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Saeed Al-Asad K, Martinez Salazar A, Radwan Y, Wang E, Salam MF, Sabanci R, Saeed M, Halboni A, Al-Abcha A, Abela G. Transcatheter Aortic Valve Replacement in Bicuspid Versus Tricuspid Aortic Valve Stenosis: Meta-Analysis and Systemic Review. Am J Cardiol 2023; 203:105-112. [PMID: 37487404 DOI: 10.1016/j.amjcard.2023.06.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 07/26/2023]
Abstract
Because of its anatomic and procedural complexities, bicuspid aortic valve (BAV) has been excluded from previous trials investigating transcatheter aortic valve replacement (TAVR). We aimed to compare the clinical outcomes of TAVR in BAV and tricuspid aortic valve patients. We searched the databases systematically from inception until March 2023 for studies that reported the outcomes of TAVR in BAV and tricuspid aortic valve patients. The primary focus was all-cause mortality at 1 year. Additional outcomes included outcomes at 30-day follow-up. Secondary and subgroup analyses were performed on propensity-matched patients, patients at low surgical risk, and based on the type of transcatheter valve type. We included 30 studies with a total of 193,274 patients who underwent TAVR, of which 14,353 patients had BAV stenosis. The rate of 1-year mortality was lower in the BAV group compared with the tricuspid group with the results reaching statistical significance (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.75 to 0.98, p = 0.02). The rate of 30-day stroke, however, was higher in patients with BAV who underwent TAVR (OR 1.24, 95% CI 1.08 to 1.43, p <0.05). Other 30-day clinical outcomes were similar between the 2 groups. Similar outcomes were observed in secondary analysis of matched populations with less mortality and higher rate of stroke in patients with BAV (OR 0.84, 95% CI 0.72 to 0.96, p = 0.01, and OR 1.38, 95% CI 1.09 to 1.75, p <0.05, respectively). Comparing the outcomes for self-expandable and balloon-expandable valves resulted in similar results. Subgroup analysis of low-surgical-risk patients similarly showed lower 1-year mortality in patients with BAV (OR 0.67, 95% CI 0.50 to 0.91, p = 0.01), without difference in 30-day stroke between the 2 groups (OR 1.24, 95% CI 0.83 to 1.88, p = 0.30). In conclusion, this report indicates that TAVR is safe and feasible in patients with BAV, including patients at low surgical risk. The higher rate of 30-day stroke, however, warrants caution when pursuing TAVR in this population. More studies, specifically randomized trials, are still warranted to further assess the safety and the long-term outcomes in this group.
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Affiliation(s)
- Khalid Saeed Al-Asad
- Department of Internal Medicine, Michigan State University, East Lansing, Michigan.
| | | | - Yasser Radwan
- Department of Internal Medicine, Michigan State University, East Lansing, Michigan
| | - Enhua Wang
- Department of Internal Medicine, Michigan State University, East Lansing, Michigan
| | - Mohammad Fahad Salam
- Department of Internal Medicine, Michigan State University, East Lansing, Michigan
| | - Rand Sabanci
- Department of Internal Medicine, Michigan State University, East Lansing, Michigan
| | - Moiz Saeed
- Department of Internal Medicine, Michigan State University, East Lansing, Michigan
| | - Adnan Halboni
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | | | - George Abela
- Department of Cardiology, Michigan State University, East Lansing, Michigan
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2
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Li Y, Lei R, Zhou J, Wang J, Zhang H. Lower incidence of new-onset severe conduction disturbances after transcatheter aortic valve implantation with bicuspid aortic valve in patients with no baseline conduction abnormality: a cross-sectional investigation in a single center in China. Front Cardiovasc Med 2023; 10:1176984. [PMID: 37441707 PMCID: PMC10333533 DOI: 10.3389/fcvm.2023.1176984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/09/2023] [Indexed: 07/15/2023] Open
Abstract
Background With technological advancements, the incidence of most transcatheter aortic valve implantation (TAVI)-related complications, with the exception of conduction disturbances, has decreased. Bicuspid aortic valve (BAV) is also no longer considered a contraindication to TAVI; however, the effect of BAV on postoperative conduction disturbances after TAVI is unknown. Methods We collected information on patients who met the indications for TAVI and successfully underwent TAVI at our center between January 2018 and January 2021. Patients with preoperative pacemaker implantation status or conduction disturbances (atrioventricular block, bundle branch block, and intraventricular block) were excluded. Based on imaging data, the patients were categorized into the BAV group and the tricuspid aortic valve (TAV) group. The incidence of new perioperative conduction disturbances was compared between the two groups. Results A total of 187 patients were included in this study, 64 (34.2%) of whom had BAV. The incidence of third-degree block in the BAV group was 1.6%, which was lower than that (13.0%) in the TAV group (P < 0.05). Multivariate logistic regression results showed that the risk of third-degree conduction disturbances was 15-fold smaller in the BAV group than that in the TAV group [relative risk (RR) = 0.067, 95% CI = 0.008-0.596, P < 0.05]. The risk of other blocks in the BAV group was about half of that in the TAV group (RR = 0.498, 95% CI = 0.240-1.032); however, the difference was not statistically significant (P > 0.05). Conclusion The present study found that patients with BAV had a lower rate of third-degree conduction disturbances after TAVI than patients with TAV.
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Affiliation(s)
- Yuehuan Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ruobing Lei
- Chevidence Lab Child & Adolescent Health, Department of Pediatric Research Institute, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Jiawei Zhou
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiangang Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haibo Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Xiong TY, Ali WB, Feng Y, Hayashida K, Jilaihawi H, Latib A, Lee MKY, Leon MB, Makkar RR, Modine T, Naber C, Peng Y, Piazza N, Reardon MJ, Redwood S, Seth A, Sondergaard L, Tay E, Tchetche D, Yin WH, Chen M, Prendergast B, Mylotte D. Transcatheter aortic valve implantation in patients with bicuspid valve morphology: a roadmap towards standardization. Nat Rev Cardiol 2023; 20:52-67. [PMID: 35726019 DOI: 10.1038/s41569-022-00734-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 02/08/2023]
Abstract
Indications for transcatheter aortic valve implantation (TAVI) have expanded in many countries to include patients with aortic stenosis who are at low surgical risk, and a similar expansion to this cohort is anticipated elsewhere in the world, together with an increase in the proportion of patients with bicuspid aortic valve (BAV) morphology as the age of the patients being treated decreases. To date, patients with BAV have been excluded from major randomized trials of TAVI owing to anatomical considerations. As a consequence, BAV has been a relative contraindication to the use of TAVI in international guidelines. Although clinical experience and observational data are accumulating, BAV presents numerous anatomical challenges for successful TAVI, despite advances in device design. Furthermore, in those with BAV, substantial geographical variation exists in patient characteristics, clinical approach and procedural strategy. Therefore, in this Roadmap article, we summarize the existing evidence and provide consensus recommendations from an international group of experts on the application of TAVI in patients with BAV in advance of the anticipated growth in the use of this procedure in this challenging cohort of patients.
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Affiliation(s)
- Tian-Yuan Xiong
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | | | - Yuan Feng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, New York, NY, USA
| | | | - Martin B Leon
- Columbia University Medical Center, New York, NY, USA
| | - Raj R Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Thomas Modine
- Department of Heart Valve Therapy, CHU Bordeaux, Bordeaux, France.,IHU Lyric, Bordeaux-, Pessac, France.,Shanghai Jiaotong University, Shanghai, China
| | - Christoph Naber
- Department of Cardiology, Klinikum Wilhelmshaven, Wilhelmshaven, Germany
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Nicolo Piazza
- Division of Cardiology, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Michael J Reardon
- Houston Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX, USA
| | - Simon Redwood
- Department of Cardiology, St Thomas' Hospital, London, UK
| | - Ashok Seth
- Fortis Escorts Heart Institute, New Delhi, India
| | - Lars Sondergaard
- The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Edgar Tay
- National University Heart Center, National University of Singapore, Singapore, Singapore
| | - Didier Tchetche
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Wei-Hsian Yin
- Heart Center, ChengHsin General Hospital, Taipei, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.
| | - Bernard Prendergast
- Department of Cardiology, St Thomas' Hospital, London, UK. .,Cleveland Clinic London, London, UK.
| | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, National University of Ireland, Galway, Ireland.
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4
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Niu G, Ali WB, Wang M, Jilaihawi H, Zhang H, Zhang Q, Ye Y, Liu X, Yao J, Zhao Q, Wang Y, Zhou Z, Zhang L, Ren X, An Y, Lu B, Modine T, Wu Y, Song G. Anatomical morphology of the aortic valve in Chinese aortic stenosis patients and clinical results after downsize strategy of transcatheter aortic valve replacement. Chin Med J (Engl) 2022; 135:2968-2975. [PMID: 36728213 PMCID: PMC10106152 DOI: 10.1097/cm9.0000000000002517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The study aimed to describe the aortic valve morphology in Chinese patients underwent transcatheter aortic valve replacement (TAVR) for symptomatic severe aortic stenosis (AS), and the impact of sizing strategies and related procedural outcomes. METHODS Patients with severe AS who underwent TAVR were consecutively enrolled from 2012 to 2019. The anatomy and morphology of the aortic root were assessed. "Downsize" strategy was preformed when patients had complex morphology. The clinical outcomes of patients who performed downsize strategy were compared with those received annular sizing strategy. The primary outcome was device success rate, and secondary outcomes included Valve Academic Research Consortium-3 clinical outcomes variables based on 1-year follow-up. RESULTS A total of 293 patients were enrolled. Among them, 95 patients (32.4%) had bicuspid aortic valve. The calcium volume (Hounsfield Unit-850) of aortic root was 449.90 (243.15-782.15) mm 3 . Calcium is distributed mostly on the leaflet level. Downsize strategy was performed in 204 patients (69.6%). Compared with the patients who performed annular sizing strategy, those received downsize strategy achieved a similar device success rate (82.0% [73] vs . 83.3% [170], P = 0.79). Aortic valve gradients (downsize strategy group vs . annular sizing group, 11.28 mmHg vs. 11.88 mmHg, P = 0.64) and percentages of patients with moderate or severe paravalvular regurgitation 2.0% (4/204) vs . 4.5% (4/89), P = 0.21) were similar in the two groups at 30 days after TAVR. These echocardiographic results were sustainable for one year. CONCLUSIONS Chinese TAVR patients have more prevalent bicuspid morphology and large calcium volume of aortic root. Calcium is distributed mostly on the leaflet level. Compare with annular sizing strategy, downsize strategy provided a non-inferior device success rate and transcatheter heart valve hemodynamic performance in self-expanding TAVR procedure.
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Affiliation(s)
- Guannan Niu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Walid Ben Ali
- Structural Heart Intervention Program, Department of Surgery, Montreal Heart Institute, Montreal H1T 1C8, Quebec, Canada
| | - Moyang Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Hasan Jilaihawi
- Heart Valve Center, NYU Langone Health, New York, NY 10016, USA
| | - Haitong Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Qian Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Yunqing Ye
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Xinmin Liu
- Interventional Center of Valvular Heart Disease, Anzhen Hospital Affiliate of Capital University of Medical Sciences, Beijing 100029, China
| | - Jing Yao
- Interventional Center of Valvular Heart Disease, Anzhen Hospital Affiliate of Capital University of Medical Sciences, Beijing 100029, China
| | - Qinghao Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Yubin Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Zheng Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Lizhi Zhang
- Eagles Corelab., YingKe Medical (Beijing) Co., Ltd, Beijing 100160, China
| | - Xinshuang Ren
- Department of Radiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yunqiang An
- Department of Radiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Bin Lu
- Department of Radiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Thomas Modine
- Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévèque, CHU Bordeaux, Bordeaux 33000, France
| | - Yongjian Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
| | - Guangyuan Song
- Interventional Center of Valvular Heart Disease, Anzhen Hospital Affiliate of Capital University of Medical Sciences, Beijing 100029, China
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5
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Zghouzi M, Osman H, Ullah W, Suleiman AR, Razvi P, Abdalrazzak M, Rabbat F, Alraiyes M, Sattar Y, Bagur R, Paul T, Matetic A, Mamas MA, Lakkis N, Alraies MC. Safety and efficacy of transcatheter aortic valve implantation in stenotic bicuspid aortic valve compared to tricuspid aortic valve: a systematic review and meta-analysis. Expert Rev Cardiovasc Ther 2022; 20:581-588. [PMID: 35770517 DOI: 10.1080/14779072.2022.2094368] [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: 01/10/2023]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has emerged as a safe and effective alternative to surgical replacement for tricuspid aortic valve (TAV) stenosis. However, utilization of TAVI for aortic stenosis in bicuspid aortic valve (BAV) compared to TAV remains controversial. METHODS We queried online databases with various keywords to identify relevant articles. We compared major cardiovascular events and procedural outcomes using a random effect model to calculate odds ratios (OR). RESULTS We included a total of 22 studies comprising 189,693 patients (BAV 12,669 vs. TAV 177,024). In the pooled analysis, there were no difference in TAVI for BAV vs. TAV for all-cause mortality, cardiovascular mortality, myocardial infarction (MI), vascular complications, acute kidney injury (AKI), coronary occlusion, annulus rupture, and reintervention/reoperation between the groups. The incidence of stroke (OR 1.24; 95% CI 1.1-1.39), paravalvular leak (PVLR) (OR 1.42; 95% CI 1.26-1.61), and the need for pacemaker (OR 1.15; 95% CI 1.06-1.26) was less in the TAV group compared to the BAV group, while incidence of life-threatening bleeding was higher in the TAV group. Subgroup analysis mirrored pooled outcomes except for all-cause mortality. CONCLUSION The use of TAVI for the treatment of aortic stenosis in selective BAV appears to be safe and effective.
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Affiliation(s)
- Mohamed Zghouzi
- Department of Internal Medicine, Detroit Medical Center, Detroit, MI, USA
| | - Heba Osman
- Department of Internal Medicine, Detroit Medical Center, Detroit, MI, USA
| | - Waqas Ullah
- Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Parveen Razvi
- Department of Internal Medicine, Detroit Medical Center, Detroit, MI, USA
| | - Mukhlis Abdalrazzak
- Division of Cardiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Firas Rabbat
- Division of Cardiolog, Internal medicine, Baptist hospital, Miami, FL, USA
| | - Mowaffak Alraiyes
- Division of Cardiology, Vernon Hills High School, Vernon Hills, IL, USA
| | - Yasar Sattar
- Division of cardiology, West Virginia University, Morgantown, WV, USA
| | - Rodrigo Bagur
- Division of Cardiology, London Health Sciences Centre, Western University, London, ON, Canada
| | - Timir Paul
- Department of Medical Education, University of Tennessee at Nashville, Nashville, TN, USA
| | - Andrija Matetic
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
| | - Nasser Lakkis
- Division of cardiology, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - M Chadi Alraies
- Division of cardiology, Wayne State University/Detroit Medical Center, Detroit, MI, USA
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6
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Zhang Y, Xiong TY, Li YM, Yao YJ, He JJ, Yang HR, Zhu ZK, Chen F, Ou Y, Wang X, Liu Q, Li X, Li YJ, Liao YB, Huang FY, Zhao ZG, Li Q, Wei X, Peng Y, He S, Wei JF, Zhou WX, Zheng MX, Bao Y, Zhou X, Tang H, Meng W, Feng Y, Chen M. Patients With Bicuspid Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:794850. [PMID: 35369357 PMCID: PMC8965870 DOI: 10.3389/fcvm.2022.794850] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/07/2022] [Indexed: 01/10/2023] Open
Abstract
Objective We sought to conduct a systematic review and meta-analysis of clinical adverse events in patients undergoing transcatheter aortic valve replacement (TAVR) with bicuspid aortic valve (BAV) vs. tricuspid aortic valve (TAV) anatomy and the efficacy of balloon-expandable (BE) vs. self-expanding (SE) valves in the BAV population. Comparisons aforementioned will be made stratified into early- and new-generation devices. Differences of prosthetic geometry on CT between patients with BAV and TAV were presented. In addition, BAV morphological presentations in included studies were summarized. Method Observational studies and a randomized controlled trial of patients with BAV undergoing TAVR were included according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Results A total of 43 studies were included in the final analysis. In patients undergoing TAVR, type 1 BAV was the most common phenotype and type 2 BAV accounted for the least. Significant higher risks of conversion to surgical aortic valve replacement (SAVR), the need of a second valve, a moderate or severe paravalvular leakage (PVL), device failure, acute kidney injury (AKI), and stroke were observed in patients with BAV than in patients with TAV during hospitalization. BAV had a higher risk of new permanent pacemaker implantation (PPI) both at hospitalization and a 30-day follow-up. Risk of 1-year mortality was significantly lower in patients with BAV than that with TAV [odds ratio (OR) = 0.85, 95% CI 0.75–0.97, p = 0.01]. BE transcatheter heart valves (THVs) had higher risks of annular rupture but a lower risk of the need of a second valve and a new PPI than SE THVs. Moreover, BE THV was less expanded and more elliptical in BAV than in TAV. In general, the rates of clinical adverse events were lower in new-generation THVs than in early-generation THVs in both BAV and TAV. Conclusions Despite higher risks of conversion to SAVR, the need of a second valve, moderate or severe PVL, device failure, AKI, stroke, and new PPI, TAVR seems to be a viable option for selected patients with severe bicuspid aortic stenosis (AS), which demonstrated a potential benefit of 1-year survival, especially among lower surgical risk population using new-generation devices. Larger randomized studies are needed to guide patient selection and verified the durable performance of THVs in the BAV population.
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Affiliation(s)
- Yi Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Tian-Yuan Xiong
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi-Ming Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi-Jun Yao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing-Jing He
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hao-Ran Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhong-Kai Zhu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Fei Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yuanweixiang Ou
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xi Wang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qi Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xi Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi-Jian Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan-Biao Liao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Fang-Yang Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Zhen-Gang Zhao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiao Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Wei
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Sen He
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jia-Fu Wei
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wen-Xia Zhou
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming-Xia Zheng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yun Bao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xuan Zhou
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Tang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Meng
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan Feng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
- Yuan Feng
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Mao Chen
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7
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Gorla R, Casenghi M, Finotello A, De Marco F, Morganti S, Regazzoli D, Bianchi G, Acerbi E, Popolo Rubbio A, Brambilla N, Testa L, Castriota F, Auricchio F, Reimers B, Bedogni F. Outcome of transcatheter aortic valve replacement in bicuspid aortic valve stenosis with new-generation devices. Interact Cardiovasc Thorac Surg 2021; 32:20-28. [PMID: 33201993 DOI: 10.1093/icvts/ivaa231] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/05/2020] [Accepted: 09/03/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To compare device success and paravalvular leak rates of 3 new-generation transcatheter aortic valve replacement devices in patients with bicuspid aortic valve stenosis and to test their biomechanical performance in a computer-based simulation model of aortic root with increasing ellipticity. METHODS This retrospective multicentre study included 56 bicuspid aortic valve patients undergoing transcatheter aortic valve replacement with new-generation devices: Lotus/Lotus Edge (N = 15; 27%), Evolut-R (N = 20; 36%) and ACURATE neo (N = 21; 37%). Three virtual simulation models of aortic root with increasing index of eccentricity (0-0.25-0.5) were implemented. Stress distribution, stent-root contact area and paravalvular orifice area were computed. RESULTS Device success was achieved in 43/56 patients (77%) with comparable rates among Lotus (87%), Evolut-R (60%) and ACURATE neo (86%; P = 0.085). Moderate paravalvular leak rate was significantly lower in the Lotus group as compared to Evolut-R group (0% vs 30%; P = 0.027) and comparable to the ACURATE neo group (0% vs 10%; P = 0.33). By index of eccentricity = 0.5, Lotus showed a uniform and symmetric pattern of stress distribution with absent paravalvular orifice area, ACURATE neo showed a mild asymmetry with small paravalvular orifice area (1.1 mm2), whereas a severely asymmetric pattern was evident with Evolut-R, resulting in a large paravalvular orifice area (12.0 mm2). CONCLUSIONS Transcatheter aortic valve replacement in bicuspid aortic valve patients with new-generation devices showed comparable device success rates. Lotus showed moderate paravalvular leak rate comparable to that of ACURATE neo and significantly lower than Evolut-R. On simulation, Lotus and ACURATE neo showed optimal adaptability to elliptic anatomies as compared to Evolut-R.
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Affiliation(s)
- Riccardo Gorla
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Matteo Casenghi
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Alice Finotello
- Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Genoa, Italy
| | - Federico De Marco
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Simone Morganti
- Department of Electrical, Computer, and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Damiano Regazzoli
- Department of Clinical and Interventional Cardiology, Cardio Center, Humanitas Research Hospital, Rozzano-Milano, Italy
| | - Giovanni Bianchi
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Elena Acerbi
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Antonio Popolo Rubbio
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Nedy Brambilla
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Luca Testa
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Fausto Castriota
- Department of Clinical and Interventional Cardiology, Humanitas Gavazzeni Hospital, Bergamo, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Bernhard Reimers
- Department of Clinical and Interventional Cardiology, Cardio Center, Humanitas Research Hospital, Rozzano-Milano, Italy
| | - Francesco Bedogni
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
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8
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Tarantini G, Fabris T. Transcatheter Aortic Valve Replacement for Bicuspid Aortic Valve Stenosis: A Practical Operative Overview. Circ Cardiovasc Interv 2021; 14:e009827. [PMID: 34130478 DOI: 10.1161/circinterventions.120.009827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The bicuspid aortic valve (BAV) represents a complex anatomic scenario for transcatheter aortic valve replacement (TAVR) because of its unique technical challenges. As TAVR is moving towards younger and lower-risk populations, the proportion of BAV patients undergoing TAVR is expected to rise. Initial experiences of TAVR with first-generation transcatheter heart valves in high surgical risk patients with BAV stenosis showed higher rates of device failure and periprocedural complications as compared to tricuspid anatomy. The subsequent advances in imaging techniques and understanding of BAV anatomy, new iterations of transcatheter heart valves, and growing operators' experience yielded better outcomes. However, in the lack of randomized trials and rigorous evidence, the field of TAVR in BAV has been driven by empirical observations, with wide variability in transcatheter heart valve sizing and implantation techniques across different centers and operators. Thus, in this review article, we provide a fully illustrated overview of operative periprocedural steps for TAVR in BAV stenosis, though recognizing that it still remains anecdotal.
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Affiliation(s)
- Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy
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9
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Toggweiler S. The LOTUS Edge Is Up for a Challenge. JACC Cardiovasc Interv 2021; 14:182-184. [PMID: 33478634 DOI: 10.1016/j.jcin.2020.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/27/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Stefan Toggweiler
- Heart Center Lucerne, Department of Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland.
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10
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Majmundar M, Kumar A, Doshi R, Shah P, Arora S, Shariff M, Adalja D, Visco F, Amin H, Vallabhajosyula S, Gullapalli N, Kapadia SR, Kalra A, Panaich SS. Meta-Analysis of Transcatheter Aortic Valve Implantation in Patients With Stenotic Bicuspid Versus Tricuspid Aortic Valve. Am J Cardiol 2021; 145:102-110. [PMID: 33460604 DOI: 10.1016/j.amjcard.2020.12.085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/28/2020] [Accepted: 12/31/2020] [Indexed: 01/10/2023]
Abstract
Most of the trials investigating the role of transcatheter aortic valve implantation (TAVI) across various strata of risk categories have excluded patients with bicuspid aortic stenosis (BAS) due to its anatomical complexities. The aim of this study was to perform a meta-analysis with meta-regression of studies comparing clinical, procedural, and after-procedural echocardiographic outcomes in BAS versus tricuspid aortic stenosis (TAS) patients who underwent TAVI. We searched the PubMed and Cochrane databases for relevant articles from the inception of the database to October 2019. Continuous and categorical variables were pooled using inverse variance and Mantel-Haenszel method, respectively, using the random-effect model. To rate the certainty of evidence for each outcome, we used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) approach. Nineteen articles were included in the final analysis. There was no difference in the risk of 30-day mortality, 1-year mortality, 30-day cardiovascular mortality, major and/or life-threatening bleeding, major vascular complications, acute kidney injury, permanent pacemaker implantation, device success, annular rupture, after-procedural aortic valve area, and mean pressure gradient between the 2 groups. BAS patients who underwent TAVI had a higher risk of 30-day stroke, conversion to surgery, need for second valve implantation, and moderate to severe paravalvular leak. In conclusion, the present meta-analysis supports the feasibility of TAVI in surgically ineligible patients with BAS. However, the incidence of certain procedural complications such as stroke, conversion to surgery, second valve implantation, and paravalvular leak is higher among BAS patients compared with TAS patients, which must be discussed with the patient during the decision-making process.
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11
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First-in-Human Experience With Patient-Specific Computer Simulation of TAVR in Bicuspid Aortic Valve Morphology. JACC Cardiovasc Interv 2020; 13:184-192. [DOI: 10.1016/j.jcin.2019.07.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 01/14/2023]
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12
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Greutmann M, Benson L, Silversides CK. Percutaneous Valve Interventions in the Adult Congenital Heart Disease Population: Emerging Technologies and Indications. Can J Cardiol 2019; 35:1740-1749. [PMID: 31813506 DOI: 10.1016/j.cjca.2019.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/01/2019] [Accepted: 10/17/2019] [Indexed: 11/28/2022] Open
Abstract
Adult survivors with congenital heart disease are not cured and residual cardiac valve lesions are common and contribute substantially to long-term morbidity. Given the increased risk of reoperations in patients with previous cardiac surgery, percutaneous treatment options have been developed. Initially percutaneous therapies focused on right ventricular outflow tract lesions, but they have now expanded to include mitral and aortic valve interventions. Although some of these procedures, such as balloon valvuloplasty of pulmonary valve stenosis and percutaneous pulmonary valve replacement, have become standard of care, there are many new and evolving technologies that will likely become important treatment strategies over the coming decade. The key for success of these transcatheter valve procedures is the careful evaluation of the patient's individual anatomy and physiology and a multidisciplinary assessment involving cardiologists specialized in adult congenital heart disease, specialized imagers, cardiac surgeons, and interventionalists. Because many of these percutaneous interventions are relatively new, long-term outcomes are not yet well defined, dictating the need for careful and structured long-term observational studies on outcomes of these novel procedures, which will allow refining the indications of a specific intervention and to improve its technical aspects. The aim of this article is to provide an overview of common valve lesions in the adult congenital heart disease population and to discuss treatment options and strategies with a specific focus on percutaneous options.
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Affiliation(s)
- Matthias Greutmann
- University Heart Centre, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland.
| | - Lee Benson
- Toronto Congenital Cardiac Centre for Adults, University Health Network, Division of Cardiology, University of Toronto, Toronto, Ontario, Canada; Labatt Family Heart Centre, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Candice K Silversides
- Toronto Congenital Cardiac Centre for Adults, Division of Cardiology, University of Toronto, Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
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13
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Kochman J, Zbroński K, Kołtowski Ł, Parma R, Ochała A, Huczek Z, Rymuza B, Wilimski R, Dąbrowski M, Witkowski A, Scisło P, Grygier M, Lesiak M, Opolski G. Transcatheter aortic valve implantation in patients with bicuspid aortic valve stenosis utilizing the next-generation fully retrievable and repositionable valve system: mid-term results from a prospective multicentre registry. Clin Res Cardiol 2019; 109:570-580. [PMID: 31478072 PMCID: PMC7182541 DOI: 10.1007/s00392-019-01541-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 08/22/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the outcomes of transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve (BiAV) stenosis using a mechanically expanded Lotus™ device. The prior experience with first-generation devices showed disappointing results mainly due to increased prevalence of aortic regurgitation (AR) that exceeded those observed in tricuspid stenosis. METHODS AND RESULTS We collected baseline, in-hospital, 30-day and 2-year follow-up data from a prospective, multicentre registry of patients with BiAV undergoing TAVI using Lotus™ valve. Safety and efficacy endpoints were assessed according to VARC-2 criteria. The study group comprised 24 patients. The mean age was 73.5 years and the mean EuroSCORE 2 was 4.35 ± 2.56%. MDCT analysis revealed Type 1 BiAV in 75% of patients. The mean gradient decreased from 60.1 ± 18.3 to 15 ± 6.4 mm Hg, the AVA increased from 0.6 ± 0.19 to 1.7 ± 0.21 cm2. One in-hospital death was observed secondary to aortic perforation. There was no severe AR and the rate of moderate AR equalled 9% at 30 days (n = 2). Device success was achieved in 83% and the 30-day safety endpoint was 17%. In the 2-year follow-up, the overall mortality was 12.5% and the 2-year composite clinical efficacy endpoint was met in 25% of the patients (n = 6) CONCLUSIONS: The TAVI in selected BiAV patients using the Lotus™ is feasible and characterized by encouraging valve performance and mid-term clinical outcomes.
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Affiliation(s)
- Janusz Kochman
- First Department of Cardiology, Medical University of Warsaw, ul. Banacha 1a, PL, 02-097, Warsaw, Poland
| | - Karol Zbroński
- First Department of Cardiology, Medical University of Warsaw, ul. Banacha 1a, PL, 02-097, Warsaw, Poland.
| | - Łukasz Kołtowski
- First Department of Cardiology, Medical University of Warsaw, ul. Banacha 1a, PL, 02-097, Warsaw, Poland
| | | | | | - Zenon Huczek
- First Department of Cardiology, Medical University of Warsaw, ul. Banacha 1a, PL, 02-097, Warsaw, Poland
| | - Bartosz Rymuza
- First Department of Cardiology, Medical University of Warsaw, ul. Banacha 1a, PL, 02-097, Warsaw, Poland
| | - Radosław Wilimski
- Department of Cardiac Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Dąbrowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Piotr Scisło
- First Department of Cardiology, Medical University of Warsaw, ul. Banacha 1a, PL, 02-097, Warsaw, Poland
| | - Marek Grygier
- Department of Cardiology, Poznan University of Medical Science, Poznan, Poland
| | - Maciej Lesiak
- Department of Cardiology, Poznan University of Medical Science, Poznan, Poland
| | - Grzegorz Opolski
- First Department of Cardiology, Medical University of Warsaw, ul. Banacha 1a, PL, 02-097, Warsaw, Poland
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14
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van Gils L, Van Mieghem NM. Transcatheter Aortic Valve Replacement with the Lotus Valve: Concept and Current State of the Data. Interv Cardiol Clin 2019; 8:393-402. [PMID: 31445723 DOI: 10.1016/j.iccl.2019.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Multiple transcatheter heart valve iterations have created an interesting range of options with which to perform transcatheter aortic valve replacement. The Lotus valve has several attractive features. The ability to eradicate even mild paravalvular leak mirrors the outcomes of surgical aortic valve replacement. New design iterations of the Lotus valve and refined sizing algorithms may help mitigate the need for permanent pacemaker implantation and consolidate its best-in-class results in terms of paravalvular leak. Ongoing trials should help define the safety and efficacy of the Lotus transcatheter heart valve in contemporary practice.
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Affiliation(s)
- Lennart van Gils
- Department of Interventional Cardiology, Thoraxcenter, ErasmusMC, Room Rg-628, 's Gravendijkwal 230, Rotterdam 3015 CE, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, ErasmusMC, Room Rg-628, 's Gravendijkwal 230, Rotterdam 3015 CE, The Netherlands.
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15
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Blackman DJ, Van Gils L, Bleiziffer S, Gerckens U, Petronio AS, Abdel-Wahab M, Werner N, Khogali SS, Wenaweser P, Wöhrle J, Soliman O, Laborde JC, Allocco DJ, Meredith IT, Falk V, Van Mieghem NM. Clinical outcomes of the Lotus Valve in patients with bicuspid aortic valve stenosis: An analysis from the RESPOND study. Catheter Cardiovasc Interv 2019; 93:1116-1123. [PMID: 30773838 PMCID: PMC6593645 DOI: 10.1002/ccd.28120] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 01/04/2019] [Accepted: 01/20/2019] [Indexed: 11/08/2022]
Abstract
AIMS Patients with bicuspid valves represent a challenging anatomical subgroup for transcatheter aortic valve implantation (TAVI). This analysis evaluated the clinical outcomes of the fully repositionable and retrievable Lotus Valve System in patients with bicuspid aortic valves enrolled in the RESPOND post-market registry. METHODS AND RESULTS The prospective, open-label RESPOND study enrolled 1,014 patients at 41 centers in Europe, New Zealand, and Latin America, 31 (3.1%) of whom had bicuspid aortic valves. The mean age in the bicuspid patient cohort was 76.4 years, 64.5% were male, and the baseline STS score was 6.0 ± 10.2. Procedural success was 100%, with no cases of malpositioning, valve migration, embolization, or valve-in-valve. Repositioning was attempted in 10 cases (32.3%). There was one death (3.2%) and one stroke (3.2%) at 30-day follow-up. Mean AV gradient was reduced from 48.7 ± 17.0 mmHg at baseline to 11.8 ± 5.1 mmHg at hospital discharge (P < 0.001); mean effective orifice area (EOA) was increased from 0.6 ± 0.2 cm2 to 1.7 ± 0.4 cm2 (P < 0.001). There were no cases of moderate or severe paravalvular leak (PVL) adjudicated by the core laboratory; four subjects (13.8%) had mild PVL, 5 (17.2%) had trace PVL. The rate of pacemaker (PM) implantation for PM-naïve patients was 22.2% (6/27). CONCLUSIONS Data from the RESPOND registry demonstrate good clinical and echocardiographic outcomes up to 1 year postimplantation in patients with bicuspid aortic valves using the repositionable Lotus Valve.
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Affiliation(s)
- Daniel J Blackman
- Department of Cardiology, Leeds General Infirmary, Leeds, United Kingdom
| | - Lennart Van Gils
- Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, CE, Rotterdam, The Netherlands
| | - Sabine Bleiziffer
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Ulrich Gerckens
- Department of Cardiology, University of Rostock, Rostock, Germany
| | - Anna Sonia Petronio
- Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Mohamed Abdel-Wahab
- Cardiology Department, Heart Center Leipzig at the University of Leipzig, Leipzig, Germany
| | - Nikos Werner
- Interventional Cardiology, Heart Center, University Hospital Bonn, Bonn, Germany
| | - Saib S Khogali
- The Heart and Lung Centre, New Cross Hospital, Wolverhampton, United Kingdom
| | - Peter Wenaweser
- Swiss Cardiovascular Center Bern, University Hospital Bern, Bern, Switzerland
| | - Jochen Wöhrle
- Department of Internal Medicine II, University of Ulm, Germany
| | - Osama Soliman
- Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, CE, Rotterdam, The Netherlands
| | - Jean-Claude Laborde
- Department of Cardiology and Cardiothoracic Surgery, St. George's Hospital, London, United Kingdom
| | - Dominic J Allocco
- Interventional Cardiology, Boston Scientific Corporation, Marlborough, Massachusetts
| | - Ian T Meredith
- Interventional Cardiology, Boston Scientific Corporation, Marlborough, Massachusetts
| | - Volkmar Falk
- Deutsches Herzzentrum Berlin, Klinik für Herz-Thorax-Gefässchirurgie, Berlin, Germany
| | - Nicolas M Van Mieghem
- Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, CE, Rotterdam, The Netherlands
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