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Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024:ehae177. [PMID: 39210710 DOI: 10.1093/eurheartj/ehae177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Vervoort D, Sud M, Zeis TM, Haouzi AA, An KR, Rocha R, Eikelboom R, Fremes SE, Tamis-Holland JE. Do the Few Dictate Care for the Many? Revascularisation Considerations That Go Beyond the Guidelines. Can J Cardiol 2024; 40:275-289. [PMID: 38181974 DOI: 10.1016/j.cjca.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 01/07/2024] Open
Abstract
The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient's preferences and values, and the treating team's expertise. The recent American guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.
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Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Maneesh Sud
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Tessa M Zeis
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alice A Haouzi
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Eikelboom
- Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Barac YD, Witberg G, Assali A, Klempfner R, Krutzwald-Josefson E, Rubchevsky V, Abergel E, Kornowski R, Aravot D. The Clinical SYNTAX score predicts survival better than the SYNTAX score in coronary revascularization. J Thorac Cardiovasc Surg 2024; 167:164-173.e4. [PMID: 35331554 DOI: 10.1016/j.jtcvs.2022.02.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 01/30/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) trial showed that the SYNTAX score (SS) is a useful tool for customizing revascularization treatment for patients with multivessel coronary disease. In the past decade, the Clinical SS (CSS) has emerged as a comprehensive tool. This novel tool considers the SS as well as patient clinical parameters such as age, creatinine clearance, and ejection fraction, which were shown to be relevant for patient prognosis. Thus, in the current work we set out to compare the survival predictive values of the SS versus the CSS and their future application in real-world implementation of the revascularization guidelines. METHODS This study was a subanalysis of data collected in a prospective national registry in Israel that enrolled consecutive patients with left main and/or 2- to 3-vessel coronary artery disease involving the proximal or mid-left anterior descending artery; the MULTI-vessel Coronary Artery Disease (MULTICAD). The revascularization method was chosen by the physicians taking care of the patients at each hospital and the patients were followed for 5 years. Patients were categorized according to their SS, the CSS, and their revascularization method (primary coronary intervention [PCI] vs coronary artery bypass grafting [CABG]) and patient survival were compared. RESULTS A total of 585 patients were enrolled in the study and were followed for 5 years. The median CSS was 27, with 288 patients showing a CSS ≥27, with a mean CSS of 47.85 and a mean SS of 29.05. At 3 and 5 years post-treatment, the CSS ≥27 group had a lower survival probability, CSS ≥27 was associated with a lower survival probability among patients who underwent PCI compared with those who underwent CABG. More specifically, the high-CSS CABG group had a 5-year mortality rate of 16.8%, whereas the high-CSS PCI group had a 5-year mortality rate of 32.2%. In a comparison of SS with CSS for the 5-year mortality outcome prediction, CSS was superior to SS with a higher area under the curve. CONCLUSIONS This prospective registry of real-world revascularization strategies in patients with multivessel disease showed that CSS is a better predictive tool of postrevascularization survival than SS. Moreover, it showed that surgical revascularization in patients with CSS ≥27 is associated with better all-cause mortality outcome after CABG as compared with after PCI. This attests to the need for a score that considers clinical parameters in a real-world scenario.
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Affiliation(s)
- Yaron D Barac
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Rabin Medical Center, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Guy Witberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Abid Assali
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Cardiology, Meir Medical Center, Cefar Sava, Israel
| | - Robert Klempfner
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Leviev Heart Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Efrat Krutzwald-Josefson
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Rabin Medical Center, Petach-Tikva, Israel
| | - Victor Rubchevsky
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Rabin Medical Center, Petach-Tikva, Israel
| | - Eytan Abergel
- Division of Cardiology, Rambam Medical Center, Haifa, Israel
| | - Ran Kornowski
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Division of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
| | - Dan Aravot
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Rabin Medical Center, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Lee C, Tully A, Fang JC, Sugeng L, Elmariah S, Grubb KJ, Young MN. Building and Optimizing the Interdisciplinary Heart Team. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101067. [PMID: 39129880 PMCID: PMC11308725 DOI: 10.1016/j.jscai.2023.101067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/16/2023] [Accepted: 06/22/2023] [Indexed: 08/13/2024]
Abstract
A multidisciplinary care team model, or Heart Team approach, has become a central tenet of cardiovascular care. Though initially applied to the management of heart transplantation and subsequently complex coronary artery disease, the Heart Team is now utilized broadly across cardiovascular medicine, including in the treatment of valvular disease, pulmonary embolism, cardiogenic shock, high-risk pregnancies in patients with pre-existing cardiovascular disease, and adult congenital heart disease. The Heart Team model improves interdisciplinary collaboration among specialties, adherence to societal guidelines, and shared decision-making with patients and families. In this review, we highlight the development and rationale supporting the Heart Team model, address the challenges of implementing a multidisciplinary care team, and discuss the optimal methods to continue to build, optimize, and implement this approach.
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Affiliation(s)
- Christopher Lee
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Andrew Tully
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - James C. Fang
- Division of Cardiology, University of Utah Health, Salt Lake City, Utah
| | - Lissa Sugeng
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Sammy Elmariah
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Kendra J. Grubb
- Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Michael N. Young
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Ma H, Lin S, Li X, Wang Y, Xu B, Zheng Z. Effect of a standardised heart team protocol versus a guideline-based protocol on revascularisation decision stability in stable complex coronary artery disease: rationale and design of a randomised trial of cardiology specialists using historic cases. BMJ Open 2022; 12:e064761. [PMID: 36456006 PMCID: PMC9716884 DOI: 10.1136/bmjopen-2022-064761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION A multidisciplinary heart team approach has been recommended by revascularisation guidelines, but how to organise and implement the heart team in a standardised way has not been validated. Inter-team and intra-team decision instability existed in the guideline-based heart team protocol, and our standardised heart team protocol based on a mixed method study may improve decision stability. The objective of this study is to evaluate the effect of the standardised heart team protocol versus the guideline-based protocol on decision-making stability in stable complex coronary artery disease (CAD). METHODS AND ANALYSIS Eighty-four eligible interventional cardiologists, cardiac surgeons or non-interventional cardiologists from 26 hospitals in China have been enrolled. They will be randomised to a standardised heart team protocol group or a guideline-based protocol group to make revascularisation decisions for 480 historic cases (from a prospective registry) with stable complex CAD. In the standardised group, we will establish 12 heart teams based on an evidence-based protocol, including specialist selection, specialist training, team composition, team training and a standardised meeting process. In the guideline-based group, we will organise 12 heart teams according to the guideline principles, including team composition and standardised meeting process. The primary outcome is the overall percent agreement in revascularisation decisions between heart teams within a group. To demonstrate the clinical implication of decision-making stability, we will further explore the association between decision stability and 1-year clinical outcomes. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board (IRB) of Fuwai Hospital (No. 2019-1303). All participants have provided informed consent and all patients included as historic cases provided written informed consent at the time of entry to the prospective registry. The results of this trial will be disseminated through manuscript publication and national/international conferences, and reported in the trial registry entry. TRIAL REGISTRATION NUMBER NCT05039567.
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Affiliation(s)
- Hanping Ma
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shen Lin
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Central China Sub-center of the National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
| | - Yang Wang
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Bo Xu
- Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- National Health Commission Key Laboratory of Cardiovascular Regenerative Medicine, Fuwai Central-China Hospital, Central-China Branch of National Center for Cardiovascular Diseases, Zhengzhou, People's Republic of China
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Witberg G, Landes U, Codner P, Barbanti M, Valvo R, De Backer O, Ooms JF, McInerney A, Masiero G, Werner P, Armario X, Fiorina C, Arzamendi D, Santos-Martinez S, Baz JA, Steblovnik K, Mauri V, Adam M, Merdler I, Hein M, Ruile P, Russo M, Musumeci F, Sedaghat A, Sugiura A, Grasso C, Branca L, Estévez-Loureiro R, Amat-Santos IJ, Mylotte D, Andreas M, Bunc M, Tarantini G, Nombela-Franco L, Søndergaard L, Van Mieghem NM, Finkelstein A, Kornowski R. Clinical outcomes of transcatheter aortic valve implantation in patients younger than 70 years rejected for surgery: the AMTRAC registry. EUROINTERVENTION 2022; 17:1289-1297. [PMID: 34673502 PMCID: PMC9743236 DOI: 10.4244/eij-d-21-00613] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The mean age of transcatheter aortic valve implantation (TAVI) patients is steadily decreasing. AIMS The aim of the study was to describe the characteristics, the indications for and the outcomes of TAVI in patients <70 years old. METHODS All patients undergoing TAVI (n=8,626) from the 18 participating centres between January 2007 and June 2020 were stratified by age (</>70). For patients <70, the indications for TAVI were extracted from Heart Team discussions and the baseline characteristics and mortality were compared between the two groups. RESULTS Overall, 640 (7.4%) patients were <70 (9.1% during 2018-2020, p<0.001); the mean age was 65.0±2.3 years. The younger patients were more often male, with bicuspid valves or needing valve-in-valve procedures. They had a higher prevalence of lung disease and diabetes. In 80.7% of cases, the Heart Team estimated an increased surgical risk and TAVI was selected, reflected by an STS score >4% in 20.4%. Five-year mortality was similar (29.4 vs 29.8%, HR 0.95, p=0.432) in the <70 and >70 groups. In the <70 group, mortality was higher for those referred for TAVI due to an increased surgical risk compared to those referred for other reasons (31.6 vs 24.5%, HR 1.23, p=0.021). Mortality was similar regardless of the STS stratum in patients judged by the Heart Team to be at increased surgical risk (32.6 vs 30.4%, HR 0.98, p=0.715). CONCLUSIONS Use of TAVI in patients <70 is becoming more frequent. The main reason for choosing TAVI is due to an increased surgical risk not adequately represented by the STS score. The outcomes for these patients are similar to those for older TAVI patients. Dedicated trials of TAVI/SAVR in younger patients are needed to guide decisions concerning expansion of TAVI indications. ((ClinicalTrials.gov: NCT04031274).
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Affiliation(s)
- Guy Witberg
- Division of Cardiology, Rabin Medical Centre, Petah-Tikva, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Landes
- Division of Cardiology, Rabin Medical Centre, Petah-Tikva, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pablo Codner
- Division of Cardiology, Rabin Medical Centre, Petah-Tikva, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marco Barbanti
- Division of Cardiology, University of Catania, Catania, Italy
| | - Roberto Valvo
- Division of Cardiology, University of Catania, Catania, Italy
| | - Ole De Backer
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joris F Ooms
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Angela McInerney
- Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Paul Werner
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Xavier Armario
- Department of Cardiology, University Hospital Galway, National University of Ireland, Galway, Ireland
| | | | - Dabit Arzamendi
- Hospital de Sant Creu i Sant Pau Barcelona, Barcelona, Spain
| | | | - Jose A Baz
- Servicio de Cardiología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Klemen Steblovnik
- Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| | - Victor Mauri
- Department of Cardiology, Heart Centre, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Matti Adam
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ilan Merdler
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Manuel Hein
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Philipp Ruile
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | | | | | | | | | - Carmelo Grasso
- Division of Cardiology, University of Catania, Catania, Italy
| | - Luca Branca
- Cardiovascular Department, Spedali Civili, Brescia, Italy
| | | | | | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Martin Andreas
- Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Matjaž Bunc
- Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Lars Søndergaard
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ariel Finkelstein
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ran Kornowski
- Division of Cardiology, Rabin Medical Centre, Petah-Tikva, Israel.,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kuno T, Ikemura N, Kohsaka S. Letter by Kuno et al Regarding Article, "Heart Team/Guidelines Discordance Is Associated With Increased Mortality: Data From a National Survey of Revascularization in Patients With Complex Coronary Artery Disease". Circ Cardiovasc Interv 2021; 14:e010649. [PMID: 34148376 DOI: 10.1161/circinterventions.121.010649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY (T.K.)
| | - Nobuhiro Ikemura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (N.I., S.K.)
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (N.I., S.K.)
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