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Feroze R, Kang P, Dallan LAP, Akula N, Galo J, Yoon SH, Ukaigwe A, Filby SJ, Baeza C, Pelletier M, Rushing G, Rajagopalan S, Al-Kindi S, Rashid I, Attizzani GF. Elevated myocardial extracellular volume fraction is associated with the development of conduction pathway defects following transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2024. [PMID: 38952304 DOI: 10.1002/ccd.31136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 05/27/2024] [Accepted: 06/16/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has become an established method of aortic stenosis treatment but suffers from the risk of heart block and pacemaker requirement. Risk stratification for patients who may develop heart block remains imperfect. Simultaneously, myocardial fibrosis as measured by cardiac magnetic resonance imaging (CMR) has been demonstrated as a prognostic indicator of ventricular recovery and mortality following TAVR. However, the association of CMR-based measures of myocardial fibrosis with post-TAVR conduction disturbances has not yet been explored. AIMS We evaluated whether myocardial fibrosis, as measured by late gadolinium enhancement and extracellular volume (ECV) from CMR would be associated with new conduction abnormalities following TAVR. METHODS One hundred seventy patients who underwent CMR within 2 months before TAVR were retrospectively reviewed. Septal late gadolinium enhancement (LGE) and ECV measurements were made as surrogates for replacement and interstitial fibrosis respectively. New conduction abnormalities were defined by the presence of transient or permanent atrioventricular block, new bundle branch blocks, and need for permanent pacemaker. Association of myocardial fibrosis and new conduction derangements were tested using receiver operator curve (ROC) and regression analysis in patients with and without pre-existing conduction issues. RESULTS Forty-six (27.1%) patients developed post-TAVR conduction deficits. ECV was significantly higher among patients who experienced new conduction defects (26.2 ± 3.45% vs. 24.7% ± 4.15%, p value: 0.020). A greater fraction of patients that had new conduction defects had an elevated ECV of ≥26% (54.3% vs. 36.3%, p value: 0.026). ECV ≥ 26% was independently associated with the development of new conduction defects (odds ratio [OR]: 2.364, p value: 0.030). ROC analysis revealed a significant association of ECV with new conduction defects with an area under the receiver operating characteristic curve (AUC) of 0.632 (95% confidence interval: 0.555-0.705, p value: 0.005). The combination of prior right bundle branch block (RBBB) and ECV revealed a greater AUC of 0.779 (0.709-0.839, p value: <0.001) than RBBB alone (Delong p value: 0.049). No association of LGE/ECV with new conduction defects was observed among patients with pre-existing conduction disease. Among patients without baseline conduction disease, ECV was independently associated with the development of new conduction deficits (OR: 3.685, p value: 0.008). CONCLUSION The present study explored the association of myocardial fibrosis, as measured by LGE and ECV with conduction deficits post-TAVR. Our results demonstrate an association of ECV, and thereby interstitial myocardial fibrosis, with new conduction derangement post-TAVR and introduce ECV as a potentially new risk stratification tool to identify patients at higher risk for needing post-TAVR surveillance and/or permanent pacemaker.
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Affiliation(s)
- Rafey Feroze
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Puneet Kang
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luis Augusto Palma Dallan
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Navya Akula
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jason Galo
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sung-Han Yoon
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Anene Ukaigwe
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven J Filby
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Cristian Baeza
- Division of Cardiovascular Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Marc Pelletier
- Division of Cardiovascular Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Gregory Rushing
- Division of Cardiovascular Surgery, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sanjay Rajagopalan
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sadeer Al-Kindi
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Imran Rashid
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Guilherme F Attizzani
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Kato S, Misumi Y, Horita N, Yamamoto K, Utsunomiya D. Clinical Utility of Computed Tomography-Derived Myocardial Extracellular Volume Fraction: A Systematic Review and Meta-Analysis. JACC Cardiovasc Imaging 2024; 17:516-528. [PMID: 37999657 DOI: 10.1016/j.jcmg.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 09/06/2023] [Accepted: 10/16/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Computed tomography (CT)-derived extracellular volume fraction (ECV) is a noninvasive method to quantify myocardial fibrosis. Although studies suggest CT is a suitable measure of ECV, clinical use remains limited. OBJECTIVES A meta-analysis was performed to determine the clinical value of CT-derived ECV in cardiovascular diseases. METHODS Electronic database searches of PubMed, Web of Science Core Collection, Cochrane advanced search, and EMBASE were performed. The most pivotal analysis entailed the comparison of ECV ascertained through CT-ECV among the control, aortic stenosis, and cardiac amyloidosis cohorts. The diagnostic test accuracy for detecting cardiac amyloidosis was assessed using summary receiver-operating characteristics curve. RESULTS Pooled CT-derived ECV values were 28.5% (95% CI: 27.3%-29.7%) in the control, 31.9% (95% CI: 30.2%-33.8%) in the aortic stenosis, and 48.9% (95% CI: 44.5%-53.3%) in the cardiac amyloidosis group. ECV was significantly elevated in aortic stenosis (P = 0.002) (vs controls) but further elevated in cardiac amyloidosis (P < 0.001) (vs aortic stenosis). CT-derived ECV had a high diagnostic accuracy for cardiac amyloidosis, with sensitivity of 92.8% (95% CI: 86.7%-96.2%), specificity of 84.8% (95% CI: 68.6%-93.4%), and area under the summary receiver-operating characteristic curve of 0.94 (95% CI: 0.88-1.00). CONCLUSIONS This study is the first comprehensive systematic review and meta-analysis of CT-derived ECV evaluation in cardiac disease. The high diagnostic accuracy of CT-ECV suggests the usefulness of CT-ECV in the diagnosis of cardiac amyloidosis in preoperative CT planning for transcatheter aortic valve replacement.
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Affiliation(s)
- Shingo Kato
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Yuka Misumi
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Nobuyuki Horita
- Chemotherapy Center, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kouji Yamamoto
- Department of Biostatistics, Yokohama City University School of Medicine, Yokohama, Japan
| | - Daisuke Utsunomiya
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Pontone G, Maragna R. TAVI: What Happens Behind the Stage? JACC Cardiovasc Imaging 2024; 17:408-410. [PMID: 37943234 DOI: 10.1016/j.jcmg.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023]
Affiliation(s)
- Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
| | - Riccardo Maragna
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
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Cundari G, Galea N, Mergen V, Alkadhi H, Eberhard M. Myocardial extracellular volume quantification with computed tomography-current status and future outlook. Insights Imaging 2023; 14:156. [PMID: 37749293 PMCID: PMC10519917 DOI: 10.1186/s13244-023-01506-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/18/2023] [Indexed: 09/27/2023] Open
Abstract
Non-invasive quantification of the extracellular volume (ECV) is a method for the evaluation of focal and diffuse myocardial fibrosis, potentially obviating the need for invasive endomyocardial biopsy. While ECV quantification with cardiac magnetic resonance imaging (ECVMRI) is already an established method, ECV quantification with CT (ECVCT) is an attractive alternative to ECVMRI, similarly using the properties of extracellular contrast media for ECV calculation. In contrast to ECVMRI, ECVCT provides a more widely available, cheaper and faster tool for ECV quantification and allows for ECV calculation also in patients with contraindications for MRI. Many studies have already shown a high correlation between ECVCT and ECVMRI and accumulating evidence suggests a prognostic value of ECVCT quantification in various cardiovascular diseases. Adding a late enhancement scan (for dual energy acquisitions) or a non-enhanced and late enhancement scan (for single-energy acquisitions) to a conventional coronary CT angiography scan improves risk stratification, requiring only minor adaptations of the contrast media and data acquisition protocols and adding only little radiation dose to the entire scan.Critical relevance statementThis article summarizes the technical principles of myocardial extracellular volume (ECV) quantification with CT, reviews the literature comparing ECVCT with ECVMRI and histopathology, and reviews the prognostic value of myocardial ECV quantification for various cardiovascular disease.Key points• Non-invasive quantification of myocardial fibrosis can be performed with CT.• Myocardial ECV quantification with CT is an alternative in patients non-eligible for MRI.• Myocardial ECV quantification with CT strongly correlates with ECV quantification using MRI.• Myocardial ECV quantification provides incremental prognostic information for various pathologies affecting the heart (e.g., cardiac amyloidosis).
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Affiliation(s)
- Giulia Cundari
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Nicola Galea
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Victor Mergen
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Matthias Eberhard
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
- Radiology, Spital Interlaken, Spitäler FMI AG, Unterseen, Switzerland
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Ishiyama M, Kurita T, Takafuji M, Sato K, Sugiura E, Nakamori S, Fujimoto N, Kitagawa K, Sakuma H, Dohi K. The cardiac computed tomography-derived extracellular volume fraction predicts patient outcomes and left ventricular mass reductions after transcatheter aortic valve implantation for aortic stenosis. J Cardiol 2022; 81:476-484. [PMID: 36503064 DOI: 10.1016/j.jjcc.2022.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/23/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) improved outcome of patients with severe aortic valve stenosis (AS). Myocardial fibrosis is associated with AS-related pathological left ventricular (LV) remodeling and predicts cardiovascular mortality after TAVI. The present study aimed to investigate the impact of preoperative extracellular volume (ECV) assessed by computed tomography (CT) on left ventricular mass (LVM) regression and clinical outcomes in severe AS patients after TAVI. METHODS We examined 71 consecutive severe AS patients who underwent CT with ECV determination before TAVI. ECV was calculated as the ratio of the change in Hounsfield units in the myocardium and LV blood before and after contrast administration, multiplied by (1-hematocrit). Delayed scan was performed at 5 min after contrast injection. Echocardiography was performed before and 6 months after TAVI. The primary endpoint was heart failure (HF) hospitalization after TAVI. Patients were divided into two subgroups according to the median value of global ECV with 32 % (Low-ECV group: n = 35, and High-ECV group: n = 36). RESULTS No significant differences were observed in background characteristics between the 2 groups. However, the preoperative LV ejection fraction and LVM index were similar between the 2 groups, the Low-ECV group had greater LVM index reduction than the High-CV group after 6 months (p < 0.001). Kaplan-Meier curves demonstrated that the High-ECV group had significantly higher rate of HF hospitalization than the Low-ECV group (p = 0.016). In addition, multivariate analyses identified high global ECV as an independent predictor of HF hospitalization (HR 10.8, 95 % confidence interval 1.36 to 84.8, p = 0.024). CONCLUSION The low preoperative ECV assessed by CT is associated with the greater LVM regression, and predict better outcome in AS patients after TAVI.
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Affiliation(s)
- Masaki Ishiyama
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Tairo Kurita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Masafumi Takafuji
- Department of Radiology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kei Sato
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Emiyo Sugiura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Shiro Nakamori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Naoki Fujimoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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Relation of Serum Albumin Levels to Myocardial Extracellular Volume in Patients With Severe Aortic Stenosis. Am J Cardiol 2022; 163:71-76. [PMID: 34772478 DOI: 10.1016/j.amjcard.2021.09.044] [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: 08/25/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022]
Abstract
Severe aortic stenosis (AS) is often characterized by myocardial interstitial fibrosis. Myocardial interstitial fibrosis, classically measured by magnetic resonance imaging, was also shown to be accurately measured by computed tomography (CT)-derived extracellular volume fraction (ECVF). Serum albumin (SA) level (g/dl) has been shown to correlate with ECVF among patients with heart failure and preserved ejection fraction. Our objective was to evaluate the association between SA and ECVF among patients with severe symptomatic AS. Patients with symptomatic severe AS who were evaluated as candidates for intervention between 2016 and 2018 were enrolled prospectively. All patients underwent precontrast and postcontrast CT for estimating myocardial ECVF. Valid ambulatory SA within 6 weeks of the cardiac CT were obtained and classified as (tertiles) <3.8, 3.8 to 4.19, and ≥4.2 g/dl. Patients with acute systemic illness at the time of the albumin test were excluded. The study included 68 patients, mean age 81 ± 6 years, 53% women. Patients with lower SA were more likely to have chronic renal failure, previous percutaneous coronary interventions, and a reduced functional class. The mean ECVF (%) in the study cohort was 41 ± 12%, significantly higher among the patients in the lower SA level groups (50 ± 12% vs 38 ± 7% vs 33 ± 9% in the <3.8 g/dl, 3.8 to 4.19 g/dl and ≥4.2 g/dl groups respectively, p for trend <0.001). A statistically significant inverse correlation was found between SA levels and ECVF (r -0.7, p <0.001). Multivariable analysis showed significant independent association between low SA and ECVF. In conclusion, the SA level is inversely associated with CT-derived ECVF in patients with severe AS.
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Gonska B, Buckert D, Mörike J, Scharnbeck D, Kersten J, Cuspidi C, Rottbauer W, Tadic M. Imaging Challenges in Patients with Severe Aortic Stenosis and Heart Failure: Did We Find a Way Out of the Labyrinth? J Clin Med 2022; 11:jcm11020317. [PMID: 35054012 PMCID: PMC8777924 DOI: 10.3390/jcm11020317] [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: 11/30/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022] Open
Abstract
Aortic stenosis (AS) is the most frequent degenerative valvular disease in developed countries. Its incidence has been constantly rising due to population aging. The diagnosis of AS was considered straightforward for a very long time. High gradients and reduced aortic valve area were considered as "sine qua non" in diagnosis of AS until a growing body of evidence showed that patients with low gradients could also have severe AS with the same or even worse outcome. This completely changed the paradigm of AS diagnosis and involved large numbers of parameters that had never been used in the evaluation of AS severity. Low gradient AS patients may present with heart failure (HF) with preserved or reduced left ventricular ejection fraction (LVEF), associated with changes in cardiac output and flow across the aortic valve. These patients with low-flow low-gradient or paradoxical low-flow low-gradient AS are particularly challenging to diagnose, and cardiac output and flow across the aortic valve have become the most relevant parameters in evaluation of AS, besides gradients and aortic valve area. The introduction of other imaging modalities in the diagnosis of AS significantly improved our knowledge about cardiac mechanics, tissue characterization of myocardium, calcium and inflammation burden of the aortic valve, and their impact on severity, progression and prognosis of AS, not only in symptomatic but also in asymptomatic patients. However, a variety of novel parameters also brought uncertainty regarding the clinical relevance of these indices, as well as the necessity for their validation in everyday practice. The aim of this review is to summarize the prevalence of HF in patients with severe AS and elaborate on the diagnostic challenges and advantages of comprehensive multimodality cardiac imaging to identify the patients that may benefit from surgical or transcatheter aortic valve replacement, as well as parameters that may help during follow-up.
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Affiliation(s)
- Birgid Gonska
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Dominik Buckert
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Johannes Mörike
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Dominik Scharnbeck
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Johannes Kersten
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Cesare Cuspidi
- Department for Internal Medicine, University of Milan-Bicocca, 20126 Milan, Italy;
| | - Wolfang Rottbauer
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
| | - Marijana Tadic
- Klinik für Innere Medizin II, Universitätsklinikum Ulm, Albert-Einstein Allee 23, 89081 Ulm, Germany; (B.G.); (D.B.); (J.M.); (D.S.); (J.K.); (W.R.)
- Correspondence: ; Tel.: +49-176-3236-0011
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Sevilla T, Revilla-Orodea A, San Román JA. Timing of Intervention in Asymptomatic Patients with Aortic Stenosis. Eur Cardiol 2021; 16:e32. [PMID: 34603512 PMCID: PMC8477179 DOI: 10.15420/ecr.2021.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/25/2021] [Indexed: 11/23/2022] Open
Abstract
Aortic stenosis is a very common disease. Current guidelines recommend intervention mainly in symptomatic patients; aortic valve replacement can be considered in asymptomatic patients under specific conditions, but the evidence supporting these indications is poor. Continuous advances in both surgical and percutaneous techniques have substantially decreased rates of perioperative complications and mortality; with this in mind, many authors suggest that earlier intervention in patients with severe aortic stenosis, when they are still asymptomatic, may be indicated. This paper summarises what is known about the natural history of severe aortic stenosis and the scientific evidence available about the optimal timing for aortic valve replacement.
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Affiliation(s)
- Teresa Sevilla
- Department of Cardiology, Hospital Clínico Universitario de Valladolid Valladolid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Madrid, Spain
| | - Ana Revilla-Orodea
- Department of Cardiology, Hospital Clínico Universitario de Valladolid Valladolid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Madrid, Spain
| | - J Alberto San Román
- Department of Cardiology, Hospital Clínico Universitario de Valladolid Valladolid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Madrid, Spain
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