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1
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Randazzo M, Maffessanti F, Kotta A, Grapsa J, Lang RM, Addetia K. Added value of 3D echocardiography in the diagnosis and prognostication of patients with right ventricular dysfunction. Front Cardiovasc Med 2023; 10:1263864. [PMID: 38179507 PMCID: PMC10764503 DOI: 10.3389/fcvm.2023.1263864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/22/2023] [Indexed: 01/06/2024] Open
Abstract
Recent inroads into percutaneous-based options for the treatment of tricuspid valve disease has brought to light how little we know about the behavior of the right ventricle in both health and disease and how incomplete our assessment of right ventricular (RV) physiology and function is using current non-invasive technology, in particular echocardiography. The purpose of this review is to provide an overview of what three-dimensional echocardiography (3DE) can offer currently to enhance RV evaluation and what the future may hold if we continue to improve the 3D evaluation of the right heart.
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Affiliation(s)
- Michael Randazzo
- Department of Medicine, Section of Cardiology, University of Chicago Heart and Vascular Center, Chicago, IL, United States
| | | | - Alekhya Kotta
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Julia Grapsa
- Department of Cardiology, Guys and St Thomas NHS Trust, London, United Kingdom
| | - Roberto M. Lang
- Department of Medicine, Section of Cardiology, University of Chicago Heart and Vascular Center, Chicago, IL, United States
| | - Karima Addetia
- Department of Medicine, Section of Cardiology, University of Chicago Heart and Vascular Center, Chicago, IL, United States
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2
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Lang RM, Cameli M, Sade LE, Faletra FF, Fortuni F, Rossi A, Soulat-Dufour L. Imaging assessment of the right atrium: anatomy and function. Eur Heart J Cardiovasc Imaging 2022; 23:867-884. [PMID: 35079782 DOI: 10.1093/ehjci/jeac011] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/12/2022] [Indexed: 01/07/2023] Open
Abstract
The right atrium (RA) is the cardiac chamber that has been least well studied. Due to recent advances in interventional cardiology, the need for greater understanding of the RA anatomy and physiology has garnered significant attention. In this article, we review how a comprehensive assessment of RA dimensions and function using either echocardiography, cardiac computed tomography, and magnetic resonance imaging may be used as a first step towards a better understanding of RA pathophysiology. The recently published normative data on RA size and function will likely shed light on RA atrial remodelling in atrial fibrillation (AF), which is a complex phenomenon that occurs in both atria but has only been studied in depth in the left atrium. Changes in RA structure and function have prognostic implications in pulmonary hypertension (PH), where the increased right ventricular (RV) afterload first induces RV remodelling, predominantly characterized by hypertrophy. As PH progresses, RV dysfunction and dilatation may begin and eventually lead to RV failure. Thereafter, RV overload and increased RV stiffness may lead to a proportional increase in RA pressure. This manuscript provides an in-depth review of RA anatomy, function, and haemodynamics with particular emphasis on the changes in structure and function that occur in AF, tricuspid regurgitation, and PH.
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Affiliation(s)
- Roberto M Lang
- Heart and Vascular Center, University of Chicago, 5758 S Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Matteo Cameli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Leila E Sade
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA, USA.,Department of Cardiology, University of Baskent, Ankara, Turkey
| | | | - Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, Foligno, Italy.,Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexia Rossi
- Department of Nuclear Medicine, Zurich University Hospital, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Schlieren, Zurich, Switzerland
| | - Laurie Soulat-Dufour
- Saint Antoine and Tenon Hospital, AP-HP, Pr Ariel Cohen, Sorbonne Université, INSERM, Unité de recherche sur les maladies cardiovasculaires, le métabolisme et la nutrition, ICAN, Paris F-75013, France
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3
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Ferrara F, Capone V, Cademartiri F, Vriz O, Cocchia R, Ranieri B, Franzese M, Castaldo R, D’Andrea A, Citro R, Chianese S, Annunziata R, Marullo F, Siniscalchi M, Conte M, Sepe C, Maramaldi R, Rega S, Russo G, Majolo M, Raiola E, Salzano A, Mauro C, Trimarco B, Izzo R, Bossone E. Physiologic Range of Myocardial Mechano-Energetic Efficiency among Healthy Subjects: Impact of Gender and Age. J Pers Med 2022; 12:jpm12060996. [PMID: 35743780 PMCID: PMC9224845 DOI: 10.3390/jpm12060996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Myocardial mechano-energetic efficiency (MEE) is the capability of the left ventricle (LV) to convert the chemical energy obtained from the cardiac oxidative metabolism into mechanical work. The aim of present study was to establish normal non-invasive MEE and MEEi reference values. METHODS In total, 1168 healthy subjects underwent physical examinations, clinical assessment, and standardized transthoracic echocardiographic (TTE) examination. MEE was obtained by TTE as the ratio between stroke volume (SV) and heart rate (HR): MEE = SV/HR [HR expressed in seconds (HR/60)]. Because MEE is highly related to left ventricular mass (LVM), MEE was then divided by LVM with the purpose of obtaining an estimate of energetic expenditure per unit of myocardial mass (i.e., indexed MEE, MEEi, mL/s/g). RESULTS The mean values of MEE and MEEi in the overall population were 61.09 ± 18.19 mL/s; 0.45 ± 0.14, respectively. In a multivariable analysis, gender, body surface area (BSA), diastolic blood pressure, left atrial volume indexed to BSA, E/e' and tricuspid annular plane systolic excursion (TAPSE) were the independent variables associated with MEE, while age, gender, BSA and TAPSE were the independent variables associated with MEEi. CONCLUSIONS The knowledge of age- and gender-based MEE and MEEi normal values may improve the global assessment of LV cardiac mechanics and serve as a reference to identify phenotypes at high risk of cardiovascular events.
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Affiliation(s)
- Francesco Ferrara
- Heart Department, University Hospital of Salerno, 84131 Salerno, Italy;
| | - Valentina Capone
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, 80131 Naples, Italy; (B.T.); (R.I.)
| | - Filippo Cademartiri
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, 56124 Pisa, Italy;
| | - Olga Vriz
- Echocardiography Department, Heart Centre, King Faisal Specialist Hospital & Research Centre, Riyadh 11211, Saudi Arabia;
| | - Rosangela Cocchia
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
| | - Brigida Ranieri
- IRCCS SYNLAB SDN, Via Emanuele Gianturco, 113-80143 Naples, Italy; (B.R.); (M.F.); (R.C.); (A.S.)
| | - Monica Franzese
- IRCCS SYNLAB SDN, Via Emanuele Gianturco, 113-80143 Naples, Italy; (B.R.); (M.F.); (R.C.); (A.S.)
| | - Rossana Castaldo
- IRCCS SYNLAB SDN, Via Emanuele Gianturco, 113-80143 Naples, Italy; (B.R.); (M.F.); (R.C.); (A.S.)
| | - Antonello D’Andrea
- Department of Cardiology and Intensive Coronary Unit, “Umberto I” Hospital, 84014 Nocera Inferiore, Italy;
| | - Rodolfo Citro
- Heart Department, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, 84125 Salerno, Italy;
| | - Salvatore Chianese
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
| | - Roberto Annunziata
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
| | - Flavio Marullo
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
| | - Mario Siniscalchi
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
| | - Marianna Conte
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
| | - Chiara Sepe
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
| | - Renato Maramaldi
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
| | - Salvatore Rega
- Department of Translational Medical Sciences, Federico II University, 80131 Naples, Italy;
| | - Giuseppe Russo
- Health Management Office, Antonio Cardarelli Hospital, 80131 Naples, Italy; (G.R.); (M.M.); (E.R.)
| | - Massimo Majolo
- Health Management Office, Antonio Cardarelli Hospital, 80131 Naples, Italy; (G.R.); (M.M.); (E.R.)
| | - Eliana Raiola
- Health Management Office, Antonio Cardarelli Hospital, 80131 Naples, Italy; (G.R.); (M.M.); (E.R.)
| | - Andrea Salzano
- IRCCS SYNLAB SDN, Via Emanuele Gianturco, 113-80143 Naples, Italy; (B.R.); (M.F.); (R.C.); (A.S.)
| | - Ciro Mauro
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, 80131 Naples, Italy; (B.T.); (R.I.)
| | - Raffaele Izzo
- Department of Advanced Biomedical Sciences, “Federico II” University of Naples, 80131 Naples, Italy; (B.T.); (R.I.)
| | - Eduardo Bossone
- Division of Cardiology, A Cardarelli Hospital, 80131 Naples, Italy; (V.C.); (R.C.); (S.C.); (R.A.); (F.M.); (M.S.); (M.C.); (C.S.); (R.M.); (C.M.)
- Correspondence:
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Reference Ranges of Left Ventricular Hemodynamic Forces in Healthy Adults: A Speckle-Tracking Echocardiographic Study. J Clin Med 2021; 10:jcm10245937. [PMID: 34945231 PMCID: PMC8707005 DOI: 10.3390/jcm10245937] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 01/28/2023] Open
Abstract
Background: The normal limits of left ventricular (LV) hemodynamic forces (HDFs) are not exactly known. The aim of this study was to explore the full spectrum of HDF parameters in healthy subjects and determine their physiologic correlates. Methods: 269 healthy subjects were enrolled (mean age: 43 ± 14 years; 123 (45.7%) men). All participants underwent an echo-Doppler examination. Tri-plane tissue tracking from apical views was used to measure 2D global endocardial longitudinal strain (GLS), circumferential strain (GCS), and LV HDFs. HDFs were normalized with LV volume and divided by specific weight. Results: LV systolic longitudinal HDFs (%) were higher in men (20.8 ± 6.5 vs. 18.9 ± 5.6, p = 0.009; 22.0 ± 6.7 vs. 19.8 ± 5.6, p = 0.004, respectively). There was a significant correlation between GCS (increased) (r = −0.240, p < 0.001) and LV longitudinal HDFs (reduced) (r = −0.155, p = 0.01) with age. In a multivariable analysis age, BSA, pulse pressure, heart rate and GCS were the only independent variables associated with LV HDFs (β coefficient = −0.232, p < 0.001; 0.149, p = 0.003; 0.186, p < 0.001; 0.396, p < 0.001; −0.328, p < 0.001; respectively). Conclusion: We report on the physiologic range of LV HDFs. Knowledge of reference values of HDFs may prompt their implementation into clinical routine and allow a more comprehensive assessment of the LV function.
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Ferrara F, Gargani L, Naeije R, Rudski L, Armstrong WF, Wierzbowska-Drabik K, Argiento P, Bandera F, Cademartiri F, Citro R, Cittadini A, Cocchia R, Contaldi C, D'Alto M, D'Andrea A, Grünig E, Guazzi M, Kolias TJ, Limongelli G, Marra AM, Mauro C, Moreo A, Ranieri B, Saggar R, Salzano A, Stanziola AA, Vriz O, Vannan M, Kasprzak JD, Bossone E. Feasibility of semi-recumbent bicycle exercise Doppler echocardiography for the evaluation of the right heart and pulmonary circulation unit in different clinical conditions: the RIGHT heart international NETwork (RIGHT-NET). Int J Cardiovasc Imaging 2021; 37:2151-2167. [PMID: 33866467 DOI: 10.1007/s10554-021-02243-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/09/2021] [Indexed: 11/29/2022]
Abstract
Exercise Doppler echocardiography (EDE) is a well-validated tool in ischemic and valvular heart diseases. However, its use in the assessment of the right heart and pulmonary circulation unit (RH-PCU) is limited. The aim of this study is to assess the semi-recumbent bicycle EDE feasibility for the evaluation of RH-PCU in a large multi-center population, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension (PH). From January 2019 to July 2019, 954 subjects [mean age 54.2 ± 16.4 years, range 16-96, 430 women] underwent standardized semi-recumbent bicycle EDE with an incremental workload of 25 watts every 2 min, were prospectively enrolled among 7 centers participating to the RIGHT Heart International NETwork (RIGHT-NET). EDE parameters of right heart structure, function and pressures were obtained according to current recommendations. Right ventricular (RV) function at peak exercise was feasible in 903/940 (96%) by tricuspid annular plane systolic excursion (TAPSE), 667/751 (89%) by tissue Doppler-derived tricuspid lateral annular systolic velocity (S') and 445/672 (66.2%) by right ventricular fractional area change (RVFAC). RV-right atrial pressure gradient [RV-RA gradient = 4 × tricuspid regurgitation velocity2 (TRV)] was feasible in 894/954 patients (93.7%) at rest and in 816/954 (85.5%) at peak exercise. The feasibility rate in estimating pulmonary artery pressure improved to more than 95%, if both TRV and/or right ventricular outflow tract acceleration time (RVOT AcT) were considered. In high specialized echocardiography laboratories semi-recumbent bicycle EDE is a feasible tool for the assessment of the RH-PCU pressure and function.
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Affiliation(s)
- Francesco Ferrara
- Cardio-Thoracic-Vascular Department, University Hospital "San Giovanni Di Dio E Ruggi D'Aragona", Salerno, Italy
| | - Luna Gargani
- Institute of Clinical Physiology - C.N.R, Pisa, Italy
| | | | - Lawrence Rudski
- Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - William F Armstrong
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | | | - Paola Argiento
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Bandera
- Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato University Hospital, Milan, Italy.,Department for Biomedical Sciences for Health, University of Milano, Milan, Italy
| | | | - Rodolfo Citro
- Cardio-Thoracic-Vascular Department, University Hospital "San Giovanni Di Dio E Ruggi D'Aragona", Salerno, Italy
| | - Antonio Cittadini
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | | | - Carla Contaldi
- Cardio-Thoracic-Vascular Department, University Hospital "San Giovanni Di Dio E Ruggi D'Aragona", Salerno, Italy
| | - Michele D'Alto
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonello D'Andrea
- Department of Cardiology, Umberto I Hospital Nocera Inferiore, Nocera Inferiore, Italy
| | - Ekkehard Grünig
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA.,Center of Pulmonary Hypertension, Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Marco Guazzi
- Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato University Hospital, Milan, Italy.,Department for Biomedical Sciences for Health, University of Milano, Milan, Italy
| | - Theodore John Kolias
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Giuseppe Limongelli
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alberto Maria Marra
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Ciro Mauro
- Cardiology Division, A Cardarelli Hospital, Naples, Italy
| | - Antonella Moreo
- A. De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Rajan Saggar
- Lung & Heart-Lung Transplant and Pulmonary Hypertension Programs, David Geffen School of Medicine, UCLA, Los Angeles, USA
| | - Andrea Salzano
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Anna Agnese Stanziola
- Department of Respiratory Diseases, Monaldi Hospital, University "Federico II", Naples, Italy
| | - Olga Vriz
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mani Vannan
- Piedmont Heart Institute, Marcus Heart Valve Center, Atlanta, USA
| | - Jaroslaw D Kasprzak
- I Department and Chair of Cardiology, Bieganski Hospital, Medical University of Lodz, Lodz, Poland
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Mavrogeni SI, Buch M, Markousis-Mavrogenis G, Dumitru B, Pugliese NR, Gargani L. The perpetual sword of Damocles: Cardiac involvement in systemic sclerosis and the role of non-invasive imaging modalities in medical decision making. Eur J Rheumatol 2020; 7:S203-S211. [PMID: 32697932 DOI: 10.5152/eurjrheum.2020.19110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/15/2020] [Indexed: 12/23/2022] Open
Abstract
Cardiac involvement in systemic sclerosis (SSc-CI) may be either primary or secondary to pathologic processes in other organs. In contrast to other autoimmune rheumatic diseases, primary SSc-CI preferentially manifests as non-ischemic myocardial fibrosis, with or without myocardial inflammation and minimal involvement of epicardial coronary arteries. Recent developments in cardiovascular (CV) imaging modalities and their increasing availability necessitate the creation of concrete recommendations for use in SSc patients, based on the most recent scientific evidence. Echocardiography offers rapid, effective, multiparametric, and widely available imaging evaluation of SSc patients, owing to its ability to analyze both left and right chambers, as well as pulmonary hemodynamics. However, it is an operator- and acoustic window-dependent modality that cannot perform tissue characterization, which is crucial in these conditions. CV magnetic resonance in SSc patients can accurately evaluate biventricular volumes, ejection fractions, myocardial fibrosis load, and changes suggestive of myocarditis. T2 mapping is the best index of edema indicating acute myocardial inflammation, while late gadolinium enhancement is an index of replacement fibrosis. Extracellular volume fraction (ECV) is an indicator of diffuse myocardial fibrosis only in the absence of significant myocardial inflammation. However, if myocardial inflammation/fibrosis coexist, ECV reflects a combination of the two, but it cannot completely discriminate between them. SSc-CI hangs like the sword of Damocles over physicians managing SSc patients. A constructive partnership between the rheumatologist and the cardiologist is necessary to provide each SSc patient with a comprehensive screening protocol for early detection and treatment of cardiopulmonary pathologic processes.
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Affiliation(s)
| | - Maya Buch
- Division of Rheumatic and Musculoskeletal Medicine, Institute of Rheumatic and Musculoskeletal Medicine, Leeds Institute of Molecular Medicine (LIMM), Section of Clinical Musculoskeletal Disease, Leeds, UK
| | | | - Bianca Dumitru
- Division of Rheumatic and Musculoskeletal Medicine, Institute of Rheumatic and Musculoskeletal Medicine, Leeds Institute of Molecular Medicine (LIMM), Section of Clinical Musculoskeletal Disease, Leeds, UK
| | - Nicola Riccardo Pugliese
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
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Zhou X, Ferrara F, Contaldi C, Bossone E. Right Ventricular Size and Function in Chronic Heart Failure. Heart Fail Clin 2019; 15:205-217. [DOI: 10.1016/j.hfc.2018.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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8
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Ferrara F, Zhou X, Gargani L, Wierzbowska-Drabik K, Vriz O, Fadel BM, Stanziola AA, Kasprzak J, Vannan M, Bossone E. Echocardiography in Pulmonary Arterial Hypertension. Curr Cardiol Rep 2019; 21:22. [DOI: 10.1007/s11886-019-1109-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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