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Sukul D, Seth M, Madder RD, Basir MB, Menees DS, Kaki A, Azzalini L, Lee D, Gurm HS. Contemporary Trends and Outcomes of Intravascular Lithotripsy in Percutaneous Coronary Intervention: Insights From BMC2. JACC Cardiovasc Interv 2024; 17:1811-1821. [PMID: 38970579 DOI: 10.1016/j.jcin.2024.04.039] [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: 10/10/2023] [Revised: 04/10/2024] [Accepted: 04/23/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND With an aging population and an increase in the comorbidity burden of patients undergoing percutaneous coronary intervention (PCI), the management of coronary calcification for optimal PCI is critical in contemporary practice. OBJECTIVES This study sought to examine the trends and outcomes of coronary intravascular lithotripsy (IVL), rotational/orbital atherectomy, or both among patients who underwent PCI in Michigan. METHODS We included all PCIs between January 1, 2021, and June 30, 2022, performed at 48 Michigan hospitals. Outcomes included in-hospital major adverse cardiac events (MACEs) and procedural success. RESULTS IVL was used in 1,090 patients (2.57%), atherectomy was used in 1,743 (4.10%) patients, and both were used in 240 patients (0.57% of all PCIs). IVL use increased from 0.04% of PCI cases in January 2021 to 4.28% of cases in June 2022, ultimately exceeding the rate of atherectomy use. The rate of MACEs (4.3% vs 5.4%; P = 0.23) and procedural success (89.4% vs 89.1%; P = 0.88) were similar among patients treated with IVL compared with atherectomy, respectively. Only 15.6% of patients treated with IVL in contemporary practice were similar to the population enrolled in the pivotal IVL trials. Among such patients (n = 169), the rate of MACEs (0.0%) and procedural success (94.7%) were similar to the outcomes reported in the pivotal IVL trials. CONCLUSIONS Since its introduction in February 2021, coronary IVL use has steadily increased, exceeding atherectomy use in Michigan by February 2022. Contemporary use of IVL and atherectomy is generally associated with high rates of procedural success and low rates of complications.
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Affiliation(s)
- Devraj Sukul
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
| | - Milan Seth
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ryan D Madder
- Frederik Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, Michigan, USA
| | - Mir B Basir
- Division of Cardiology, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Daniel S Menees
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Amir Kaki
- Division of Cardiology, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Lorenzo Azzalini
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Daniel Lee
- Division of Cardiology, McLaren Bay Region, Bay City, Michigan, USA
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Sagris M, Ktenopoulos N, Dimitriadis K, Papanikolaou A, Tzoumas A, Terentes-Printzios D, Synetos A, Soulaidopoulos S, Lichtenberg M, Korosoglou G, Honton B, Tousoulis D, Tsioufis C, Toutouzas K. Efficacy of intravascular lithotripsy (IVL) in coronary stenosis with severe calcification: A multicenter systematic review and meta-analysis. Catheter Cardiovasc Interv 2024; 103:710-721. [PMID: 38482928 DOI: 10.1002/ccd.31006] [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: 09/04/2023] [Revised: 12/08/2023] [Accepted: 02/26/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND With heavily calcified coronary and peripheral artery lesions, lesion preparation is crucial before stent placement to avoid underexpansion, associated with stent thrombosis or restenosis and patency failure in the long-term. Intravascular lithotripsy (IVL) technology disrupts superficial and deep calcium by using localized pulsative sonic pressure waves, making it to a promising tool for patients with severe calcification in coronary bed. AIMS The aim of the study is to systematically review and summarize available data regarding the safety and efficacy of IVL for lesion preparation in severely calcified coronary arteries before stenting. METHODS This study was conducted according to the PRISMA guidelines. We systematically searched PubMed, SCOPUS, and Cochrane databases from their inception to February 23, 2023, for studies assessing the characteristics and outcomes of patients undergoing IVL before stent implantation. The diameter of the vessel lumen before and after IVL, as well as stent implantation, were analyzed. The occurrence of major adverse cardiovascular events (MACE) was assessed using a random-effects model. RESULTS This meta-analysis comprised 38 studies including 2977 patients with heavily calcified coronary lesions. The mean age was 72.2 ± 9.1 years, with an overall IVL clinical success of 93% (95% confidence interval [CI]: 91%-95%, I2 = 0%) and procedural success rate of 97% (95% CI: 95%-98%, I2 = 73.7%), while the in-hospital and 30-days incidence of MACE, myocardial infarction (MI), and death were 8% (95% CI: 6%-11%, I2 = 84.5%), 5% (95% CI: 2%-8%, I2 = 85.6%), and 2% (95% CI: 1%-3%, I2 = 69.3%), respectively. There was a significant increase in the vessel diameter (standardized mean difference [SMD]: 2.47, 95% CI: 1.77-3.17, I2 = 96%) and a decrease in diameter stenosis (SMD: -3.44, 95% CI: -4.36 to -2.52, I2 = 97.5%) immediately after IVL application, while it was observed further reduction in diameter stenosis (SMD: -6.57, 95% CI: -7.43 to -5.72, I2 = 95.8%) and increase in the vessel diameter (SMD: 4.37, 95% CI: 3.63-5.12, I2 = 96.7%) and the calculated lumen area (SMD: 3.23, 95% CI: 2.10-4.37, I2 = 98%), after stent implantation. The mean acute luminal gain following IVL and stent implantation was estimated to be 1.27 ± 0.6 and 1.94 ± 1.1 mm, respectively. Periprocedural complications were rare, with just a few cases of perforations, dissection, or no-reflow phenomena recorded. CONCLUSIONS IVL seems to be a safe and effective strategy for lesion preparation in severely calcified lesions before stent implantation in coronary arteries. Future prospective studies are now warranted to compare IVL to other lesion preparation strategies.
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Affiliation(s)
- Marios Sagris
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Ktenopoulos
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kyriakos Dimitriadis
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Angelos Papanikolaou
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas Tzoumas
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Dimitrios Terentes-Printzios
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas Synetos
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stergios Soulaidopoulos
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael Lichtenberg
- Department of Cardiology, Vascular Medicine and Pneumology, GRN Hospital, Weinheim, Germany
| | | | - Benjamin Honton
- Department of Interventional Cardiology, Clinique Pasteur, Toulouse, France
| | - Dimitris Tousoulis
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Costas Tsioufis
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Toutouzas
- School of Medicine, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Rodriguez-Leor O, Cid-Alvarez AB, Lopez-Benito M, Gonzalo N, Vilalta V, Diarte de Miguel JA, López LF, Jurado-Roman A, Diego A, Oteo JF, Cuellas C, Trillo R, Travieso A, Alfonso F, Carrillo X, Vegas-Valle JM, Cortes-Villar C, Pascual I, Muñoz Camacho JF, Flores X, Vera-Vera S, Moreu J, Barreira de Sousa G, Martí D, Jimenez-Mazuecos J, Fuertes M, Ocaranza R, de la Torre Hernandez JM, Lozano F, Solana Martinez SG, Gómez-Lara J, Perez de Prado A. A Prospective, Multicenter, Real-World Registry of Coronary Lithotripsy in Calcified Coronary Arteries: The REPLICA-EPIC18 Study. JACC Cardiovasc Interv 2024:S1936-8798(23)01654-0. [PMID: 38385926 DOI: 10.1016/j.jcin.2023.12.018] [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: 10/24/2023] [Revised: 12/05/2023] [Accepted: 12/11/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Intravascular lithotripsy (IVL) has demonstrated effectiveness in the treatment of calcified lesions in selected patients with stable coronary disease. OBJECTIVES The authors sought to assess the performance of coronary IVL in calcified coronary lesions in a real-life, all comers, setting. METHODS The REPLICA-EPIC18 study prospectively enrolled consecutive patients treated with IVL in 26 centers in Spain. An independent core laboratory performed the angiographic analysis and event adjudication. The primary effectiveness endpoint assessed procedural success (successful IVL delivery, final diameter stenosis <20%, and absence of in-hospital major adverse cardiovascular events [MACE]). The primary safety endpoint measured freedom from MACE at 30 days. A predefined substudy compared outcomes between acute coronary syndrome (ACS) and chronic coronary syndrome (CCS) patients. RESULTS 426 patients (456 lesions) were included, 63% of the patients presenting with ACS. IVL delivery was successful in 99% of cases. Before IVL, 49% of lesions were considered undilatable. The primary effectiveness endpoint was achieved in 66% of patients, with similar rates among CCS patients (68%) and ACS patients (65%). Likewise, there were no significant differences in angiographic success after IVL between CCS and ACS patients. The rate of MACE at 30 days (primary safety endpoint) was 3% (1% in CCS and 5% in ACS patients [P = 0.073]). CONCLUSIONS Coronary IVL proved to be a feasible and safe procedure in a "real-life" setting, effectively facilitating stent implantation in severely calcified lesions. Patients with ACS on admission showed similar angiographic success rates but showed a trend toward higher 30-day MACE compared with patients with CCS. (REPLICA-EPIC18 study [Registry of Coronary Lithotripsy in Spain]; NCT04298307).
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Affiliation(s)
- Oriol Rodriguez-Leor
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; CIBER de Enfermedades CardioVasculares (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain; Institut de Recerca en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain.
| | - Ana Belen Cid-Alvarez
- Cardiology Department, Hospital Clínico de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Nieves Gonzalo
- Cardiology Department, Hospital Clinico San Carlos, Madrid, Spain; Fundación para la Investigación Biomédica del Hospital Clínico San Carlos, Madrid, Spain
| | - Victoria Vilalta
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; CIBER de Enfermedades CardioVasculares (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain; Institut de Recerca en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | | | | | | | - Alejandro Diego
- Cardiology Department, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - Juan Francisco Oteo
- Cardiology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | | | - Ramiro Trillo
- Cardiology Department, Hospital Clínico de Santiago de Compostela, Santiago de Compostela, Spain
| | - Alejandro Travieso
- Cardiology Department, Hospital Clinico San Carlos, Madrid, Spain; Fundación para la Investigación Biomédica del Hospital Clínico San Carlos, Madrid, Spain
| | - Fernando Alfonso
- Cardiology Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Xavier Carrillo
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; CIBER de Enfermedades CardioVasculares (CIBERCV) Instituto de Salud Carlos III, Madrid, Spain; Institut de Recerca en Ciències de la Salut Germans Trias i Pujol, Badalona, Spain
| | | | | | - Isaac Pascual
- Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Xacobe Flores
- Cardiology Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Silvio Vera-Vera
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Jose Moreu
- Cardiology Department, Hospital Universitario de Toledo, Toledo, Spain
| | | | - David Martí
- Cardiology Department, Hospital Central de la Defensa Gomez Hulla, Madrid, Spain
| | | | - Monica Fuertes
- Cardiology Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Raymundo Ocaranza
- Cardiology Department, Hospital Universitario Lucus Augusti, Lugo, Spain
| | | | - Fernando Lozano
- Cardiology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | | | - Josep Gómez-Lara
- Cardiology Department, Hospital Universitari de Bellvitge, l'Hospitalet de Llobregat, Spain
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Coronary lithotripsy - a state of the art review. Trends Cardiovasc Med 2022; 33:215-222. [PMID: 35045278 DOI: 10.1016/j.tcm.2022.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 11/24/2022]
Abstract
Lesion calcification is frequently encountered during percutaneous coronary intervention and has been directly linked to procedural complications and future cardiac events. Intravascular lithotripsy is a novel balloon-based modality that does not rely on barotrauma or debulking, but converts electrical energy into mechanical energy creating sonic pressure waves that selectively disrupt calcium. The present review provides an overview of its mechanism of action, the available evidence on its safety and efficacy and indications for use.
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Wiens EJ, Sklar JC, Wei YH, Aleem Q, Minhas K. Real-world outcomes in treatment of highly calcified coronary lesions with intravascular shockwave lithotripsy. Indian Heart J 2021; 73:653-655. [PMID: 34627588 PMCID: PMC8514397 DOI: 10.1016/j.ihj.2021.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 07/28/2021] [Accepted: 09/04/2021] [Indexed: 11/09/2022] Open
Abstract
Real-world data regarding the efficacy and safety of coronary intravascular lithotripsy (IVL) are lacking. We conducted a study of 50 consecutive patients (64 lesions) who underwent IVL. 3 patients suffered in-hospital mortality unrelated to the IVL; there was no other occurrence of MACE up to 30 days. Angiographic success was nearly universal (98% of patients with residual stenosis <50%, 96% of patients with TIMI 3 flow) and complication was rare, including among patients undergoing IVL for in-stent restenosis or left main coronary artery lesions. In a high-risk real-world cohort, IVL was a safe and effective treatment for highly-calcified coronary lesions.
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Affiliation(s)
- Evan J Wiens
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada.
| | - Jaime C Sklar
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Yi Hui Wei
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Qaiser Aleem
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Kunal Minhas
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Kassimis G, Ziakas A, Didagelos M, Theodoropoulos KC, Patoulias D, Voultsos P, Papadopoulos C, Rocchiccioli P, Karamasis GV, Alexopoulos D, Sianos G. Shockwave coronary intravascular lithotripsy system for heavily calcified de novo lesions and the need for a cost-effectiveness analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 37:128-134. [PMID: 34246610 DOI: 10.1016/j.carrev.2021.06.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 12/24/2022]
Abstract
The optimal management for severely calcified coronary artery disease is multi-adjunctive. Different strategies with dedicated devices should be available in the cardiac catheterization laboratory with their selection depending on the nature of the calcific disease and its anatomical distribution. Shockwave Intravascular Lithotripsy (S-IVL) system offers a novel option for lesion preparation of heavily calcified plaques in coronary and peripheral vessels. S-IVL is based on the fundamental principles of lithotripsy, a technology that has been used to modify renal stones for over 30 years. Pulsatile mechanical energy is used to fragment selectively amorphous calcium, sparing soft tissue. S-IVL has the potential of more widespread adoption because of its proven safety, efficacy and operational simplicity, but cost-effectiveness of such advanced technology will need to be analyzed.
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Affiliation(s)
- George Kassimis
- 2nd Cardiology Department, Hippokration Hospital, Medical School, Aristotle University of Thessaloniki, Greece; 1st Cardiology Department, AHEPA General Hospital, Aristotle University of Thessaloniki, Greece.
| | - Antonios Ziakas
- 2nd Cardiology Department, Hippokration Hospital, Medical School, Aristotle University of Thessaloniki, Greece
| | - Matthaios Didagelos
- 1st Cardiology Department, AHEPA General Hospital, Aristotle University of Thessaloniki, Greece; Interventional Cardiology Department, West of Scotland Heart and Lung Centre, Golden Jubilee National, Hospital, Clydebank, United Kingdom
| | | | - Dimitrios Patoulias
- 2nd Propaedeutic Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Petros Voultsos
- 1st Cardiology Department, AHEPA General Hospital, Aristotle University of Thessaloniki, Greece
| | - Christodoulos Papadopoulos
- 3rd Cardiology Department, Hippokration Hospital, Medical School, Aristotle University of Thessaloniki, Greece
| | - Paul Rocchiccioli
- Interventional Cardiology Department, West of Scotland Heart and Lung Centre, Golden Jubilee National, Hospital, Clydebank, United Kingdom
| | - Grigoris V Karamasis
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - George Sianos
- 1st Cardiology Department, AHEPA General Hospital, Aristotle University of Thessaloniki, Greece
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Efficacy and safety of intravascular lithotripsy in calcified coronary lesions: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:73-82. [PMID: 34024748 DOI: 10.1016/j.carrev.2021.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/11/2021] [Accepted: 05/11/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Intravascular lithotripsy (IVL) is a recently introduced therapeutic modality in the management of calcified coronary lesions (CCAD). IVL delivers sonic pressure waves to modulate calcium, hence promote vessel compliance and optimize stent deployment. METHODS We performed a comprehensive literature search for studies that evaluated the utility of adjunctive IVL. The primary outcomes of our study were the clinical success, defined as the ability of IVL to produce residual diameter stenosis <50% (RDS < 50%) after stenting with no evidence of in-hospital major adverse cardiac events, and the angiographic success, defined as success in facilitating stent delivery with RDS < 50% and without serious angiographic complications. The secondary outcomes included post-IVL and post-stenting changes in lumen area, calcium angle, and the maximum calcium thickness. Proportional analysis was used for binary data and mean difference was used for continuous data. All meta-analyses were conducted using a random-effect model and 95% confidence intervals (CIs) were included. RESULTS A total of eight single-arm observational studies, including 980 patients (1011 lesions), were included. 48.8% of the patients presented with acute coronary syndrome. Severe calcifications were present in 97% of lesions. Clinical success was achieved in 95.4% of patients (95%CI:92.9%-97.9%). Angiographic success was achieved in 97% of patients (95%CI:95%-99%). There was an overall increase in postprocedural lumen area as well as significant reduction of calcium angle and maximum calcium thickness. CONCLUSIONS IVL seems to have excellent efficacy and safety in the management of CCAD. However, adequately powered RCTs are needed to evaluate IVL compared to other calcium/plaque modifying techniques.
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Urbano-Carrillo CA, Muñoz-Jiménez LD, Cano-García M. Litoplastia coronaria: un pulso al calcio. Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2020.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Urbano-Carrillo CA, Muñoz-Jiménez LD, Cano-García M. Coronary lithoplasty: applying a pulse to calcified lesions. ACTA ACUST UNITED AC 2020; 73:978-980. [PMID: 32792315 DOI: 10.1016/j.rec.2020.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Cristóbal A Urbano-Carrillo
- Unidad de Hemodinámica y Cardiología Intervencionista, Servicio de Cardiología, Hospital Regional Universitario de Málaga, Málaga, Spain.
| | - Luz D Muñoz-Jiménez
- Unidad de Hemodinámica y Cardiología Intervencionista, Servicio de Cardiología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Macarena Cano-García
- Unidad de Hemodinámica y Cardiología Intervencionista, Servicio de Cardiología, Hospital Regional Universitario de Málaga, Málaga, Spain
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