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Langenbach IL, Langenbach MC, Mayrhofer T, Foldyna B, Maintz D, Klein K, Wienemann H, Krug KB, Hellmich M, Adam M, Naehle CP. Reduction of contrast medium for transcatheter aortic valve replacement planning using a spectral detector CT: a prospective clinical trial. Eur Radiol 2024; 34:4089-4099. [PMID: 37979008 PMCID: PMC11166752 DOI: 10.1007/s00330-023-10403-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/25/2023] [Accepted: 09/17/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION This study investigated the use of dual-energy spectral detector computed tomography (CT) and virtual monoenergetic imaging (VMI) reconstructions in pre-interventional transcatheter aortic valve replacement (TAVR) planning. We aimed to determine the minimum required contrast medium (CM) amount to maintain diagnostic CT imaging quality for TAVR planning. METHODS In this prospective clinical trial, TAVR candidates received a standardized dual-layer spectral detector CT protocol. The CM amount (Iohexol 350 mg iodine/mL, standardized flow rate 3 mL/s) was reduced systematically after 15 patients by 10 mL, starting at 60 mL (institutional standard). We evaluated standard, and 40- and 60-keV VMI reconstructions. For image quality, we measured signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and diameters in multiple vessel sections (i.e., aortic annulus: diameter, perimeter, area; aorta/arteries: minimal diameter). Mixed regression models (MRM), including interaction terms and clinical characteristics, were used for comparison. RESULTS Sixty consecutive patients (mean age, 79.4 ± 7.5 years; 28 females, 46.7%) were included. In pre-TAVR CT, the CM reduction to 40 mL is possible without affecting the image quality (MRM: SNR: -1.1, p = 0.726; CNR: 0.0, p = 0.999). VMI 40-keV reconstructions showed better results than standard reconstructions with significantly higher SNR (+ 6.04, p < 0.001). Reduction to 30 mL CM resulted in a significant loss of quality (MRM: SNR: -12.9, p < 0.001; CNR: -13.9, p < 0.001), regardless of the reconstruction. Across the reconstructions, we observed no differences in the metric evaluation (p > 0.914). CONCLUSION Among TAVR candidates undergoing pre-interventional CT at a dual-layer spectral detector system, applying 40 mL CM is sufficient to maintain diagnostic image quality. VMI 40-keV reconstructions improve the vessel attenuation and are recommended for evaluation. CLINICAL RELEVANCE STATEMENT Contrast medium reduction to 40 mL in pre-interventional transcatheter aortic valve replacement CT using dual-energy CT maintains image quality, while 40-keV virtual monoenergetic imaging reconstructions enhance vessel attenuation. These results offer valuable recommendations for interventional transcatheter aortic valve replacement evaluation and potentially improve nephroprotection in patients with compromised renal function. KEY POINTS • Patients undergoing transcatheter aortic valve replacement (TAVR), requiring pre-interventional CT, are often multimorbid with impaired renal function. • Using a spectral detector dual-layer CT, contrast medium reduction to 40 mL is feasible, maintaining diagnostic image quality. • The additional application of virtual monoenergetic image reconstructions with 40 keV improves vessel attenuation significantly in clinical practice.
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Affiliation(s)
- Isabel L Langenbach
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany.
| | - Marcel C Langenbach
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Borek Foldyna
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - David Maintz
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Konstantin Klein
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Hendrik Wienemann
- Clinic III for Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Kathrin B Krug
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Medical Faculty, University of Cologne, Cologne, Germany
| | - Matti Adam
- Clinic III for Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
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Computed tomography predictors of structural valve degeneration in patients undergoing transcatheter aortic valve implantation with balloon-expandable prostheses. Eur Radiol 2022; 32:6017-6027. [PMID: 35364711 DOI: 10.1007/s00330-022-08747-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Computed tomography (CT) provides excellent anatomy assessment of the aortic annulus (AoA) and is utilized for pre-procedural planning of transcatheter aortic valve implantation (TAVI). We sought to investigate if geometrical characteristics of the AoA determined by CT may represent predictors of structural valve degeneration (SVD) in patients undergoing TAVI with balloon-expandable valves. METHODS This is a retrospective study on 124 consecutive patients (mean age: 79 ± 7 years; female: 61%) undergoing balloon-expandable TAVI prospectively enrolled in a registry. AoA maximum diameter (Dmax), minimum diameter (Dmin), and area were assessed using pre-procedural CT. SVD was identified during follow-up with transthoracic echocardiography documenting structural prosthetic valve abnormalities with or without hemodynamic changes. RESULTS The mean follow-up was 5.9 ± 1.7 years. SVD was found in 48 out of 124 patients (38%). AoA Dmax, Dmin, and area were significantly smaller in patients with SVD compared to patients without SVD (25.6 ± 2.2 mm vs. 27.1 ± 2.8 mm, p = 0.012; 20.5 ± 2.1 mm vs. 21.8 ± 2.1 mm, p = 0.001 and 419 ± 77 mm2 vs. 467 ± 88 mm2, p = 0.002, respectively). At univariable analysis, female sex, BSA, 23-mm prosthetic valve size, Dmax < 27.1 mm, and a Dmin < 19.9 mm were associated with SVD, whereas at multivariable analysis, only Dmin < 19.9 mm (OR = 2.873, 95% CI: 1.191-6.929, p = 0.019) and female sex (OR = 2.659, 95% CI: 1.095-6.458, p = 0.031) were independent predictors of SVD. CONCLUSIONS Female sex and AoA Dmin < 19.9 mm are associated with SVD in patients undergoing TAVI with balloon-expandable valves. When implanting large prostheses in order to avoid paraprosthetic regurgitation, caution should be observed due to the risk of excessive stretching of the AoA Dmin, which may play a role in SVD. KEY POINTS • Long-term durability is a concern for transcatheter aortic valve bioprosthesis. • CT provides an excellent assessment of the aortic annulus's geometrical characteristics for prosthesis sizing before transcatheter aortic valve implantation (TAVI). • Female sex and a small minimum aortic annulus diameter measured with CT are independent predictors of structural valve degeneration in patients undergoing TAVI with balloon-expandable valves.
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Cristoforetti A, Masè M, Bonmassari R, Dallago M, Nollo G, Ravelli F. A patient-specific mass-spring model for biomechanical simulation of aortic root tissue during transcatheter aortic valve implantation. Phys Med Biol 2019; 64:085014. [PMID: 30884468 DOI: 10.1088/1361-6560/ab10c1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The success of transcatheter aortic valve implantation (TAVI) is highly dependent on the prediction of the interaction between the prosthesis and the aortic root anatomy. The simulation of the surgical procedure may be useful to guide artificial valve selection and delivery, nevertheless the introduction of simulation models into the clinical workflow is often hindered by model complexity and computational burden. To address this point, we introduced a patient-specific mass-spring model (MSM) with viscous damping, as a good trade-off between simulation accuracy and time-efficiency. The anatomical model consisted of a hexahedral mesh, segmented from pre-procedural patient-specific cardiac computer tomographic (CT) images of the aortic root, including valve leaflets and attached calcifications. Nodal forces were represented by linear-elastic springs acting on edges and angles. A fast integration approach based on the modulation of nodal masses was also tested. The model was validated on seven patients, comparing simulation results with post-procedural CT images with respect to calcification and aortic wall position. The validation showed that the MSM was able to predict calcification displacement with an average accuracy of 1.72 mm and 1.54 mm for the normal and fast integration approaches, respectively. Wall displacement root mean squared error after valve expansion was about 1 mm for both approaches, showing an improved matching with respect to the pre-procedural configuration. In terms of computational burden, the fast integration approach allowed a consistent reduction of the computational times, which decreased from 36 h to 21.8 min per 100 K hexahedra. Our findings suggest that the proposed linear-elastic MSM model may provide good accuracy and reduced computational times for TAVI simulations, fostering its inclusion in clinical routines.
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Affiliation(s)
- Alessandro Cristoforetti
- Department of Industrial Engineering, University of Trento, Trento, Italy. Department of Physics, University of Trento, Trento, Italy
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Fu W, Marin D, Ramirez-Giraldo JC, Choudhury KR, Solomon J, Schabel C, Patel BN, Samei E. Optimizing window settings for improved presentation of virtual monoenergetic images in dual-energy computed tomography. Med Phys 2017; 44:5686-5696. [PMID: 28777467 DOI: 10.1002/mp.12501] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 06/06/2017] [Accepted: 07/20/2017] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Dual-energy computed tomography virtual monoenergetic imaging (VMI) at 40 keV exhibits superior contrast-to-noise ratio (CNR), although practicing radiologists do not consistently prefer it over VMI at 70 keV due to high perceivable noise. We hypothesize that the presentation of 40 keV VMI may be compromised using window settings (i.e., window-and-level values [W-L values]) designed for conventional single-energy CT. This study aimed to devise optimum window settings that reduce the apparent noise and utilize the high CNR of 40 keV VMI, in order to improve the conspicuity of hypervascular liver lesions. MATERIALS AND METHODS Three W-L value adjustment methods were investigated to alter the presentation of 40 keV VMI. To harness the high CNR of 40 keV VMI, the methods were designed to achieve (a) liver histogram distribution, (b) lesion-to-liver contrast, or (c) liver background noise comparable to those perceived in 70 keV VMI. This IRB-approved study included 18 patient abdominal datasets reconstructed at 40 and 70 keV. For each patient, the W-L values were determined using the three methods. For each of the images with default or adjusted W-L values, the noise, contrast, and CNR were calculated in terms of both display space and native CT number (referred to as HU) space. An observer study was performed to compare the 40 keV images with the three adjusted W-L values, and 40 and 70 keV images with default W-L values in terms of noise, contrast, and diagnostic preference. A comparison was also made in terms of the applicability of using patient-specific or patient-averaged W-L values. RESULTS Using the default W-L values, 40 keV VMI exhibited higher HU CNR than 70 keV VMI by 24.6 ± 14.9% (P < 0.001) but lower display CNR by 38.0 ± 16.4% (P < 0.001). Using adjusted W-L values, 40 keV images showed increased display CNR as compared to 70 keV images, by 21.2 ± 13.1%, 17.4 ± 13.6%, and 24.2 ± 15.9% (P < 0.001) for histogram-, noise-, and contrast equalization methods, respectively. The 40 keV images with all three W-L value adjustment methods showed improved perceived conspicuity (CNR) of liver presentation by 103-120% (P < 0.001), as compared to default W-L values. The qualitative observer study revealed that 40 keV images with noise- and histogram-equalized W-L values were the most preferred, followed by 40 keV images with contrast-equalized W-L values and 70 keV images with default W-L values. The 40 keV images with default W-L values were the least preferred. Patient-specific W-L values offered similar results to those of patient-averaged W-L values. CONCLUSION The adjusted W-L values can significantly improve the perception of VMI dataset image quality by improving the actual display CNR.
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Affiliation(s)
- Wanyi Fu
- Department of Electrical and Computer Engineering, and Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Duke University, Durham, NC, 27705, USA
| | - Daniele Marin
- Department of Radiology, Duke University Medical Center, Durham, NC, 27705, USA
| | | | - Kingshuk Roy Choudhury
- Carl E. Ravin Advanced Imaging Laboratories, Department of Radiology, Duke University, Durham, NC, 27705, USA
| | - Justin Solomon
- Carl E. Ravin Advanced Imaging Laboratories, Clinical Imaging Physics Group, Department of Radiology, Duke University Medical Center, Durham, NC, 27705, USA
| | - Christoph Schabel
- Department of Radiology, Duke University Medical Center, Durham, NC, 27705, USA
| | - Bhavik N Patel
- Department of Radiology, Duke University Medical Center, Durham, NC, 27705, USA
| | - Ehsan Samei
- Carl E. Ravin Advanced Imaging Laboratories, Medical Physics Graduate Program, Department of Radiology, and Departments of Physics, Biomedical Engineering, and Electrical and Computer Engineering, Duke University, Durham, NC, 27705, USA
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Cinematic Rendering in CT: A Novel, Lifelike 3D Visualization Technique. AJR Am J Roentgenol 2017; 209:370-379. [DOI: 10.2214/ajr.17.17850] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Transcatheter aortic valve replacement (TAVR) has become a widely accepted therapeutic option for patients with severe, symptomatic aortic stenosis at intermediate, high, or extreme risk for conventional surgery as determined through a heart team approach. Two valve prostheses are currently available and the Food and Drug Administration (FDA) approved in the United States for TAVR: the self-expandable Medtronic CoreValve (Medtronic, Inc., Minneapolis, MN, USA) and the balloon-expandable Edwards Sapien Valve (Edwards Lifesciences, Irvine CA, USA). The preoperative evaluation for TAVR includes transthoracic echocardiography (TTE) for the diagnosis of aortic stenosis. Cardiac computed tomography (CTA) has become the imaging modality of choice for annular sizing. Aortic root dimensions and coronary ostia height, and the degree of annular and left ventricular outflow tract calcification are also assessed to estimate the risk of coronary obstruction, annular rupture, and postoperative aortic regurgitation. Finally, CTA is essential to determine the adequacy of the peripheral vasculature for a transfemoral approach. Intraoperatively, fluoroscopy is mandatory for valve positioning, whereas the use of TTE or transesophageal echocardiography (TEE) varies by center. TTE is used for postoperative surveillance of valve function.
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Affiliation(s)
- Arash Salemi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
| | - Berhane M Worku
- Department of Cardiothoracic Surgery, Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA.,Departmemt of Cardiothoracic Surgery, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
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Kallianos K, Henry TS, Yeghiazarians Y, Zimmet J, Shunk KA, Tseng EE, Mahadevan V, Hope MD. Ferumoxytol MRA for transcatheter aortic valve replacement planning with renal insufficiency. Int J Cardiol 2017; 231:255-257. [PMID: 28100426 DOI: 10.1016/j.ijcard.2016.12.147] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/08/2016] [Accepted: 12/20/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Computed tomography angiography (CTA) is the test of choice for pre-procedure imaging of transcatheter aortic valve replacement (TAVR) candidates. The iodinated contrast required, however, increases the risk of renal dysfunction in patients with pre-existing renal failure. Ferumoxytol is a magnetic resonance imaging (MRI) contrast agent that can be used with renal failure. Its long vascular resonance time allows gated MRA sequences that approach CTA in image quality. We present respiratory and cardiac gated MRA enabled by ferumoxytol that can be post-processed in an analogous fashion to CTA. METHODS Seven patients with renal failure presenting for TAVR were imaged with respiratory and cardiac gated MRA at 3T using ferumoxtyol for contrast. Aortic annulus, root and peripheral access dimensions were calculated in a fashion identical to that used for CTA. Of these, 6 patients underwent a TAVR procedure and 5 had intraoperative valve assessment with transesophageal echocardiograph (TEE) using standard clinical protocols that employed both two- and three-dimensional techniques. RESULTS Good correlation between MRA aortic annulus measurements and those from TEE were shown in 5 patients with mean annulus area of 392.4mm2 (290-470 range) versus 374.1mm2 (285-440 range), with a pairwise correlation coefficient of 0.92, p=0.029. All patients received Sapien valve implants (one 20mm, three 23mm, and two 26mm valves). Access decisions were guided by MRA with no complications. Annulus sizing resulted in no greater than trace/mild aortic regurgitation in all patients. CONCLUSIONS Ferumoxytol MRA is a safe alternative to CTA in patients with renal failure for pre-TAVR analysis of the aortic root and peripheral access.
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Affiliation(s)
- Kimberly Kallianos
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, United States
| | - Travis S Henry
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, United States
| | - Yerem Yeghiazarians
- Department of Cardiology, University of California, San Francisco, United States
| | - Jeffrey Zimmet
- Department of Cardiology, San Francisco VA Medical Center, United States
| | - Kendrick A Shunk
- Department of Cardiology, San Francisco VA Medical Center, United States
| | - Elaine E Tseng
- Department of Surgery, San Francisco VA Medical Center, United States
| | - Vaikom Mahadevan
- Department of Cardiology, University of California, San Francisco, United States
| | - Michael D Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, United States.
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Mangold S, De Cecco CN, Schoepf UJ, Kuhlman TS, Varga-Szemes A, Caruso D, Duguay TM, Tesche C, Vogl TJ, Nikolaou K, Steinberg DH, Wichmann JL. CT angiography for planning transcatheter aortic valve replacement using automated tube voltage selection: Image quality and radiation exposure. Eur J Radiol 2017; 86:276-283. [DOI: 10.1016/j.ejrad.2016.11.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 09/19/2016] [Accepted: 11/22/2016] [Indexed: 11/30/2022]
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Martin SS, Albrecht MH, Wichmann JL, Hüsers K, Scholtz JE, Booz C, Bodelle B, Bauer RW, Metzger SC, Vogl TJ, Lehnert T. Value of a noise-optimized virtual monoenergetic reconstruction technique in dual-energy CT for planning of transcatheter aortic valve replacement. Eur Radiol 2016; 27:705-714. [DOI: 10.1007/s00330-016-4422-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 02/10/2016] [Accepted: 05/19/2016] [Indexed: 10/21/2022]
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Beeres M, Wichmann JL, Frellesen C, Bucher AM, Albrecht M, Scholtz JE, Nour-Eldin NEA, Gruber-Rouh T, Lee C, Vogl TJ, Lehnert T. ECG-gated Versus Non-ECG-gated High-pitch Dual-source CT for Whole Body CT Angiography (CTA). Acad Radiol 2016; 23:163-7. [PMID: 26548854 DOI: 10.1016/j.acra.2015.09.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 08/31/2015] [Accepted: 09/03/2015] [Indexed: 12/27/2022]
Abstract
RATIONALE AND OBJECTIVES To investigate motion artifacts, image quality, and practical differences in electrocardiographic (ECG)-gated versus non-ECG-gated high-pitch dual-source computed tomography angiography (CTA) of the whole aorta. MATERIALS AND METHODS Two groups, each including 40 patients, underwent either ECG-gated or non-ECG-gated high-pitch dual-source CTA of the whole aorta. The aortic annulus, aortic valve, coronary ostia, and the presence of motion artifacts of the thoracic aorta as well as vascular contrast down to the femoral arteries were independently assessed by two readers. Additional objective parameters including image noise and signal-to-noise ratio were analyzed. RESULTS Subjective and objective scoring revealed no presence of motional artifacts regardless of whether the ECG-gated or the non-ECG-gated protocol was used (P > 0.1). Image acquisition parameters (examination length, examination duration, radiation dose) were comparable between the two groups without significant differences. The aortic annulus, aortic valve, and coronary ostia were reliably evaluable in all patients. Vascular contrast was rated excellent in both groups. CONCLUSIONS High-pitch dual-source CTA of the whole aorta is a robust and dose-efficient examination strategy for the evaluation of aortic pathologies whether or not ECG gating is used.
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Caruso D, Rosenberg RD, De Cecco CN, Mangold S, Wichmann JL, Varga-Szemes A, Steinberg DH, Laghi A, Schoepf UJ. Vascular Imaging Before Transcatheter Aortic Valve Replacement (TAVR): Why and How? Curr Cardiol Rep 2016; 18:14. [DOI: 10.1007/s11886-015-0694-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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