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Vogelhuber J, Tanaka T, Kavsur R, Goto T, Öztürk C, Silaschi M, Nickenig G, Zimmer S, Weber M, Sugiura A. Outcomes of Transcatheter Tricuspid Edge-to-Edge Repair in Patients With Right Ventricular Dysfunction. Circ Cardiovasc Interv 2024; 17:e013156. [PMID: 38629314 DOI: 10.1161/circinterventions.123.013156] [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: 04/16/2023] [Accepted: 03/08/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND We assessed the safety profile of tricuspid transcatheter edge-to-edge repair (TEER) in patients with right ventricular (RV) dysfunction. METHODS We identified patients undergoing TEER to treat tricuspid regurgitation from June 2015 to October 2021 and assessed tricuspid annular plane systolic excursion (TAPSE) and RV fractional area change (RVFAC). RV dysfunction was defined as TAPSE <17 mm and RVFAC <35%. The primary end point was 30-day mortality after TEER. We also investigated the change in the RV function in the early phase and clinical outcomes at 2 years. RESULTS The study participants (n=262) were at high surgical risk (EuroSCORE II, 6.2% [interquartile range, 4.0%-10.3%]). Among them, 44 patients met the criteria of RV dysfunction. Thirty-day mortality was 3.2% in patients with normal RV function and 2.3% in patients with RV dysfunction (P=0.99). Tricuspid regurgitation reduction to ≤2+ was consistently achieved irrespective of RV dysfunction (76.5% versus 70.5%; P=0.44). TAPSE and RVFAC declined after TEER in patients with normal RV function (TAPSE, 19.0±4.7 to 17.9±4.5 mm; P=0.001; RVFAC, 46.2%±8.1% to 40.3%±9.7%; P<0.001). In contrast, those parameters were unchanged or tended to increase in patients with RV dysfunction (TAPSE, 13.2±2.3 to 15.3±4.7 mm; P=0.011; RVFAC, 29.6%±4.1% to 31.6%±8.3%; P=0.14). Two years after TEER, compared with patients with normal RV function, patients with RV dysfunction had significantly higher mortality (27.0% versus 56.3%; P<0.001). CONCLUSIONS TEER was safe and feasible to treat tricuspid regurgitation in patients with RV dysfunction. The decline in the RV function was observed in patients with normal RV function but not in patients with RV dysfunction.
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Affiliation(s)
- Johanna Vogelhuber
- Department of Internal Medicine II (J.V., T.T., R.K., C.O., G.N., S.Z., M.W., A.S.), Heart Center Bonn, University Hospital Bonn, Germany
| | - Tetsu Tanaka
- Department of Internal Medicine II (J.V., T.T., R.K., C.O., G.N., S.Z., M.W., A.S.), Heart Center Bonn, University Hospital Bonn, Germany
| | - Refik Kavsur
- Department of Internal Medicine II (J.V., T.T., R.K., C.O., G.N., S.Z., M.W., A.S.), Heart Center Bonn, University Hospital Bonn, Germany
| | - Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan (T.G.)
| | - Can Öztürk
- Department of Internal Medicine II (J.V., T.T., R.K., C.O., G.N., S.Z., M.W., A.S.), Heart Center Bonn, University Hospital Bonn, Germany
| | - Miriam Silaschi
- Department of Cardiac Surgery (M.S.), Heart Center Bonn, University Hospital Bonn, Germany
| | - Georg Nickenig
- Department of Internal Medicine II (J.V., T.T., R.K., C.O., G.N., S.Z., M.W., A.S.), Heart Center Bonn, University Hospital Bonn, Germany
| | - Sebastian Zimmer
- Department of Internal Medicine II (J.V., T.T., R.K., C.O., G.N., S.Z., M.W., A.S.), Heart Center Bonn, University Hospital Bonn, Germany
| | - Marcel Weber
- Department of Internal Medicine II (J.V., T.T., R.K., C.O., G.N., S.Z., M.W., A.S.), Heart Center Bonn, University Hospital Bonn, Germany
| | - Atsushi Sugiura
- Department of Internal Medicine II (J.V., T.T., R.K., C.O., G.N., S.Z., M.W., A.S.), Heart Center Bonn, University Hospital Bonn, Germany
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Alwan L, Tomii D, Heg D, Okuno T, Lanz J, Praz F, Chong-Nguyen C, Stortecky S, Reineke D, Windecker S, Pilgrim T. Impact of right ventricular-pulmonary arterial coupling on clinical outcomes in patients undergoing transcatheter aortic valve implantation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 56:27-34. [PMID: 37210220 DOI: 10.1016/j.carrev.2023.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023]
Abstract
AIMS The interplay between pulmonary hypertension (PH) and right ventricular (RV) function is reflected in an index of RV function to pulmonary artery (PA) systolic pressure (PASP). The present study aimed to assess the importance of RV-PA coupling on clinical outcomes after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS In a prospective TAVI registry, clinical outcomes of TAVI patients with RV dysfunction or PH were stratified according to coupling or uncoupling of tricuspid annular plane systolic excursion (TAPSE) to PASP, and compared to those of patients with normal RV function and absence of PH. The median TAPSE/PASP ratio was used to differentiate uncoupling (>0.39) from coupling (<0.39). Among 404 TAVI patients, 201 patients (49.8 %) had RVD or PH at baseline: 174 patients had RV-PA uncoupling, and 27 had coupling at baseline. RV-PA hemodynamics normalized in 55.6 % of patients with RV-PA coupling and in 28.2 % of patients with RV-PA uncoupling, and deteriorated in 33.3 % of patients with RV-PA coupling and in 17.8 % of patients with no RVD, respectively, at discharge. Patients with RV-PA uncoupling after TAVI showed a trend towards an increased risk of cardiovascular death at 1 year as compared to patients with normal RV-function (HRadjusted 2.06, 95 % CI 0.97-4.37). CONCLUSION After TAVI, RV-PA coupling changed in a significant proportion of patients and is a potentially important metric for risk stratification of TAVI patients with RVD or PH. TWEET: "Patients with right ventricular dysfunction and pulmonary hypertension are at increased risk of death after TAVI. Integrated right ventricular to pulmonary artery hemodynamics change after TAVI in a significant proportion of patients and is instrumental to refine risk stratification." CLINICAL TRIAL REGISTRATION https://www. CLINICALTRIALS gov: NCT01368250.
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Affiliation(s)
- Louhai Alwan
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland. https://twitter.com/DaijiroTomii
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - Taishi Okuno
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | | | - Stefan Stortecky
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland.
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Tanaka T, Sugiura A, Kavsur R, Öztürk C, Vogelhuber J, Wilde N, Kütting D, Meyer C, Zimmer S, Grube E, Bakhtiary F, Nickenig G, Weber M. Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve repair. Eur Heart J Cardiovasc Imaging 2023; 24:1501-1508. [PMID: 37232362 DOI: 10.1093/ehjci/jead102] [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: 10/21/2022] [Revised: 04/03/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
AIMS The role of right ventricular function in patients undergoing transcatheter tricuspid valve repair (TTVR) is poorly understood. This study investigated the association of right ventricular ejection fraction (RVEF) assessed by cardiac computed tomography (CCT) with clinical outcomes in patients undergoing TTVR. METHODS AND RESULTS We retrospectively assessed three-dimensional (3D) RVEF by using pre-procedural CCT images in patients undergoing TTVR. RV dysfunction was defined as a CT-RVEF of <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within 1 year after TTVR. Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Procedural success and in-hospital mortality were comparable between patients with CT-RVEF <45% and ≥45%. However, CT-RVEF of <45% was associated with a higher risk of the composite outcome (hazard ratio: 2.99; 95% confidence interval: 1.65-5.41; P = 0.001), which had an additional value beyond two-dimensional echocardiographic assessments of RV function to stratify the risk of the composite outcome. In addition, patients with CT-RVEF ≥45% exhibited the association of procedural success (i.e. residual tricuspid regurgitation of ≤2+ at discharge) with a decreased risk of the composite outcome, while this association was attenuated in those with CT-RVEF <45% (P for interaction = 0.035). CONCLUSION CT-RVEF is associated with the risk of the composite outcome after TTVR, and a reduced CT-RVEF might attenuate the prognostic benefit of TR reduction. The assessment of 3D-RVEF by using CCT may refine the patient selection for TTVR.
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Affiliation(s)
- Tetsu Tanaka
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Atsushi Sugiura
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Refik Kavsur
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Can Öztürk
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Johanna Vogelhuber
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Nihal Wilde
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Daniel Kütting
- Department of Radiology, University Hospital Bonn, Germany
| | - Carsten Meyer
- Department of Radiology, University Hospital Bonn, Germany
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Eberhard Grube
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Farhad Bakhtiary
- Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Germany
| | - Georg Nickenig
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Marcel Weber
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
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Tomasoni D, Adamo M, Porcari A, Aimo A, Bonfioli GB, Castiglione V, Franzini M, Inciardi RM, Khalil A, Lombardi CM, Lupi L, Nardi M, Oriecuia C, Pagnesi M, Panichella G, Rossi M, Saccani N, Specchia C, Vergaro G, Merlo M, Sinagra G, Emdin M, Metra M. Right ventricular to pulmonary artery coupling and outcome in patients with cardiac amyloidosis. Eur Heart J Cardiovasc Imaging 2023; 24:1405-1414. [PMID: 37379445 DOI: 10.1093/ehjci/jead145] [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: 12/30/2022] [Revised: 05/11/2023] [Accepted: 05/20/2023] [Indexed: 06/30/2023] Open
Abstract
AIMS To investigate the prognostic value of the right ventricle-to-pulmonary artery (RV-PA) coupling in patients with either transthyretin (ATTR) or immunoglobulin light-chain (AL) cardiac amyloidosis (CA). METHODS AND RESULTS Overall, 283 patients with CA from 3 Italian high-volume centres were included (median age 76 years; 63% males; 53% with ATTR-CA, 47% with AL-CA). The RV-PA coupling was evaluated by using the tricuspid annular plane systolic excursion/pulmonary artery systolic pressure (TAPSE/PASP) ratio. The median value of TAPSE/PASP was 0.45 (0.33-0.63) mm/mmHg. Patients with a TAPSE/PASP ratio <0.45 were older, had lower systolic blood pressure, more severe symptoms, higher cardiac troponin and N-terminal pro-B-type natriuretic peptide levels, greater left ventricular (LV) thickness, and worse LV systolic and diastolic function. A TAPSE/PASP ratio <0.45 was independently associated with a higher risk of all-cause death or heart failure (HF) hospitalization [hazard ratio (HR) 1.98, 95% confidence interval (CI) 1.32-2.96; P = 0.001] and all-cause death (HR 2.18, 95% CI 1.31-3.62; P = 0.003). The TAPSE/PASP ratio reclassified the risk of both endpoints [net reclassification index 0.46 (95% CI 0.18-0.74) P = 0.001 and 0.49 (0.22-0.77) P < 0.001, respectively], while TAPSE or PASP alone did not (all P > 0.05). The prognostic impact of the TAPSE/PASP ratio was significant both in AL-CA patients (HR for the composite endpoint 2.47, 95% CI 1.58-3.85; P < 0.001) and in ATTR-CA (HR 1.81, 95% CI 1.11-2.95; P = 0.017). The receiver operating characteristic curve showed that the optimal cut-off for predicting prognosis was 0.47 mm/mmHg. CONCLUSION In patients with CA, RV-PA coupling predicted the risk of mortality or HF hospitalization. The TAPSE/PASP ratio was more effective than TAPSE or PASP in predicting prognosis.
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Affiliation(s)
- Daniela Tomasoni
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
| | - Aldostefano Porcari
- Department of Cardiovascular, Azienda Sanitaria Universitaria Integrata Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giovanni Battista Bonfioli
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
| | - Vincenzo Castiglione
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Maria Franzini
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
| | - Riccardo Maria Inciardi
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
| | - Anas Khalil
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Carlo Mario Lombardi
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
| | - Laura Lupi
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
| | - Matilde Nardi
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
| | - Chiara Oriecuia
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
| | - Giorgia Panichella
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Maddalena Rossi
- Department of Cardiovascular, Azienda Sanitaria Universitaria Integrata Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Nicola Saccani
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
| | - Claudia Specchia
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Giuseppe Vergaro
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Marco Merlo
- Department of Cardiovascular, Azienda Sanitaria Universitaria Integrata Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Department of Cardiovascular, Azienda Sanitaria Universitaria Integrata Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazzale Spedali Civili, Brescia 25123, Italy
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Carpenito M, Cammalleri V, Vitez L, De Filippis A, Nobile E, Bono MC, Mega S, Bunc M, Grigioni F, Ussia GP. Edge-to-Edge Repair for Tricuspid Valve Regurgitation. Preliminary Echo-Data and Clinical Implications from the Tricuspid Regurgitation IMAging (TRIMA) Study. J Clin Med 2022; 11:jcm11195609. [PMID: 36233476 PMCID: PMC9571515 DOI: 10.3390/jcm11195609] [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: 08/01/2022] [Revised: 09/05/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The natural history of tricuspid valve regurgitation (TR) is characterized by poor prognosis and high in-hospital mortality when treated with isolated surgery. We report the preliminary echocardiographic and procedural results of a prospective cohort of symptomatic patients with high to prohibitive surgical risk and at least severe TR who underwent transcatheter edge-to-edge repair through the TriClipTM system. Methods: From June 2020 to March 2022, 27 consecutive patients were screened, and 13 underwent transcatheter TriClipTM repair. In-hospital, 30-day and six-month clinical and echocardiographic outcomes were collected. Results: Nine patients had severe, three massive and one baseline torrential TR. Sustained TR reduction of ≥1 grade was achieved in all patients, of which 90% reached a moderate TR or less. On transthoracic echocardiographic examination, there were significant reductions in vena contracta width (p < 0.001), effective regurgitant orifice area (p < 0.001) and regurgitant volume (p < 0.001) between baseline and hospital discharge. We also observed a significant reduction in tricuspid annulus diameter (p < 0.001), right ventricular basal diameter (p = 0.001) and right atrial area (p = 0.026). Conclusion: Treatment with the edge-to-edge TriClip device is safe and effective. The resulting echocardiographic improvements indicate tricuspid valve leaflet approximation does not just significantly reduce the grade of TR but also affects adjacent structures and improves right ventricular afterload adaptation.
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Affiliation(s)
- Myriam Carpenito
- Operative Research Unit of Cardiovascular Science, Fondazione Policlinico, Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Valeria Cammalleri
- Operative Research Unit of Cardiovascular Science, Fondazione Policlinico, Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Luka Vitez
- Department of Cardiology, University Medical Center Ljubljana, 1000 Lubljana, Slovenia
| | - Aurelio De Filippis
- Research Unit of Cardiovascular Science, Department Medicine, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Edoardo Nobile
- Research Unit of Cardiovascular Science, Department Medicine, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Maria Caterina Bono
- Operative Research Unit of Cardiovascular Science, Fondazione Policlinico, Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Simona Mega
- Operative Research Unit of Cardiovascular Science, Fondazione Policlinico, Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Matjaz Bunc
- Department of Cardiology, University Medical Center Ljubljana, 1000 Lubljana, Slovenia
| | - Francesco Grigioni
- Operative Research Unit of Cardiovascular Science, Fondazione Policlinico, Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Science, Department Medicine, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Gian Paolo Ussia
- Operative Research Unit of Cardiovascular Science, Fondazione Policlinico, Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
- Research Unit of Cardiovascular Science, Department Medicine, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
- Correspondence: ; Tel.: +39-06225411612
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