1
|
Dall'Ara G, Piciucchi S, Moretti C, Cavazza C, Compagnone M, Guerrieri G, Grotti S, Spartà D, Carletti R, Fabbri E, Giampalma E, Santarelli A, Ottani F, Balducelli M, Saia F, Tarantino FF, Galvani M. Aortic balloon valvuloplasty outcome according to calcium distribution and valve geometry - The ABCD study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00627-4. [PMID: 39164142 DOI: 10.1016/j.carrev.2024.08.004] [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: 05/16/2024] [Revised: 08/02/2024] [Accepted: 08/14/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND There is little data on the outcome of balloon aortic valvuloplasty (BAV) in relation to valve dimensions and calcification patterns. The procedure is not standardized, particularly the choice of balloon size. METHODS This retrospective multicenter study focused on BAV efficacy and safety by analyzing the relationship between balloon size, annulus geometry (i.e., diameters, perimeter, and area), and calcification patterns (total burden and calcium distribution over each individual leaflet). From March 2018 to March 2023, all consecutive patients who underwent clinically indicated BAV and ECG-gated multidetector computed tomography of the aorta were included, except those with a bicuspid valve. Calcium score was calculated on contrast-enhanced images based on a luminal attenuation threshold of +100 HU. RESULTS One hundred and fifteen patients were included. Procedural success was 82.6 %. The balloon-to-annulus ratio (BAR) relative to diameter, perimeter, and area was higher in patients with successful BAV. Patients with unsuccessful BAV had a significantly higher aortic valve calcium burden. The complication rate was 4.3 % and there was no association with valve geometry or calcium burden. A trend towards a reduced complication rate was found as calcium asymmetry increased. BAR minimum annulus diameter was the best parameter in predicting procedural success, with a cut-off at 0.85. CONCLUSIONS BAV efficacy is correlated directly with balloon size in relation to annulus dimension and inversely with total calcium burden. The minimum diameter of the valve may be adopted as a reference for balloon sizing.
Collapse
Affiliation(s)
- Gianni Dall'Ara
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy.
| | - Sara Piciucchi
- Department of Radiology, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Carolina Moretti
- Cardiology Unit, Santa Maria delle Croci Hospital, Ravenna, Italy
| | | | | | | | - Simone Grotti
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Daniela Spartà
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | | | | | | | | | | | - Marco Balducelli
- Cardiology Unit, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Francesco Saia
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy
| | | | - Marcello Galvani
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy; Cardiovascular Research Unit, Myriam Zito Sacco Heart Foundation, Forlì, Italy
| |
Collapse
|
2
|
Clavel MA, Pibarot P. Adjudication of Low-Flow, Low-Gradient Aortic Stenosis Severity: Dobutamine Stress Echocardiography and MSCT Are Complementary, Not Competitive. JACC Cardiovasc Imaging 2024; 17:861-864. [PMID: 38934977 DOI: 10.1016/j.jcmg.2024.04.018] [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: 04/07/2024] [Accepted: 04/22/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec, Québec, Canada
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec, Québec, Canada.
| |
Collapse
|
3
|
Laohachewin D, Ruile P, Breitbart P, Minners J, Jander N, Soschynski M, Schlett CL, Neumann FJ, Westermann D, Hein M. Quantification of Aortic Valve Calcification in Contrast-Enhanced Computed Tomography. J Clin Med 2024; 13:2386. [PMID: 38673658 PMCID: PMC11051576 DOI: 10.3390/jcm13082386] [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: 03/12/2024] [Revised: 04/09/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Background: The goal of our study is to evaluate a method to quantify aortic valve calcification (AVC) in contrast-enhanced computed tomography for patients with suspected severe aortic stenosis pre-interventionally. Methods: A total of sixty-five patients with aortic stenosis underwent both a native and a contrast-enhanced computed tomography (CECT) scan of the aortic valve (45 in the training cohort and 20 in the validation cohort) using a standardized protocol. Aortic valve calcification was semi-automatically quantified via the Agatston score method for the native scans and was used as a reference. For contrast-enhanced computed tomography, a calcium threshold of the Hounsfield units of the aorta plus four times the standard deviation was used. Results: For the quantification of aortic valve calcification in contrast-enhanced computed tomography, a conversion formula (691 + 1.83 x AVCCECT) was derived via a linear regression model in the training cohort. The validation in the second cohort showed high agreement for this conversion formula with no significant proportional bias (Bland-Altman, p = 0.055) and with an intraclass correlation coefficient in the validation cohort of 0.915 (confidence interval 95% 0.786-0.966) p < 0.001. Conclusions: Calcium scoring in patients with aortic valve stenosis can be performed using contrast-enhanced computed tomography with high validity. Using a conversion factor led to an excellent agreement, thereby obviating an additional native computed tomography scan. This might contribute to a decrease in radiation exposure.
Collapse
Affiliation(s)
- Danai Laohachewin
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Philipp Ruile
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Philipp Breitbart
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Jan Minners
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Nikolaus Jander
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Martin Soschynski
- Department of Diagnostic and Interventional Radiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Christopher L. Schlett
- Department of Diagnostic and Interventional Radiology, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| | - Manuel Hein
- Department of Cardiology and Angiology, Medical Center—University of Freiburg, Faculty of Medicine, Suedring 15, 79189 Bad Krozingen, Germany
| |
Collapse
|
4
|
Flores-Umanzor E, Keshvara R, Reza S, Asghar A, Rashidul Anwar M, Cepas-Guillen PL, Osten M, Halankar J, Abrahamyan L, Horlick E. A systematic review of contrast-enhanced computed tomography calcium scoring methodologies and impact of aortic valve calcium burden on TAVI clinical outcomes. J Cardiovasc Comput Tomogr 2023; 17:373-383. [PMID: 37635033 DOI: 10.1016/j.jcct.2023.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/25/2023] [Accepted: 08/19/2023] [Indexed: 08/29/2023]
Abstract
Different methodologies have been used to assess the role of AV calcification (AVC) on TAVI outcomes. This systematic review aims to describe the burden of AVC, synthesize the different methods of calcium score quantification, and evaluate the impact of AVC on outcomes after TAVI. We included studies of TAVI patients who had reported AV calcium scoring by contrast-enhanced multidetector CT and the Agatston method. The impact of calcification on TAVI outcomes without restrictions on follow-up time or outcome type was evaluated. Results were reported descriptively, and a meta-analysis was conducted when feasible. Sixty-eight articles were included, with sample sizes ranging from 23 to 1425 patients. Contrast-enhanced calcium scoring was reported in 30 studies, calcium volume score in 28 studies, and unique scoring methods in two. All studies with calcium volume scores had variable protocols, but most utilized a modified Agatston method with variable attenuation threshold values of 300-850 HU. Eight studies used the Agatston method, with the overall mean AV calcium score in studies published from 2010 to 2012 of 3342.9 AU [95%CI: 3150.4; 3535.4, I2 = 0%]. The overall mean score was lower and heterogenous in studies published from 2014 to 2020 (2658.9 AU [95% CI: 2517.3; 2800.5, I2 = 79%]. Most studies reported a positive association between calcium burden and increased risk of adverse outcomes, including implantation of permanent pacemaker (7/8 studies), paravalvular leak (13/13 studies), and risk of aortic rupture (2/2 studies). AVC quantification methodology with contrast-enhanced CT is still variable. AVC negatively impacts TAVI outcomes independently of the quantification method.
Collapse
Affiliation(s)
- Eduardo Flores-Umanzor
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Rajesh Keshvara
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Seleman Reza
- Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, ON, Canada
| | - Areeba Asghar
- Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, ON, Canada
| | - Mohammed Rashidul Anwar
- Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, ON, Canada
| | - Pedro L Cepas-Guillen
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Spain
| | - Mark Osten
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Jaydeep Halankar
- Joint Department of Medical Imaging, Toronto General Hospital, Peter Munk Cardiac Centre, University Health Network, University of Toronto, ON, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, ON, Canada
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
| |
Collapse
|
5
|
Wang TKM, Abou Hassan OK, Popović ZB, Griffin BP, Rodriguez LL. Quantification of Significant Aortic Stenosis by Echocardiography versus Four-Dimensional Cardiac Computed Tomography: A Multi-Modality Imaging Study. Diagnostics (Basel) 2022; 12:diagnostics12123106. [PMID: 36553113 PMCID: PMC9777111 DOI: 10.3390/diagnostics12123106] [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: 11/08/2022] [Revised: 11/28/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Transthoracic echocardiography (TTE) grading of aortic stenosis (AS) is challenging when parameters are discrepant, and four-dimensional cardiac computed tomography (4D-CCT) is increasingly utilized for transcatheter intervention workup. We compared TTE and 4D-CCT measures contributing to AS quantification. AS patients (n = 80, age 86 ± 10 years, 71% men) referred for transcatheter replacement in 2014−2017 were retrospectively studied, 20 each with high-gradient AS (HG-AS), classical and paradoxical low-flow low-gradient AS (CLFLG-AS and PLFLG-AS), and normal-flow low-gradient AS (NFLG-AS). Correlation and Bland−Altman analyses were performed between TTE and 4D-CCT parameters. There were moderate-to-high TTE versus 4D-CCT correlations for left ventricular volumes, function, mass, and outflow tract dimensions (r = 0.51−0.88), though values were mostly significantly higher by 4D-CCT (p < 0.001). Compared with 4D-CCT planimetry of aortic valve area (AVA), TTE estimates had modest correlation (r = 0.37−0.43) but were significantly lower (by 0.15−0.32 cm2). The 4D-CCT estimate of LVSVi lead to significant reclassification of AS subtype defined by TTE. In conclusion, 4D-CCT quantified values were higher than TTE for the left ventricle and AVA, and the AS subtype was reclassified based on LVSVi by 4D-CCT, warranting further research to establish its clinical implications and optimal thresholds in severe AS management.
Collapse
|
6
|
Sato K, Wang TKM, Desai MY, Kapadia SR, Krishnaswamy A, Rodriguez LL, Grimm RA, Griffin BP, Popović ZB. Physical and physiological effects of dobutamine stress echocardiography in low-gradient aortic stenosis. Am J Physiol Heart Circ Physiol 2022; 322:H94-H104. [PMID: 34860593 DOI: 10.1152/ajpheart.00183.2021] [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] [Indexed: 11/22/2022]
Abstract
Dobutamine stress echocardiography (DSE) is a useful tool for assessing low-gradient significant aortic stenosis (AS) and contractile reserve (CR), but its prognostic utility has become controversial in recent studies. We evaluated the impact of DSE on aortic valve physiological, structural, and left ventricular parameters in low-gradient AS. Consecutive patients undergoing DSE for low-gradient AS evaluation from September 2010 to July 2016 were retrospectively studied, and DSE findings were divided into four groups: with and without severe AS and/or CR. Relationships between left ventricular chamber quantification, CR, aortic valve Doppler during DSE, and calcium score [by computerized tomography (CT)] were analyzed. There were 258 DSE studies performed on 243 patients, mean age 77.6 ± 10.8 yr and 183 (70.1%) were males. With increasing dobutamine dose, apart from systolic blood pressure, left ventricular ejection fraction, flow, cardiac power output, and longitudinal strain magnitude, along with aortic valve area and mean aortic gradient were all significantly increased (P < 0.05). Flow and mean gradient increased in both the presence and absence of CR, whereas stroke volume and aortic valve area increased mainly in those with CR only. The aortic valve area increased in both patients with low and high calcium scores; however, the baseline area was lower in those with a higher calcium score. During DSE, aortic valve area increases with increase in aortic valve gradient. Higher calcium score is associated with lower baseline aortic valve area, but the aortic valve area still increases with dobutamine even in presence of a high calcium score.NEW & NOTEWORTHY We show that even in most severe aortic stenosis, there is some residual valve pliability. This suggests that a complete loss of pliability is not compatible with survival.
Collapse
Affiliation(s)
- Kimi Sato
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y Desai
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Section of Invasive and Interventional Cardiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amar Krishnaswamy
- Section of Invasive and Interventional Cardiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - L Leonardo Rodriguez
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard A Grimm
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian P Griffin
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zoran B Popović
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
7
|
Eberhard M, Hinzpeter R, Schönenberger ALN, Euler A, Kuzo N, Reeve K, Stähli BE, Kasel AM, Manka R, Tanner FC, Alkadhi H. Incremental Prognostic Value of Coronary Artery Calcium Score for Predicting All-Cause Mortality after Transcatheter Aortic Valve Replacement. Radiology 2021; 301:105-112. [PMID: 34342499 DOI: 10.1148/radiol.2021204623] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Current risk models show limited performances for predicting all-cause mortality after transcatheter aortic valve replacement (TAVR). Purpose To determine the prognostic value of coronary artery calcium (CAC) scoring for predicting 30-day and 1-year mortality in patients undergoing TAVR. Materials and Methods In this single-center institutional review board-approved secondary analysis of prospectively collected data (SwissTAVI Registry), the authors evaluated participants who, before TAVR, underwent CT that included a nonenhanced electrocardiography-gated cardiac scan between May 2008 and September 2019 and who had not undergone previous coronary revascularization. Clinical data, including the European System for Cardiac Operative Risk Evaluation (EuroSCORE II), were recorded. The CAC score was determined, and 30-day and 1-year all-cause mortality were assessed by using Cox regression analyses. Results In total, 309 participants (mean age ± standard deviation, 81 years ± 7; 175 women) were included, with a median CAC score of 334 (interquartile range, 104-987). Seventy-seven of the 309 participants (25%) had a CAC score greater than or equal to 1000. A CAC score of 1000 or greater served as an independent predictor of 30-day (hazard ratio [HR], 4.5 [95% CI: 1.5, 13.6] compared with a CAC score <1000; P = .007) and 1-year (HR, 4.3 [95% CI: 1.5, 12.7] compared with a CAC score of 0-99; P = .008) mortality after TAVR. Similar trends were observed for each point increase of the EuroSCORE II as an independent predictor of 30-day (HR, 1.22 [95% CI: 1.10, 1.36]; P < .001) and 1-year (HR, 1.16 [95% CI: 1.08, 1.25]; P < .001) mortality. Adding the CAC score to the EuroSCORE II provided incremental prognostic value for 1-year mortality after TAVR over the EuroSCORE II alone (concordance index, 0.76 vs 0.69; P = .04). Conclusion In participants without prior coronary revascularization, the coronary artery calcium score represented an independent predictor of 30-day and 1-year mortality after transcatheter aortic valve replacement. ClinicalTrials.gov identifier, NCT01368250 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Almeida in this issue.
Collapse
Affiliation(s)
- Matthias Eberhard
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Ricarda Hinzpeter
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Amadea L N Schönenberger
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Andre Euler
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Nazar Kuzo
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Kelly Reeve
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Barbara E Stähli
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Albert M Kasel
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Robert Manka
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Felix C Tanner
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| | - Hatem Alkadhi
- From the Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland (M.E., R.H., A.L.N.S., A.E., R.M., H.A.); Department of Cardiology, University Heart Center Zurich (N.K., B.E.S., A.M.K., R.M., F.C.T.), and Epidemiology, Biostatistics and Prevention Institute (K.R.), University of Zurich, Zurich, Switzerland; and Institute for Biomedical Engineering, Swiss Federal Institute of Technology in Zurich (ETH), Zurich, Switzerland (R.M.)
| |
Collapse
|
8
|
Angelillis M, Costa G, De Backer O, Mochi V, Christou A, Giannini C, Spontoni P, De Carlo M, Søndergaard L, Miccoli M, Petronio AS. Threshold for calcium volume evaluation in patients with aortic valve stenosis: correlation with Agatston score. J Cardiovasc Med (Hagerstown) 2021; 22:496-502. [PMID: 33278208 DOI: 10.2459/jcm.0000000000001145] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The evaluation of aortic valve calcium burden is important when planning for transcatheter aortic valve implantation (TAVI). Although a robust golden standard methodology is available for calcium evaluation on noncontrast-enhanced (NCE) computed tomographic (CT) series, a standard reference for calcium assessment on contrast-enhanced CT series is currently lacking. METHODS Two hundred and forty-four preprocedural CT scans from patients who had received TAVI were analysed. We correlated the aortic calcium volumes obtained on CE series at three thresholds [450, 850, and 'probe + 100' Hounsfield Units (HU)] with the Agatston score obtained on NCE scans. A subgroup analysis was performed taking into account the contrast enhancement of the left ventricular outflow tract (LVOT), with a prespecified cut-off of 300 HU. RESULTS The overall population analysis showed higher correlation with the Agatston score using the 850 HU threshold (r = 0.45, P < 0.0001); no correlation was found with the 450 HU threshold, whilst the 'probe + 100' HU threshold showed a weaker correlation (r = 0.30, P < 0.0001). In patients with LVOT enhancement less than 300 HU, 450 HU showed the highest accuracy in calcium identification (r = 0.70, P < 0.0001), whereas in patients with LVOT enhancement of at least 300 HU, the most accurate threshold was 850 HU (r = 0.46, P < 0.0001). CONCLUSION The thresholds for correct calcium identification using the automatic 3Mensio software depend on the contrast enhancement of aortic and cardiac structures, which can be estimated by measuring the HU in the LVOT. In patients with LVOT HU of less than 300, the correct threshold to be set in the software is 450 HU, whereas in patients with LVOT HU of at least 300 the correct threshold is 850 HU.
Collapse
Affiliation(s)
- Marco Angelillis
- Cardiothoracic and Vascular Department, University Hospital Pisa, Italy
| | - Giulia Costa
- Cardiothoracic and Vascular Department, University Hospital Pisa, Italy
| | - Ole De Backer
- The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Veronica Mochi
- Cardiothoracic and Vascular Department, University Hospital Pisa, Italy
| | - Andrea Christou
- Cardiothoracic and Vascular Department, University Hospital Pisa, Italy
| | - Cristina Giannini
- Cardiothoracic and Vascular Department, University Hospital Pisa, Italy
| | - Paolo Spontoni
- Cardiothoracic and Vascular Department, University Hospital Pisa, Italy
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, University Hospital Pisa, Italy
| | - Lars Søndergaard
- The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Anna S Petronio
- Cardiothoracic and Vascular Department, University Hospital Pisa, Italy
| |
Collapse
|
9
|
Kuzo N, Stähli BE, Erhart L, Anwer S, Schindler M, Kebernik J, Mathys S, Nguyen-Kim TDL, Eberhard M, Ruschitzka F, Tanner FC. Outcome of Patients With Severe Aortic Stenosis and Normal Coronary Arteries Undergoing Transcatheter Aortic Valve Implantation. Am J Cardiol 2021; 143:89-96. [PMID: 33359230 DOI: 10.1016/j.amjcard.2020.12.030] [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: 07/05/2020] [Revised: 11/27/2020] [Accepted: 12/01/2020] [Indexed: 10/22/2022]
Abstract
Coronary artery disease and severe aortic stenosis (AS) often coexist. This study sought to investigate the impact of normal coronary arteries as negative risk marker in patients undergoing transcatheter aortic valve implantation (TAVI). Consecutive patients with severe AS undergoing TAVI were dichotomized according to the presence or absence of normal coronary arteries, defined as absence of coronary lesions with diameter stenosis ≥30% in vessels ≥1.5 mm in diameter on coronary angiogram in patients without prior coronary revascularization. The primary end point was 1-year mortality. Out of 987 patients with severe AS undergoing TAVI, 258 (26%) patients had normal coronary arteries. These patients were younger, more likely women, and had lower EuroSCORE II and STS risk scores. Although mortality at 30 days was similar in the normal coronary artery and the coronary atherosclerosis groups (3.1% vs 5.6%, p = 0.11), it was lower in those with normal coronary arteries at 1 year (8.9% vs 17%, p = 0.003). In multivariable analysis, the presence of normal coronary arteries on coronary angiogram independently predicted 1-year mortality (adjusted HR 0.57, 95% CI 0.37 to 0.90, p = 0.02). In conclusion, this study defined normal coronary arteries as negative risk marker in patients with severe AS undergoing TAVI.
Collapse
|
10
|
Pandey NN, Sharma S, Jagia P, Gulati GS, Kumar S. Feasibility and Accuracy of Aortic Valve Calcium Quantification on Computed Tomographic Angiography in Aortic Stenosis. Ann Thorac Surg 2020; 110:537-544. [DOI: 10.1016/j.athoracsur.2019.11.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/13/2019] [Accepted: 11/15/2019] [Indexed: 01/07/2023]
|
11
|
Eberhard M, Schönenberger ALN, Hinzpeter R, Euler A, Sokolska J, Weber L, Kuzo N, Manka R, Kasel AM, Tanner FC, Alkadhi H. Mitral annular calcification in the elderly - Quantitative assessment. J Cardiovasc Comput Tomogr 2020; 15:161-166. [PMID: 32798185 DOI: 10.1016/j.jcct.2020.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/04/2020] [Accepted: 06/01/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine the reliability of subjective and objective quantification of mitral annular calcification (MAC) in elderly patients with severe aortic stenosis, to define quantitative sex- and age-related reference values of MAC, and to correlate quantitative MAC with mitral valve disease. METHODS In this retrospective, IRB-approved study, we included 559 patients (268 females, median age 81 years, inter-quartile range 77-85 years) with severe aortic stenosis undergoing CT. Four independent readers performed subjective MAC categorization as follows: no, mild, moderate, and severe MAC. Two independent readers performed quantitative evaluation of MAC using the Agatston score method (AgatstonMAC). Mitral valve disease was determined by echocardiography. RESULTS Subjective MAC categorization showed high inter-reader agreement for no (k = 0.88) and severe MAC (k = 0.75), whereas agreement for moderate (k = 0.59) and mild (k = 0.45) MAC was moderate. Intra-reader agreement for subjective MAC categorization was substantial (k = 0.69 and 0.62). Inter- and intra-reader agreement for AgatstonMAC were excellent (ICC = 0.998 and 0.999, respectively), with minor inconsistencies in MAC involving the left ventricular outflow tract/aortic valve. There were significantly more women than men with MAC (n = 227, 85% versus n = 209, 72%; p < 0.001), with a significantly higher AgatstonMAC (median 597, range 81-2055 versus median 244; range 0-1565; p < 0.001), particularly in patients ≥85 years of age. AgatstonMAC showed an area-under-the-curve of 0.84 to diagnose mitral stenosis, whereas there was no association of AgatstonMAC with mitral regurgitation (p > 0.05). CONCLUSIONS Our study in elderly patients with severe aortic stenosis shows that quantitative MAC scoring is more reliable than subjective MAC assessment. Women show higher AgatstonMAC scores than men, particularly in the elderly population. AgatstonMAC shows high accuracy to diagnose mitral stenosis.
Collapse
Affiliation(s)
- M Eberhard
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland.
| | - A L N Schönenberger
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - R Hinzpeter
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - A Euler
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - J Sokolska
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland; Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - L Weber
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - N Kuzo
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - R Manka
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland; Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - A M Kasel
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - F C Tanner
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - H Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| |
Collapse
|
12
|
Pawade T, Sheth T, Guzzetti E, Dweck MR, Clavel MA. Why and How to Measure Aortic Valve Calcification in Patients With Aortic Stenosis. JACC Cardiovasc Imaging 2020; 12:1835-1848. [PMID: 31488252 DOI: 10.1016/j.jcmg.2019.01.045] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 10/26/2022]
Abstract
The first-line evaluation of aortic stenosis severity is Doppler echocardiography. However, in up to 40% of patients, resting echocardiographic assessment of aortic stenosis severity is discordant, leading to clinical uncertainty. Interest has therefore grown in aortic valve calcium scoring by multidetector computed tomography (CT-AVC) as an alternative load independent assessment of aortic stenosis severity. This paper will briefly review the pathophysiology of aortic stenosis and the crucial role that calcification plays in driving progressive obstruction of the valve. Subsequently, it will describe published reports that have investigated CT-AVC, validating this parameter against histology, and establishing its diagnostic accuracy versus echocardiography as well as its powerful independent prognostic capability. Finally, this review seeks to provide a practical guide about how best to acquire and interpret CT-AVC with a close focus on potential pitfalls and how these might be best avoided as this technique becomes more widely adopted in to clinical practice.
Collapse
Affiliation(s)
- Tania Pawade
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Tej Sheth
- Division of Cardiology, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Ezequiel Guzzetti
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
| |
Collapse
|
13
|
Hinzpeter R, Weber L, Euler A, Kasel AM, Tanner FC, Alkadhi H, Eberhard M. Aortic valve calcification scoring with computed tomography: impact of iterative reconstruction techniques. Int J Cardiovasc Imaging 2020; 36:1575-1581. [PMID: 32335821 DOI: 10.1007/s10554-020-01862-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/22/2020] [Indexed: 12/01/2022]
Abstract
To investigate whether image reconstruction with iterative reconstruction (IR) affects aortic valve calcification (AVC) scoring and likelihood categorization of severe aortic stenosis (AS). In this IRB-approved retrospective study, we included 100 consecutive patients with AS (40 females; mean age 77 ± 10 years; age range: 36-99 years) undergoing CT prior to transcatheter aortic valve replacement. Non-enhanced, electrocardiography-gated CT of the heart was reconstructed with filtered back projection (FBP) and with advanced modeled IR at strength levels 1-5. AVC Agatston scores were calculated and gender-specific cut-off values for AS likelihood categorization were applied according to current European Society of Cardiology recommendations (from unlikely to very likely). Friedman test with post-hoc Bonferroni correction was applied to analyze interval- and ordinal-scaled data. Compared to FBP, each IR strength level produced significantly different AVC Agatston scores (p < 0.001-0.002). Median AVC Agatston score for image reconstruction with FBP was 2527 (IQR: 1711-3663) and decreased with increasing IR strength levels up to 2281 (IQR: 1471-3357) at strength level 5. Likelihood categorization of severe AS was significantly different among image reconstruction algorithms (p < 0.001). Image reconstruction with IR strength level 5 led to a downward shift of likelihood categorization in 28 patients (28%) compared to images reconstructed with FBP. IR significantly impacts AVC scoring with significantly decreasing AVC scores with increasing IR strength levels. This leads to relevant changes in likelihood categorization of patients with severe AS., leading to underestimation of severe AS.
Collapse
Affiliation(s)
- Ricarda Hinzpeter
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistr. 100, CH-8091, Zurich, Switzerland
| | - Lucas Weber
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistr. 100, CH-8091, Zurich, Switzerland
| | - Andre Euler
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistr. 100, CH-8091, Zurich, Switzerland
| | - Albert M Kasel
- Department of Cardiology, University Heart Center Zurich, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Felix C Tanner
- Department of Cardiology, University Heart Center Zurich, University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistr. 100, CH-8091, Zurich, Switzerland
| | - Matthias Eberhard
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistr. 100, CH-8091, Zurich, Switzerland.
| |
Collapse
|
14
|
Graffy PM, Liu J, O'Connor S, Summers RM, Pickhardt PJ. Automated segmentation and quantification of aortic calcification at abdominal CT: application of a deep learning-based algorithm to a longitudinal screening cohort. Abdom Radiol (NY) 2019; 44:2921-2928. [PMID: 30976827 DOI: 10.1007/s00261-019-02014-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To investigate an automated aortic calcium segmentation and scoring tool at abdominal CT in an adult screening cohort. METHODS Using instance segmentation with convolutional neural networks (Mask R-CNN), a fully automated vascular calcification algorithm was applied to a data set of 9914 non-contrast CT scans from 9032 consecutive asymptomatic adults (mean age, 57.5 ± 7.8 years; 4467 M/5447F) undergoing colonography screening. Follow-up scans were performed in a subset of 866 individuals (mean interval, 5.4 years). Automated abdominal aortic calcium volume, mass, and Agatston score were assessed. In addition, comparison was made with a separate validated semi-automated approach in a subset of 812 cases. RESULTS Mean values were significantly higher in males for Agatston score (924.2 ± 2066.2 vs. 564.2 ± 1484.2, p < 0.001), aortic calcium mass (222.2 ± 526.0 mg vs. 144.5 ± 405.4 mg, p < 0.001) and volume (699.4 ± 1552.4 ml vs. 426.9 ± 1115.5 HU, p < 0.001). Overall age-specific Agatston scores increased an average of 10%/year for the entire cohort; males had a larger Agatston score increase between the ages of 40 to 60 than females (91.2% vs. 75.1%, p < 0.001) and had significantly higher mean Agatston scores between ages 50 and 80 (p < 0.001). For the 812-scan subset with both automated and semi-automated methods, median difference in Agatston score was 66.4 with an r2 agreement value of 0.84. Among the 866-patient cohort with longitudinal follow-up, the average Agatston score change was 524.1 ± 1317.5 (median 130.9), reflecting a mean increase of 25.5% (median 73.6%). CONCLUSION This robust, fully automated abdominal aortic calcification scoring tool allows for both individualized and population-based assessment. Such data could be automatically derived at non-contrast abdominal CT, regardless of the study indication, allowing for opportunistic assessment of cardiovascular risk.
Collapse
Affiliation(s)
- Peter M Graffy
- E3/311 Clinical Science Center, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792-3252, USA
| | - Jiamin Liu
- Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Stacy O'Connor
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ronald M Summers
- Radiology & Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Perry J Pickhardt
- E3/311 Clinical Science Center, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., Madison, WI, 53792-3252, USA.
| |
Collapse
|
15
|
Epicardial adipose tissue volume is associated with adverse outcomes after transcatheter aortic valve replacement. Int J Cardiol 2019; 286:29-35. [DOI: 10.1016/j.ijcard.2019.01.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 11/21/2022]
|
16
|
Eberhard M, Hinzpeter R, Polacin M, Morsbach F, Maisano F, Nietlispach F, Nguyen-Kim T, Tanner F, Alkadhi H. Reproducibility of aortic valve calcification scoring with computed tomography – An interplatform analysis. J Cardiovasc Comput Tomogr 2019; 13:92-98. [DOI: 10.1016/j.jcct.2019.01.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/20/2018] [Accepted: 01/14/2019] [Indexed: 01/09/2023]
|
17
|
Eberhard M, Milanese G, Ho M, Zimmermann S, Frauenfelder T, Nietlispach F, Maisano F, Tanner FC, Nguyen-Kim TDL. Pre-procedural CT angiography inferior vena cava measurements: a predictor of mortality in patients undergoing transcatheter aortic valve implantation. Eur Radiol 2018; 29:975-984. [DOI: 10.1007/s00330-018-5613-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/08/2018] [Accepted: 06/15/2018] [Indexed: 11/28/2022]
|
18
|
Dawkins S, Prendergast B. Transcatheter aortic valve implantation - practice makes perfect. EUROINTERVENTION 2017; 13:897-899. [PMID: 29051125 DOI: 10.4244/eijv13i8a132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sam Dawkins
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | |
Collapse
|