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Di Bacco L, D’Alonzo M, Baudo M, Montisci A, Di Eusanio M, Folliguet T, Solinas M, Miceli A, Fischlein T, Rosati F, Muneretto C. Reliability of EuroSCORE II on Prediction of Thirty-Day Mortality and Long-Term Results in Patients Treated with Sutureless Valves. J Clin Med 2024; 13:3986. [PMID: 38999550 PMCID: PMC11242606 DOI: 10.3390/jcm13133986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/19/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024] Open
Abstract
Background: EuroSCORE II (ES2) is a reliable tool for preoperative cardiac surgery mortality risk prediction; however, a patient's age, a surgical procedure's weight and the new devices available may cause its accuracy to drift. We sought to investigate ES2 performance related to the surgical risk and late mortality estimation in patients who underwent aortic valve replacement (AVR) with sutureless valves. Methods: Between 2012 and 2021, a total of 1126 patients with isolated aortic stenosis who underwent surgical AVR by means of sutureless valves were retrospectively collected from six European centers. Patients were stratified into three groups according to the EuroSCORE II risk classes (ES2 < 4%, ES2 4-8% and ES2 > 8%). The accuracy of ES2 in estimating mortality risk was assessed using the standardized mortality ratio (O/E ratio), ROC curves (AUC) and Hosmer-Lemeshow (HL) test for goodness-of-fit. Results: The overall observed mortality was 3.0% (predicted mortality ES2: 5.39%) with an observed/expected (O/E) ratio of 0.64 (confidential interval (CI): 0.49-0.89). In our population, ES2 showed a moderate discriminating power (AUC 0.65, 95%CI 0.56-0.72, p < 0.001; HL p = 0.798). Good accuracy was found in patients with ES2 < 4% (O/E ratio 0.54, 95%CI 0.23-1.20, AUC 0.75, p < 0.001, HL p = 0.999) and for patients with an age < 75 years (O/E ratio 0.98, 95%CI 0.45-1.96, AUC 0.76, p = 0.004, HL p = 0.762). Moderate discrimination was observed for ES2 in the estimation of long-term risk of mortality (AUC 0.64, 95%CI: 0.60-0.68, p < 0.001). Conclusions: EuroSCORE II showed good accuracy in patients with an age < 75 years and patients with ES2 < 4%, while overestimating risk in the other subgroups. A recalibration of the model should be taken into account based on the complexity of actual patients and impact of new technologies.
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Affiliation(s)
- Lorenzo Di Bacco
- Unit of Cardiac Surgery, Univesity of Brescia, 25123 Brescia, Italy; (L.D.B.); (A.M.); (F.R.); (C.M.)
| | - Michele D’Alonzo
- Unit of Cardiac Surgery, Univesity of Brescia, 25123 Brescia, Italy; (L.D.B.); (A.M.); (F.R.); (C.M.)
| | - Massimo Baudo
- Cardiothoracic Surgery, Lankenau Institute for Medical Research, Wynnewood, PA 19096, USA;
| | - Andrea Montisci
- Unit of Cardiac Surgery, Univesity of Brescia, 25123 Brescia, Italy; (L.D.B.); (A.M.); (F.R.); (C.M.)
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, 60121 Ancona, Italy;
| | - Thierry Folliguet
- Unit of Cardiac Surgery, Henri Mondor Hospital, 94010 Creteil, France;
| | - Marco Solinas
- Monasterio Foundation Heart Hospital, 54100 Massa, Italy;
| | - Antonio Miceli
- Department of Minimally Invasive Cardiac Surgery, Sant’Ambrogio Hospital, 20122 Milan, Italy;
| | - Theodor Fischlein
- Department of Cardiac Surgery, Paracelsus Medical University, 90419 Nuremberg, Germany;
| | - Fabrizio Rosati
- Unit of Cardiac Surgery, Univesity of Brescia, 25123 Brescia, Italy; (L.D.B.); (A.M.); (F.R.); (C.M.)
| | - Claudio Muneretto
- Unit of Cardiac Surgery, Univesity of Brescia, 25123 Brescia, Italy; (L.D.B.); (A.M.); (F.R.); (C.M.)
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Bakhtiary F, Silaschi M, El-Sayed Ahmad A, Salamate S, Meuris B. Multicentre experience of sutureless prostheses inside degenerated stentless aortic valves and bioroots. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae088. [PMID: 38696749 PMCID: PMC11088739 DOI: 10.1093/icvts/ivae088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/30/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVES Patients with failed stentless aortic prostheses are a challenging population to treat, as reoperative procedures may be complex and catheter-based treatments are associated with a high rate of procedural events. Reoperative surgery using sutureless valves may be an alternative. METHODS In this multicentre experience, we assess outcomes of 17 patients who underwent reoperative surgery using the Perceval valve (Corcym UK Limited, London, UK) inside Freestyle prosthesis (Medtronic Inc., Dublin, Ireland) or bioroots from 2018 to 2023. RESULTS Mean age was 71.1 ± standard deviation 15.1 years and mean EuroSCORE II was 13.5 ± 15.8%, Society of Thoracic Surgeons Score was 5.9 ± 11.7%. Mean transvalvular gradient at baseline was 25.3 ± 19.9 mmHg and left ventricular ejection fraction was 53.5 ± standard deviation 8.5%. In 70.6% (12/17), moderate or severe aortic regurgitation was present. Implant success was 100%. Aortic cross-clamp time was 44.5 ± standard deviation 23.6 min. No patient needed a pacemaker and no mild paravalvular regurgitation occurred. Mean gradient was 12.5 ± 4.7 mmHg; 30-day mortality was 5.9% (1/17). CONCLUSIONS Rate of mortality was lower than predicted by EuroSCORE II in these high-risk patients and haemodynamic outcomes were favourable. Heart teams should consider this treatment concept when discussing patients with failed stentless valves or bioroots.
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Affiliation(s)
- Farhad Bakhtiary
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Miriam Silaschi
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Ali El-Sayed Ahmad
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Saad Salamate
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Sohn SH, Kim KH, Kang Y, Choi JW, Lee SH, Shinn SH, Lim C, Sung K, Yoo JS, Choo SJ. Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation: Current Status in Korea. J Korean Med Sci 2023; 38:e404. [PMID: 38084028 PMCID: PMC10713441 DOI: 10.3346/jkms.2023.38.e404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/12/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND In the era of transcatheter aortic valve implantation, this study was conducted to investigate the current trend of aortic valve procedures in Korea and to evaluate the early and mid-term outcomes of isolated surgical aortic valve replacement (SAVR) using bioprosthetic valves in contemporary Korea. METHODS Contemporary outcomes of isolated bioprosthetic SAVR in Korea were analyzed using the datasets on a multicenter basis. Patients who underwent isolated SAVR using bioprostheses from June 2015 to May 2019 were included, and those with concomitant cardiac procedures, SAVR with mechanical valve, or SAVR for infective endocarditis were excluded. A total of 456 patients from 4 large-volume centers were enrolled in this study. Median follow-up duration was 43.4 months. Early postoperative outcomes, mid-term clinical outcomes, and echocardiographic outcomes were evaluated. RESULTS Mean age of the patients was 73.1 ± 7.3 years, and EuroSCORE II was 2.23 ± 2.09. The cardiopulmonary bypass time and aortic cross-clamp times were median 106 and 76 minutes, respectively. SAVR was performed with full median sternotomy (81.8%), right thoracotomy (14.7%), or partial sternotomy (3.5%). Operative mortality was 1.8%. The incidences of stroke and permanent pacemaker implantation were 1.1% and 1.1%, respectively. Paravalvular regurgitation ≥ mild was detected in 2.6% of the patients. Cumulative incidence of all-cause mortality at 5 years was 13.0%. Cumulative incidences of cardiovascular mortality and bioprosthetic valve dysfunction at 5 years were 7.6% and 6.8%, respectively. CONCLUSION The most recent data for isolated SAVR using bioprostheses in Korea resulted in excellent early and mid-term outcomes in a multicenter study.
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Affiliation(s)
- Suk Ho Sohn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Yoonjin Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Ho Shinn
- Department of Thoracic and Cardiovascular Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Suk Yoo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Tam DY, Sadri H. Annual Budget Impact Analysis Comparing Self-Expanding Transcatheter and Surgical Aortic Valve Replacement in Low-Risk Aortic Stenosis Patients. Can J Cardiol 2022; 38:1478-1484. [DOI: 10.1016/j.cjca.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 05/31/2022] [Accepted: 06/03/2022] [Indexed: 11/02/2022] Open
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Perrotti A, Francica A, Monaco F, Quintana E, Sponga S, El-Dean Z, Salizzoni S, Loizzo T, Salsano A, Di Cesare A, Benassi F, Castella M, Rinaldi M, Chocron S, Vendramin I, Faggian G, Santini F, Nicolini F, Milano AD, Ruggieri VG, Onorati F. Post-operative Quality of Life after Full-sternotomy and Mini-sternotomy Aortic Valve Replacement. Ann Thorac Surg 2021; 115:1189-1196. [PMID: 34971595 DOI: 10.1016/j.athoracsur.2021.11.055] [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: 05/25/2021] [Revised: 10/16/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Few longitudinal data exist comparing quality of life (QoL) after full sternotomy aortic valve replacement (fsAVR) vs mini-sternotomy AVR (msAVR) METHODS: 1844 consecutive AVR prospectively enrolled in a European multicentre Registry were dichotomized according to surgical access. A non-parsimonious propensity-score matching selected 187 pairs of fsAVR or msAVR with comparable baseline characteristics. Hospital outcome was compared in the two groups. QoL was assessed with Short Form-36, further detailed in its Physical Component Score (PCS) and Mental Component Score (MCS). QoL was investigated at hospital admission, discharge, 1 month, 6 months and 1 year thereafter. RESULTS There were 1654 fsAVR and 190 msAVR in the entire population. fsAVR showed a worse preoperative risk-profile, a longer ICU length of stay (59.7 hours vs 38.8, p=0.002), and a higher life-threatening/disabling bleeding (4.1% vs. 0%; p=0.011); msAVR reported a higher early reintervention for failed index intervention (2.1% vs. 0.5%, p=0.001). QoL showed better PCS and MCS at 1 month after fsAVR, but no temporal-trend differences (PCS group-time p=0.202; MCS group-time p=0.141). Propensity-matched pairs showed comparable baseline characteristics and hospital outcome (p=NS for all endpoints), and comparable improvements of PCS and MCS over time, but no between-group differences over time (PCS group-time p=0.834; MCS group-time p=0.737). CONCLUSIONS Patients with similar baseline profiles report comparable hospital outcome and comparable improvement of physical and mental health, up to 1 year after surgery, with both fsAVR and msAVR. As for QoL, mini-sternotomy does not seem to offer any advantage compared to the traditional approach.
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Affiliation(s)
- Andrea Perrotti
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Francesco Monaco
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Edward Quintana
- Division of Cardiac Surgery, Hospital Clinic, University of Barcelona Medical School, Barcelona, Spain
| | - Sandro Sponga
- Division of Cardiac Surgery, Azienda Ospedaliero Universitaria di Udine, Udine, Italy
| | - Zein El-Dean
- Department of Cardiac Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, United Kingdom
| | - Stefano Salizzoni
- Department of Cardiac Surgery, Città della Salute e della Scienza, University of Turin Medical School, Turin, Italy
| | - Tommaso Loizzo
- Cardiac Surgery Unit, Department of Emergency and Organ Transplants, Bari, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | - Alessandro Di Cesare
- Cardiovascular and Thoracic Surgery Unit, Robert Debre University Hospital, Reims, France; Université de Reims Champagne-Ardennes, Reims, France
| | - Filippo Benassi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Manuel Castella
- Division of Cardiac Surgery, Hospital Clinic, University of Barcelona Medical School, Barcelona, Spain
| | - Mauro Rinaldi
- Department of Cardiac Surgery, Città della Salute e della Scienza, University of Turin Medical School, Turin, Italy
| | - Sidney Chocron
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Igor Vendramin
- Division of Cardiac Surgery, Azienda Ospedaliero Universitaria di Udine, Udine, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy
| | | | - Aldo Domenico Milano
- Cardiac Surgery Unit, Department of Emergency and Organ Transplants, Bari, Italy
| | - Vito Giovanni Ruggieri
- Cardiovascular and Thoracic Surgery Unit, Robert Debre University Hospital, Reims, France; Université de Reims Champagne-Ardennes, Reims, France
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy.
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Saito S, Sairenchi T, Tezuka M, Takei Y, Tsuchiya G, Ogata K, Monta O, Shibasaki I, Tsutsumi Y, Fukuda H. Contemporary short-term outcomes of surgery for aortic stenosis: transcatheter vs. surgical aortic valve replacement. Gen Thorac Cardiovasc Surg 2021; 70:124-131. [PMID: 34159515 PMCID: PMC8817997 DOI: 10.1007/s11748-021-01672-8] [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: 04/19/2021] [Accepted: 06/14/2021] [Indexed: 11/24/2022]
Abstract
Objectives This study aimed to compare the short-term outcomes of transcatheter and surgical aortic valve replacements (TAVR and SAVR) in high-, intermediate-, and low-preoperative risk patients. Methods A total of 454 patients who underwent TAVR or SAVR were included. Patients were categorized into high-, intermediate-, and low-risk according to the Society of Thoracic Surgery-Predicted Risk of Mortality score and clinical outcomes were compared between TAVR and SAVR groups. Results TAVR was less invasive, with less bleeding and transfusion (p < 0.001), less frequent new-onset atrial fibrillation (p < 0.001), and shorter intensive care unit stay (p < 0.001). Furthermore, transcatheter valves performed better than surgical valves, with lower peak velocity (p = 0.003) and pressure gradient (p < 0.001) and higher effective orifice area index (p < 0.001). The clinical outcomes of TAVR were comparable to or even superior to those of SAVR in high- and intermediate-risk patients. In low-risk patients, the 1- and 2-year mortality rates were 6.3% and 12.1%, respectively, in the TAVR group and 0% and 0.9%, respectively, in the SAVR group (p < 0.001). Mild or greater paravalvular leakage was a risk factor for mortality (hazard ratio 35.78; p < 0.001). Conclusions TAVR was superior to SAVR in the sense of less invasiveness and valvular function. However, the indication of TAVR in low-risk patients should be carefully discussed, because paravalvular leakage was a risk factor for short-term mortality. Supplementary Information The online version contains supplementary material available at 10.1007/s11748-021-01672-8.
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Affiliation(s)
- Shunsuke Saito
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, 880 Kitakobayashi, Shimotsugagun, Mibu, Tochigi, 321-0293, Japan.
| | - Toshimi Sairenchi
- Center for Research Collaboration and Support, Comprehensive Research Facilities for Advanced Medical Science, Dokkyo Medical University, Mibu, Japan
| | - Masahiro Tezuka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, 880 Kitakobayashi, Shimotsugagun, Mibu, Tochigi, 321-0293, Japan
| | - Yusuke Takei
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, 880 Kitakobayashi, Shimotsugagun, Mibu, Tochigi, 321-0293, Japan
| | - Go Tsuchiya
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, 880 Kitakobayashi, Shimotsugagun, Mibu, Tochigi, 321-0293, Japan
| | - Koji Ogata
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, 880 Kitakobayashi, Shimotsugagun, Mibu, Tochigi, 321-0293, Japan
| | - Osamu Monta
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Fukui, Japan
| | - Ikuko Shibasaki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, 880 Kitakobayashi, Shimotsugagun, Mibu, Tochigi, 321-0293, Japan
| | - Yasushi Tsutsumi
- Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Fukui, Japan
| | - Hirotsugu Fukuda
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University, 880 Kitakobayashi, Shimotsugagun, Mibu, Tochigi, 321-0293, Japan
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Sumal AS, Ali JM, Kyriacou H, Tuttle CJ, Moorjani N. Aortic valve replacement in patients over 60: Real-world surgical outcomes. J Card Surg 2021; 36:1468-1476. [PMID: 33491235 DOI: 10.1111/jocs.15353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/14/2020] [Accepted: 12/30/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE With the advent of transcatheter aortic valve implantation (TAVI) has come an expectation that there will be a decline in surgical aortic valve replacement (SAVR). This has been fueled by trials comparing outcomes between TAVI and SAVR in lower-risk patients. The aim of this study was to examine outcomes following SAVR in patients over the age of 60. MATERIALS AND METHODS This retrospective cohort study observed 1005 patients ≥60 who underwent isolated primary SAVR from January 2015 to December 2018. The cohort was stratified by surgical risk, defined as European System for Cardiac Operative Risk Evaluation (EuroSCORE) II < 4 versus ≥4. The cohort was also divided by age (60-69, 70-79, ≥80) for additional comparisons. Outcomes included in-hospital complications and patient survival. RESULTS The median age and EuroSCORE II were 75 years and 1.6, respectively. The overall 30-day mortality was 1.7% and increased significantly with surgical risk (p = .007). The 30-day mortality of elective patients was 1.1%. Overall, 1- and 2-year survival rates were 94.3% and 91.7%, respectively, which significantly decreased with surgical risk (p < .001) and age (p = .002, p = .003). The rates of postoperative stroke and pacemaker implantations were 1.2% and 3.6%, respectively. CONCLUSIONS SAVR can be performed in patients ≥60 years old with excellent outcomes, which compare favorably with outcomes from TAVI trials, with their highly selected patient cohorts. SAVR remains a reliable, tried and tested, treatment option in these patients.
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Affiliation(s)
- Anoop S Sumal
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Harry Kyriacou
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
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Nampi RG, Pospishil L, Neuburger PJ. TAVR Versus SAVR for the Treatment of Aortic Stenosis: Do We Have a Clear Winner? J Cardiothorac Vasc Anesth 2020; 34:2100-2102. [PMID: 32418828 DOI: 10.1053/j.jvca.2020.04.013] [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] [Received: 03/31/2020] [Accepted: 04/08/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Robert G Nampi
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Liliya Pospishil
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY
| | - Peter J Neuburger
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY.
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