1
|
Lu R, Dismorr M, Hertzberg D, Glaser N, Sartipy U. Early Creatinine Changes After Aortic Valve Replacement and Late Survival, Heart Failure, and Chronic Kidney Disease in a National Registry. Ann Thorac Surg 2024:S0003-4975(24)00541-1. [PMID: 38971227 DOI: 10.1016/j.athoracsur.2024.06.021] [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: 02/05/2024] [Revised: 06/12/2024] [Accepted: 06/12/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND The impact of small increases in serum creatinine after surgical aortic valve replacement (SAVR) that fail to meet the acute kidney injury stage 1 criteria is unknown. The aim of this study was to investigate prognosis after primary SAVR in patients with small increases in postoperative serum creatinine. METHODS This observational cohort study included all adult patients who underwent primary SAVR in Sweden from 2009 to 2022. The primary outcome was all-cause mortality. Secondary outcomes were chronic kidney disease and heart failure. Regression standardization addressed confounding. RESULTS In 16,766 patients, 4074 (24.2%) had no change in postoperative serum creatinine, 5764 (34.3%) had a small increase in postoperative serum creatinine (0.06 mg/dL ≤ Δserum creatinine <0.3 mg/dL), and 2753 (16.4%) fulfilled the Kidney Disease Improving Global Outcomes acute kidney injury stage 1 criteria. The mean age was 67 years, and 31% of patients were female. No significant difference in long-term all-cause mortality was observed in the no change group at 13 years compared with the small increase group (absolute survival difference, 2.3% [95% CI, 0%-4.6%]). A stepwise increase in the risk of 30-day mortality was observed with increasing changes in serum creatinine. At 13 years of follow-up, there was a significant difference in the risk of chronic kidney disease (absolute difference, 2.8% [95% CI, 1.0%-4.5%]) and heart failure (absolute difference, 3.5% [95% CI, 1.3%-5.7%]) between the no change and small increase groups. CONCLUSIONS A small increase in postoperative serum creatinine after SAVR was associated with an increased risk of adverse outcomes. The acute kidney injury definition may benefit from including more reliable and specific biomarkers together with small creatinine increases to detect kidney injury.
Collapse
Affiliation(s)
- Ruixin Lu
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Michael Dismorr
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
| | - Daniel Hertzberg
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Natalie Glaser
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
2
|
Sugiyama Y, Moriyama N, Miyashita H, Yokoyama H, Ochiai T, Shishido K, Jalanko M, Yamanaka F, Vähäsilta T, Laine M, Saito S. Long-Term Assessment of Survival After Transcatheter Aortic Valve Implantation - Insights From the International Transcatheter Aortic Valve Implantation Registry. Circ J 2024; 88:462-471. [PMID: 38030300 DOI: 10.1253/circj.cj-23-0593] [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] [Indexed: 12/01/2023]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis (AS), but despite estimates of life expectancy after TAVI being essential in heart team discussion, these data are scarce. Therefore, the current study sought to assess long-term survival and its trends in relation to chronological age, surgical risk, and treatment period. METHODS AND RESULTS We included 2,414 consecutive patients who underwent TAVI for severe symptomatic AS between 2008 and 2021 at 2 international centers. For the analysis, long-term survival was evaluated according to age, surgical risk, and treatment period categorized into 3 groups, respectively. The longest follow-up was 13.5 years. Overall survival was 67.6% at 5 years and 26.9% at 10 years. Younger patients, lower surgical risk, and later treatment period showed better survival (log-rank P<0.001, respectively). In the multivariate analysis, age <75years, lower surgical risk, and later time period were significantly associated with better survival. The incidence of paravalvular leakage ≥moderate, red blood cell transfusion, and acute kidney injury were independently associated with increasing risk of 5-year death. CONCLUSIONS In a real-world registry, survival was substantial following TAVI, especially in younger and lower surgical-risk patients, with improving outcomes over time. This should be considered in heart team discussions of life-long management for AS patients after TAVI.
Collapse
Affiliation(s)
- Yoichi Sugiyama
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital
- Heart and Lung Center, Helsinki University and Helsinki University Central Hospital
| | - Noriaki Moriyama
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Hirokazu Miyashita
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Hiroaki Yokoyama
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Tomoki Ochiai
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Koki Shishido
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Mikko Jalanko
- Heart and Lung Center, Helsinki University and Helsinki University Central Hospital
| | - Futoshi Yamanaka
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Tommi Vähäsilta
- Heart and Lung Center, Helsinki University and Helsinki University Central Hospital
| | - Mika Laine
- Heart and Lung Center, Helsinki University and Helsinki University Central Hospital
| | - Shigeru Saito
- Department of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital
| |
Collapse
|
3
|
Rivera FB, Al-Abcha A, Ansay MFM, Magalong JVU, Tang VAS, Ona HM, Miralles KA, Sausa R, Uy RAF, Lerma EV, Collado FMS, McCullough PA, Volgman AS. Transcatheter Aortic Valve Replacement-Associated Acute Kidney Injury: An Update. Cardiorenal Med 2023; 13:143-157. [PMID: 36801854 DOI: 10.1159/000529729] [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: 09/14/2022] [Accepted: 02/01/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is a relatively novel minimally invasive procedure for the treatment of symptomatic patients with severe aortic stenosis. Although it has been proven effective in improving mortality and quality of life, TAVR is associated with serious complications, such as acute kidney injury (AKI). SUMMARY TAVR-associated AKI is likely due to several factors such as sustained hypotension, transapical approach, volume of contrast use, and baseline low GFR. This narrative review aims to present an overview of the latest literature and evidence regarding the definition of TAVR-associated AKI, its risk factors, and its impact on morbidity and mortality. The review used a systematic search strategy with multiple health-focused databases (Medline, EMBASE) and identified 8 clinical trials and 27 observational studies concerning TAVR-associated AKI. Results showed that TAVR-associated AKI is linked to several modifiable and nonmodifiable risk factors and is associated with higher mortality. A variety of diagnostic imaging modalities have the potential to identify patients at high risk for development of TAVR-AKI; however, there are no existing consensus recommendations regarding their use as of this time. The implications of these findings highlight the importance of identifying high-risk patients for which preventive measures may play a crucial role, and should be maximized. KEY MESSAGE This study reviews the current understanding of TAVR-associated AKI including its pathophysiology, risk factors, diagnostic modalities, and preventative management for patients.
Collapse
Affiliation(s)
| | | | | | | | | | - Hannah May Ona
- University of the Philippines College of Medicine, Manila, Philippines
| | | | - Rausche Sausa
- University of the Philippines College of Medicine, Manila, Philippines
| | | | - Edgar V Lerma
- Section of Nephrology, University of Illinois at Chicago College of Medicine/Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | | | | | | |
Collapse
|
4
|
McInerney A, García Márquez M, Tirado-Conte G, Bernal JL, Fernández-Pérez C, Jiménez-Quevedo P, Gonzalo N, Núñez-Gil I, Del Prado N, Escaned J, Fernández-Ortiz A, Elola J, Nombela-Franco L. In-hospital outcomes following percutaneous versus surgical intervention in the treatment of aortic stenosis and concomitant coronary artery disease. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023:S1885-5857(23)00025-7. [PMID: 36669732 DOI: 10.1016/j.rec.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION AND OBJECTIVES Concomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD. METHODS Using discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission. RESULTS Matching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P <.001) as was periprocedural stroke (0.9% vs 2.2%; P=.004), acute kidney injury (4.3% vs 16.0%, P <.001), blood transfusion (9.6% vs 21.1%, P <.001), and hospital-acquired pneumonia (0.1% vs 1.7%, P=.001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P <.001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P <.001) and SAVR/CABG (8.3 vs 6.8%, P <.001). Thirty-day cardiovascular readmission did not differ between groups. CONCLUSIONS In this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.
Collapse
Affiliation(s)
- Angela McInerney
- Instituto Cardiovascular, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | - Gabriela Tirado-Conte
- Instituto Cardiovascular, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - José Luis Bernal
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Información y Control de Gestión, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Cristina Fernández-Pérez
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain; Servicio de Medicina Preventiva, Área Sanitaria de Santiago de Compostela y Barbanza, Instituto de Investigaciones Sanitarias de Santiago (idis), Santiago de Compostela, A Coruña, Spain
| | - Pilar Jiménez-Quevedo
- Instituto Cardiovascular, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Nieves Gonzalo
- Instituto Cardiovascular, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Iván Núñez-Gil
- Instituto Cardiovascular, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Náyade Del Prado
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
| | - Javier Escaned
- Instituto Cardiovascular, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Antonio Fernández-Ortiz
- Instituto Cardiovascular, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Javier Elola
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
| | - Luis Nombela-Franco
- Instituto Cardiovascular, Hospital Clínico San Carlos, Fundación para la Investigación Biomédica del Hospital Clínico San Carlos (IdISSC), Madrid, Spain.
| |
Collapse
|
5
|
Crimi G, De Marzo V, De Marco F, Conrotto F, Oreglia J, D'Ascenzo F, Testa L, Gorla R, Esposito G, Sorrentino S, Spaccarotella C, Soriano F, Bruno F, Vercellino M, Balbi M, Morici N, Indolfi C, De Ferrari GM, Bedogni F, Porto I. Acute Kidney Injury After Transcatheter Aortic Valve Replacement Mediates the Effect of Chronic Kidney Disease. J Am Heart Assoc 2022; 11:e024589. [PMID: 36172945 DOI: 10.1161/jaha.121.024589] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Acute kidney injury (AKI) after transcatheter aortic valve replacement (TAVR) is associated with increased mortality. However, it is controversial whether AKI affects prognosis per se, being linked to baseline chronic kidney disease (CKD) and bleeding complications. The aim of this study was to disentangle, applying mediation analysis, the association between AKI and clinical outcome, considering CKD and bleedings. Methods and Results Consecutive patients undergoing TAVR were prospectively enrolled at 5 high-volume centers in Italy. AKI was defined according to Valve Academic Research Consortium-3 consensus, whereas bleeding with Bleeding Academic Research Consortium. Primary outcome was all-cause mortality after 1-year follow-up. Among 2621 patients undergoing TAVR, AKI occurrence was associated with 1-year mortality. This association of AKI with the primary end points remained significant after adjusting for baseline risk estimators, either Society of Thoracic Surgeons score (hazard ratio [HR], 2.78 [95% CI, 1.95-3.80], P<0.001) or EuroSCORE-II (HR, 1.85 [95% CI, 1.35-2.56], P<0.001). Both AKI and CKD significantly and independently affected primary outcome (HR, 3.06 [95% CI, 2.01-4.64], P<0.001 and HR, 1.82 [95% CI 1.27-2.65], P<0.01, respectively). The estimated proportion of the total effect of CKD mediated via AKI was, on average, 15%, 95% CI, 4%-29%, P<0.001. The significant effect of Bleeding Academic Research Consortium 2-5 bleedings on the primary outcome was not mediated by AKI. Conclusions AKI occurs in 1 out of 6 patients and significantly mediates one fifth of the effect of baseline CKD on all-cause mortality after TAVR. Our analysis supports a systematic effort to prevent AKI during TAVR, which may potentially translate into improved patients' 1-year survival.
Collapse
Affiliation(s)
- Gabriele Crimi
- Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV) IRCCS, Ospedale Policlinico San Martino Genoa Italy
| | - Vincenzo De Marzo
- Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV) IRCCS, Ospedale Policlinico San Martino Genoa Italy.,Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties University of Genoa Italy
| | - Federico De Marco
- Clinical and Interventional Cardiology Department IRCCS Policlinico San Donato San Donato Milanese Italy
| | - Federico Conrotto
- Division of Cardiology, Cardiovascular and Thoracic Department University of Turin, Città della Salute e della Scienza Turin Italy
| | - Jacopo Oreglia
- Cardiology I, "A. De Gasperis" Department Ospedale Niguarda Ca' Granda Milan Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department University of Turin, Città della Salute e della Scienza Turin Italy
| | - Luca Testa
- Clinical and Interventional Cardiology Department IRCCS Policlinico San Donato San Donato Milanese Italy
| | - Riccardo Gorla
- Clinical and Interventional Cardiology Department IRCCS Policlinico San Donato San Donato Milanese Italy
| | - Giuseppe Esposito
- Cardiology I, "A. De Gasperis" Department Ospedale Niguarda Ca' Granda Milan Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Catanzaro Italian Society of Cardiology (SIC) Magna Graecia University Catanzaro Italy
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Medical and Surgical Sciences, Catanzaro Italian Society of Cardiology (SIC) Magna Graecia University Catanzaro Italy
| | - Francesco Soriano
- Cardiology I, "A. De Gasperis" Department Ospedale Niguarda Ca' Granda Milan Italy
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department University of Turin, Città della Salute e della Scienza Turin Italy
| | - Matteo Vercellino
- Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV) IRCCS, Ospedale Policlinico San Martino Genoa Italy
| | - Manrico Balbi
- Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV) IRCCS, Ospedale Policlinico San Martino Genoa Italy.,Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties University of Genoa Italy
| | - Nuccia Morici
- Cardiology I, "A. De Gasperis" Department Ospedale Niguarda Ca' Granda Milan Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Catanzaro Italian Society of Cardiology (SIC) Magna Graecia University Catanzaro Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department University of Turin, Città della Salute e della Scienza Turin Italy
| | - Francesco Bedogni
- Clinical and Interventional Cardiology Department IRCCS Policlinico San Donato San Donato Milanese Italy
| | - Italo Porto
- Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV) IRCCS, Ospedale Policlinico San Martino Genoa Italy.,Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties University of Genoa Italy
| |
Collapse
|
6
|
Pighi M, Fezzi S, Pesarini G, Venturi G, Giovannini D, Castaldi G, Lunardi M, Ferrero V, Scarsini R, Ribichini F. Extravalvular Cardiac Damage and Renal Function Following Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis. Can J Cardiol 2020; 37:904-912. [PMID: 33383167 DOI: 10.1016/j.cjca.2020.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In this study we sought to determine the differences in incidence of acute kidney injury (AKI) and acute kidney recovery (AKR) among patients undergoing transcatheter aortic valve implantation (TAVI), according to the degree of extravalvular cardiac damage (EVCD). METHODS From the Verona Valvular Heart Disease Registry, 674 symptomatic severe aortic stenosis (AS) patients were selected and retrospectively analysed. Using echocardiographic data, patients were classified based on the degree of EVCD. RESULTS After dichotomized analysis, patients in EVCD stage 3 or 4 reported a significantly higher rate of AKI (29.5% vs 11.2%; P < 0.001). Using a multivariate analysis model, higher EVCD stage, lower glomerular filtrate rate (GFR) at admission, and amount of contrast used were found to be independent predictors of AKI, whereas stage of cardiac damage and GFR were found to be independent predictors of AKR. For the overall population after multivariate analysis AKI was associated with a higher incidence of 12-month all-cause mortality (hazard ratio, 2.142; 95% confidence interval, 1.082-4.239; P = 0.029) with a significant impact in the advanced cardiac damage stages, but not in the early stages (P for interaction = 0.006). AKR did not reduce adverse clinical outcomes but was associated with improved renal function at 12 months. CONCLUSIONS Increase in EVCD stage was associated with a higher rate of AKI after TAVI. AKI had a negative impact on long-term clinical outcomes but only in patients with advanced cardiac damage. AKR did not reduce adverse clinical outcomes but was associated with improved renal function at 12 months.
Collapse
Affiliation(s)
- Michele Pighi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy.
| | - Simone Fezzi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gabriele Pesarini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gabriele Venturi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Davide Giovannini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Gianluca Castaldi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Mattia Lunardi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Valeria Ferrero
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| |
Collapse
|
7
|
Azzalini L, Moroni F. Acute Kidney Injury in Patients With Normal Renal Function Undergoing Transcatheter or Surgical Aortic Valve Replacement: Should We Be Concerned? Can J Cardiol 2020; 37:7-10. [PMID: 32348847 DOI: 10.1016/j.cjca.2020.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Lorenzo Azzalini
- Division of Cardiology, VCU Health Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA.
| | - Francesco Moroni
- Division of Interventional Cardiology, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| |
Collapse
|