indexed: 11/28/2022] Open
Abstract
Background: The long-term performance of prostheses in the small aortic root is still unclear. Methods: Patients who received a 21 mm or smaller aortic valve between 2000–2018 were retrospectively analyzed. Propensity matching was used in order to account for baseline differences in 19 mm vs. 21 mm valve subgroups. Results: Survival at 10 years was 55.87 ± 5.54% for 19 mm valves vs. 57.17 ± 2.82% for 21 mm ones in the original cohort (p = 0.37), and 58.69 ± 5.61% in 19 mm valve recipients vs. 53.60 ± 5.66% for 21 mm valve subgroups in the matched cohort (p = 0.55). Smaller valves exhibited significantly more patient–prothesis mismatch (PPM) than larger ones (87.30% vs. 57.94%, p < 0.01). All-cause mortality was affected by PPM at 10 years (52.66 ± 3.28% vs. 64.38 ± 3.87%, p = 0.04) in the unmatched population. This difference disappeared, however, after matching: survival at 10 years was 51.82 ± 5.26% in patients with PPM and 63.12 ± 6.43% in patients without PPM. (p = 0.14) Conclusions: There is no survival penalty in using 19 mm prostheses in the small aortic root in the current era. Although PPM is more prevalent in smaller sized valve recipients, this does not translate into reduced survival at 10 years of follow-up.
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Chang HW, Kim WS, Ahn JH, Carriere KC, Jeong DS, Cho YH, Sung K, Park PW. Late clinical outcomes of aortic valve replacement with Carpentier-Edwards pericardial valves. J Thorac Dis 2019; 11:5372-5381. [PMID: 32030255 DOI: 10.21037/jtd.2019.11.65] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The present study aimed to compare the long-term clinical and hemodynamic outcomes of aortic valve replacement using Carpentier-Edwards Perimount (Perimount) or Perimount Magna (Magna) valves. Methods We enrolled 430 patients who underwent aortic valve replacements with Perimount (n=58) or Magna (n=372) valves [1998-2013]. Multivariable and inverse probability of treatment weight (IPTW) analyses were performed. Results Before IPTW analysis, the overall 8-year survival rate differed significantly between the groups [Perimount 90%±4% vs. Magna 76%±4%; P=0.02; hazard ratio (HR): 0.37 for the Perimount group; 95% confidence interval (CI): 0.17-0.83]. Multivariable analysis of the overall survival identified Perimount valve use as a protective factor (P=0.009; HR: 0.32; 95% CI: 0.14-0.75). Independent risk factors of overall survival were older age, male sex, higher preoperative left ventricular mass index, lower ejection fraction, lower aortic valve pressure gradient, and lower haemoglobin. After applying IPTW, overall survival was again found to be significantly longer in the Perimount group (P=0.04; HR: 0.43; 95% CI: 0.20-0.93). Event-free survival was also better in the Perimount group (P=0.006; HR: 0.38; 95% CI: 0.19-0.75). However, the Magna group had significantly lower aortic valve pressure gradients at one year and five years postoperative. Conclusions Although Magna use led to decreased aortic valve pressure gradients at follow-up, overall and event-free survival rates were significantly better with use of the Perimount valve. Additional and larger studies are needed to confirm these results.
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Affiliation(s)
- Hyoung Woo Chang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joong Hyun Ahn
- Bioinformatics Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Keumhee C Carriere
- Bioinformatics Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pyo Won Park
- Department of Thoracic and Cardiovascular Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Freitas-Ferraz AB, Tirado-Conte G, Dagenais F, Ruel M, Al-Atassi T, Dumont E, Mohammadi S, Bernier M, Pibarot P, Rodés-Cabau J. Aortic Stenosis and Small Aortic Annulus. Circulation 2019; 139:2685-2702. [DOI: 10.1161/circulationaha.118.038408] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Afonso B. Freitas-Ferraz
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.B.F.-F., G.T.-C., F.D., E.D., S.M., M.B., P.P., J.R.-C.)
| | - Gabriela Tirado-Conte
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.B.F.-F., G.T.-C., F.D., E.D., S.M., M.B., P.P., J.R.-C.)
| | - Francois Dagenais
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.B.F.-F., G.T.-C., F.D., E.D., S.M., M.B., P.P., J.R.-C.)
| | - Marc Ruel
- University of Ottawa Heart Institute, University of Ottawa, Ontario, Canada (M.R., T.A.-A.)
| | - Talal Al-Atassi
- University of Ottawa Heart Institute, University of Ottawa, Ontario, Canada (M.R., T.A.-A.)
| | - Eric Dumont
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.B.F.-F., G.T.-C., F.D., E.D., S.M., M.B., P.P., J.R.-C.)
| | - Siamak Mohammadi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.B.F.-F., G.T.-C., F.D., E.D., S.M., M.B., P.P., J.R.-C.)
| | - Mathieu Bernier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.B.F.-F., G.T.-C., F.D., E.D., S.M., M.B., P.P., J.R.-C.)
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.B.F.-F., G.T.-C., F.D., E.D., S.M., M.B., P.P., J.R.-C.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.B.F.-F., G.T.-C., F.D., E.D., S.M., M.B., P.P., J.R.-C.)
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Kilic A, Sultan I, Navid F, Aranda-Michel E, Chu D, Thoma F, Gleason TG. Trifecta Aortic Bioprosthesis: Midterm Results in 1,953 Patients From a Single Center. Ann Thorac Surg 2019; 107:1356-1362. [DOI: 10.1016/j.athoracsur.2018.10.063] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/04/2018] [Accepted: 10/22/2018] [Indexed: 11/30/2022]
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Lee H, Sung K, Kim WS, Jeong DS, Ahn JH, Carriere KC, Park PW. Late clinical outcomes after mechanical aortic valve replacement for aortic stenosis: old versus new prostheses. J Thorac Dis 2018; 10:3361-3371. [PMID: 30069331 DOI: 10.21037/jtd.2018.06.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background The study aimed to evaluate the late clinical outcomes of new-generation mechanical valves for severe aortic stenosis (AS) compared with old mechanical valves. Methods We retrospectively reviewed data from 254 patients with severe AS, who underwent primary mechanical aortic valve replacement from 1995 to 2013. Patients were classified into two groups: old-valve group (n=65: 33 ATS standard, 32 Medtronic-Hall) and new-valve group (n=189: 113 St. Jude Regent, 46 On-X, 30 Sorin Overline). Median patient age was 58 years (Q1-Q3: 52-61). With propensity score matching based on demographic information, 56 patients in the old-valve group were matched with 177 patients in the new-valve group. The median follow-up duration was 91 months (Q1-Q3: 48-138). Results Cardiac-related mortality and hemorrhagic events were significantly lower in the new-valve group (P=0.047 and P=0.032, respectively). The median international normalized ratio (INR) at follow-up was significantly higher in the old-valve group [2.23, Q1-Q3: 2.14-2.35 (old-valve group); 2.08, Q1-Q3: 1.92-2.23 (new-valve group), P<0.001]. The incidence of prosthesis-patient mismatch (PPM) was significantly higher in the old-valve group (P<0.001). Multivariate analysis of the total population revealed that PPM was a significant risk factor for cardiac-related events [hazard ratio (HR) =5.279, 95% CI, 1.886-14.561, P=0.002] and showed higher trend of increasing mortality (HR =3.082, P=0.076). Conclusions New mechanical prostheses showed a better hemodynamic performance and lower incidence of PPM. Anticoagulation strategy to lower the target INR in patients with new mechanical valves may improve late outcomes by reducing hemorrhagic events.
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Affiliation(s)
- Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joong Hyun Ahn
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keumhee Chough Carriere
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, AB, Canada
| | - Pyo Won Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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