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Chemtob RA, Rajeswaran J, Kalahasti V, Griffin BP, Desai MY, Kapadia SR, Blackstone EH, Karamlou T, Svensson LG. Early and late experience of the modified aortic reimplantation operation. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00709-8. [PMID: 39181443 DOI: 10.1016/j.jtcvs.2024.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 08/12/2024] [Accepted: 08/14/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVE Valve-sparing aortic root replacement for proximal aortic dilation with aortic regurgitation is associated with excellent outcomes. Modified aortic reimplantation entails reducing the anulus size to the expected size for sex and body surface area and creating neosinuses to preserve the aortic valve. We present our mid- and late-term outcomes with the modified technique, including a single-surgeon's experience over the past 2 decades. METHODS From January 2002 to January 2024, 528 patients underwent modified aortic reimplantation for aortic aneurysm or dilation; 491 were included in this study. End points included time-related mortality and postoperative morbidities, including aortic valve reintervention and longitudinal aortic regurgitation grade. RESULTS There were no operative deaths. Survival at 30 days, 1 year, and 15 years were 100%, 99.6%, and 87%, respectively. Postoperative stroke occurred in 4 patients (0.81%) and reoperation for bleeding in 7 (1.4%). Moderate or severe aortic valve regurgitation was seen in 6.2% and 10% of patients at 1 and 10 years, respectively. Aortic valve mean gradients were 7.0 and 7.5 mm Hg at 1 and 10 years, respectively. Freedom from reintervention on the aortic valve was 99.9%, 99%, and 95% at 30 days, 1 year, and 15 years, respectively. CONCLUSIONS Modified aortic reimplantation technique is a reliable and reproducible technique with excellent mid- and long-term outcomes in survival and freedom from reintervention. The results advocate for modified reimplantation in patients with enlarged aortic roots, especially in younger patients with connective tissue disorder.
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Affiliation(s)
- Raphaelle A Chemtob
- Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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2
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Coselli JS, Volguina IV, Nguyen L, Green SY, LeMaire SA, Moon MR. Outcomes of aortic root replacement in patients with Marfan syndrome: the role of valve-sparing and valve-replacing approaches. Ann Cardiothorac Surg 2023; 12:338-349. [PMID: 37554715 PMCID: PMC10405346 DOI: 10.21037/acs-2023-avs2-0085] [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: 06/13/2023] [Accepted: 06/29/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Marfan syndrome (MFS) is a heritable thoracic aortic disease with pervasive cardiovascular effects, including commonly, a dilated aortic root. Traditionally, the root is replaced using a mechanical composite valve graft (CVG); however, this valve-replacing (VR) approach necessitates a lifelong regimen of anticoagulation with a potential for late bleeding complications. In time, valve-sparing (VS) approaches were developed. Today, several options for aortic root replacement (ARR) exist; each has advantages and disadvantages that helps inform choice. The Aortic Valve Operative Outcomes in Marfan Patients (AVOMP) is a multi-center international registry to analyze clinical outcomes of ARR in MFS patients using either VR or VS techniques to better elucidate choice. We summarize outcomes of AVOMP and present our own experience. METHODS We performed 223 consecutive elective ARR [1991-2023] in patients with MFS; 15 such repairs were included in AVOMP. Repairs included 113 (51%) using a mechanical CVG, 62 (28%) using a VS approach, and 48 (22%) using a bioprosthetic root. Many patients underwent aortic arch repair (30% to 54% by type). RESULTS The median patient age was 38 [29-52] years. In comparing VS and VR groups, patients were similar in age and rates of major comorbidities and symptoms. Patients with VR repair had a more complex aortic history. The rate of redo sternotomy was 24% (n=54). Operative death was uncommon [4% overall (10/223); ranging from 2% to 8% by type], and stroke was rare [1/223 (<1%)]. Late survival and reoperation differed by operative approach; survival was improved in patients who underwent VS repair. CONCLUSIONS We found that repair in patients with MFS undergoing ARR resulted in low operative risk. Our late results were similar to those of AVOMP in that patients undergoing VS repair tended to experience greater rates of valvular-structural deterioration, although this did not appear to impact survival.
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Affiliation(s)
- Joseph S. Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
- CHI St Luke’s Health—Baylor St Luke’s Medical Center, Houston, TX, USA
| | - Irina V. Volguina
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Lynna Nguyen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Susan Y. Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Scott A. LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
- CHI St Luke’s Health—Baylor St Luke’s Medical Center, Houston, TX, USA
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Marc R. Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
- CHI St Luke’s Health—Baylor St Luke’s Medical Center, Houston, TX, USA
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Svensson LG, Rosinski BF, Tucker NJ, Gillinov AM, Rajeswaran J, Roselli EE, Johnston DR, Desai MY, Griffin BP, Blackstone EH. Comparison of Outcomes of Patients Undergoing Reimplantation versus Bentall Root Procedure. AORTA 2022; 10:57-68. [PMID: 35933986 PMCID: PMC9357471 DOI: 10.1055/s-0042-1744135] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background
A bioprosthesis- or mechanical-prosthesis–containing polyester graft (composite graft) is standard surgical management for aortic root aneurysms (Bentall procedure), but particularly in the young patient in whom a bioprosthesis is likely to deteriorate and a mechanical prosthesis mandates life-long anticoagulation, valve-sparing procedures have been devised. One such procedure involves reimplantation of the native aortic valve in the polyester graft. With focus on selecting the optimum procedure for young relatively asymptomatic patients, we compared outcomes of reimplantation of the aortic valve versus the Bentall procedure and identified factors influencing outcomes.
Methods
From January 2000 to January 2017, 643 adults age ≤ 70 with tricuspid aortic valves underwent elective aortic root replacement with either reimplantation (
n
= 448/70%) or a composite valve graft (Bentall) procedure (
n
= 195/30%). Outcomes were compared in 100 propensity-matched pairs.
Results
Patients with fewer symptoms, less aortic regurgitation (AR), higher left ventricular ejection fraction, and smaller cross-sectional aortic area/height ratio had a higher likelihood of valve repair with reimplantation (all
p
< 0.02) versus receiving a Bentall procedure. Operative mortality was 0.16% (reimplantation, 1/448, 0.22%; Bentall 0/195, 0%). After reimplantation, 8-year freedom from severe AR was 95% and 10-year freedom from reintervention was 98%. Ten-year survival was 95%. Higher preoperative AR grade (
p
< 0.0001) but not larger root diameter (
p
= 0.3) was associated with higher grade of late regurgitation after a reimplantation procedure. Among propensity-matched patients, reimplantation compared with a Bentall was associated with similar 10-year survival (89% vs. 94%), but more late AR (8-year freedom from severe AR: 93% vs. 99.9%) and greater early reduction in, but similar late, left ventricular mass (104 vs. 105 g•m
–2
at 8 years).
Conclusion
Excellent aortic valve reimplantation results versus Bentall lead us to recommend reimplantation more often in patients who present with even moderately severe or severe AR and significantly enlarged aortic roots.
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Affiliation(s)
- Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brad F. Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas J. Tucker
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A. Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y. Desai
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian P. Griffin
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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Cekmecelioglu D, Preventza O, Dougherty KG, Chatterjee S, Green SY, Silva GV, Díez JG, Coselli JS. Transcatheter valve-in-valve implantation for degenerated stentless aortic bioroots. Ann Cardiothorac Surg 2021; 10:641-650. [PMID: 34733691 DOI: 10.21037/acs-2021-tviv-124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/29/2021] [Indexed: 11/06/2022]
Abstract
Background Open surgical repair of a failed valve-sparing aortic root replacement (VSARR) or stentless bioroot aortic root replacement (bio-ARR) entails significant operative risks. Whether valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is feasible in patients with a previous VSARR or stentless bio-ARR remains unclear, given lingering concerns about the ill-defined aortic annulus in these patients and the potential for coronary obstruction. We present our experience with patients who had a previous VSARR or stentless bio-ARR and underwent ViV-TAVR to repair a degenerated aortic valve with combined valvular disease, aortic insufficiency and aortic stenosis. Methods In this retrospective data review, we identified and analyzed consecutive patients with a previous VSARR or stentless bio-ARR who underwent ViV-TAVR between December 1, 2014 and August 31, 2019. Results ViV-TAVR was performed in twelve high-risk patients with previous VSARR or bio-ARR during the study period. Of these, seven received Medtronic Freestyle porcine stentless bioprosthetic aortic roots, three received homograft aortic roots, one underwent a Ross procedure and one underwent VSARR. ViV-TAVR restored satisfactory valve function in all patients, and technical success was 100%. No patient had more than mild regurgitation after implantation. No thirty-day mortality was seen. One patient had major bleeding after transapical access, one patient had a transient ischemic stroke, and one patient needed permanent pacemaker implantation. At a median last follow-up of 21.5 months (interquartile range, 9.0-69.0 months), all patients remained alive and had satisfactory valve function. Conclusions In this study, ViV-TAVR was a clinically effective option for treating patients with a failed stentless bio-ARR or previous VSARR. Short-term and intermediate-term results after these procedures were favorable. These findings may have important implications for treating high-risk patients with structural aortic root deterioration and call for better transcatheter heart valves that are suitable for treating aortic insufficiency.
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Affiliation(s)
- Davut Cekmecelioglu
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute and CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute and CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA
| | - Kathryn G Dougherty
- Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute and CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute and CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA.,Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Texas, USA
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Guilherme V Silva
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jose G Díez
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiology, Texas Heart Institute, Houston Texas, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute and CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas, USA
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5
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Kremer J, Farag M, Zaradzki M, Szabó G, Ruhparwar A, Kallenbach K, Karck M, Arif R. The reimplantation valve-sparing aortic root replacement technique for patients with Marfan syndrome: A single-center experience. Sci Rep 2019; 9:12021. [PMID: 31427685 PMCID: PMC6700152 DOI: 10.1038/s41598-019-48572-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/07/2019] [Indexed: 01/26/2023] Open
Abstract
Valve-sparing aortic root replacement (VSARR) through reimplantation technique is widely regarded as optimal surgical approach for Marfan syndrome (MFS) patients. Perioperative and long-term data from all MFS patients undergoing VSARR using David's technique at our center from 2007-2018 were analyzed. We included 56 patients with a mean age of 32.3 ± 12.3 years. Logistic EuroSCORE was 7.96 ± 5.2. Among others concomitant surgical procedures included aortic arch surgery (8.9%), mitral valve repair (23.2%) and replacement (1.7%). There were no operative deaths, nor in-hospital-mortality. One patient underwent re-exploration for bleeding, dialysis and pacemaker implantation was required in one case each. There was no occurrence of low-output syndrome nor neurological complications. Significant gender differences were not found, except for intraoperative blood transfusion occurring significantly more often in the female gender (p = 0.009). Despite significantly longer procedural times, concomitant surgery did not negatively impact overall outcome. Freedom of reoperation of the aortic root was 100% at 1 year, 97.7% at 8 years. Until last follow-up (61 ± 38 month) all patients survived, with no evidence of endocarditis. We emphasize once more that VSARR using David's procedure is a safe method for MFS patients with excellent long-term results even if concomitant procedures are performed.
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Affiliation(s)
- Jamila Kremer
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Mina Farag
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Marcin Zaradzki
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Gabor Szabó
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Klaus Kallenbach
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany.,INCCI HaerzZenter, Department of Cardiac Surgery, Luxembourg City, Luxembourg
| | - Matthias Karck
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Rawa Arif
- Marfan Center University Hospital Heidelberg, Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany.
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6
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Di Bacco L, Glauber M, Miceli A. Commentary: Valve sparing in aortic root aneurysms-An old promise or a concrete chance? J Thorac Cardiovasc Surg 2019; 158:1514-1515. [PMID: 31005307 DOI: 10.1016/j.jtcvs.2019.03.015] [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] [Received: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Lorenzo Di Bacco
- Department of Minimally Invasive Cardiac Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Mattia Glauber
- Department of Minimally Invasive Cardiac Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Antonio Miceli
- Department of Minimally Invasive Cardiac Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy.
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