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Holmes HR, Falasa M, Neal D, Choi CY, Park K, Bavry AA, Freeman KA, Manning EW, Stinson WW, Jeng EI. Monitored Anesthesia Care Versus General Anesthesia for Transcatheter Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:401-408. [PMID: 36217748 DOI: 10.1177/15569845221124113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Monitored anesthesia care (MAC) has been increasingly used in lieu of general anesthesia (GA) for transcatheter aortic valve replacement (TAVR). We sought to compare outcomes and in-hospital costs between MAC and GA for TAVR at a Veterans Affairs Medical Center. METHODS A single-center retrospective review was performed of 349 patients who underwent transfemoral TAVR (MAC, n = 244 vs GA, n = 105) from January 2014 to December 2019. Baseline patient characteristics, operating room (OR) time, intensive care unit (ICU) length of stay (LOS), and cost, total LOS, hospital cost, total cost, and complication rates were collected. Propensity matching was performed and resulted in 83 matched pairs. RESULTS In the unmatched TAVR cohort, MAC TAVR was associated with reduced OR time (146 vs 198 min, P < 0.001), ICU LOS (1.4 vs 1.8 days, P < 0.001), total hospital LOS (3.4 vs 5.4 days, P < 0.001), and lower index total cost ($81,300 vs $85,400, P = 0.010). After propensity matching, MAC TAVR patients had reduced OR time (146 vs 196 min, P < 0.05), ICU LOS (1.2 vs 1.7 days, P = 0.006), total LOS (3.5 vs 5.1 days, P = 0.001), and 180-day mortality (2.4% vs 12%, P < 0.03). There was no difference in total hospitalization cost or total cost. CONCLUSIONS In propensity-matched groups, TAVR utilizing MAC is associated with improved OR time efficiency, decreased LOS, and a reduction in 180-day mortality but no significant difference in cost.
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Affiliation(s)
- Henry R Holmes
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Matheus Falasa
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Daniel Neal
- Department of Surgery, University of Florida Health, Gainesville, FL, USA
| | - Calvin Y Choi
- Division of Cardiology, Department of Medicine, University of Florida Health, Gainesville, FL, USA.,Division of Cardiology, Department of Medicine, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Ki Park
- Division of Cardiology, Department of Medicine, University of Florida Health, Gainesville, FL, USA.,Division of Cardiology, Department of Medicine, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Anthony A Bavry
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kirsten A Freeman
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Eddie W Manning
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Wade W Stinson
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA.,Division of Thoracic and Cardiovascular Surgery, Department of Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA
| | - Eric I Jeng
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, FL, USA
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2
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Yang R, Grober AF, Riojas R, Ponna V, Shunk KA, Zimmet JM, Gustafson J, Ge L, Tseng EE. Midterm Durability and Structural Valve Degeneration of Transcatheter Aortic Valve Replacement in a Federal Facility. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:382-391. [PMID: 36217736 PMCID: PMC9761483 DOI: 10.1177/15569845221123259] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Transcatheter aortic valve replacement (TAVR), previously reserved for patients of intermediate to prohibitive surgical risk, has now been expanded to patients of any surgical risk with severe aortic stenosis. Bioprostheses are prone to structural valve degeneration (SVD), a progressive and multifactorial process that limits valve durability. As the population undergoing TAVR shifts toward a lower-risk and younger profile, long-term durability is a crucial determinant for patient outcomes. Our objective was to determine the incidence and risk factors of SVD at midterm follow-up in a veteran TAVR population. METHODS Patients undergoing TAVR at our federal facility were retrospectively evaluated for SVD and other endpoints with standardized consensus criteria. Multivariable Cox proportional hazards analysis was performed to evaluate risk factors for mortality and SVD. RESULTS From 2013 to 2020, 344 patients (median age, 78 years) underwent TAVR. Survival from all-cause mortality was 91.3% at 1 year, 75.1% at 3 years, and 61.7% at 5 years. Cumulative freedom from SVD was 98.2% at 1 year, 96.5% at 3 years, and 93.7% at 5 years. All 13 patients with SVD met hemodynamic criteria, and 1 required intervention. Median time to hemodynamic SVD was 1.04 years. Independent risk factors for SVD included age (hazard ratio [HR] = 0.92, 95% confidence interval [CI]: 0.86 to 0.99) and valve size (HR = 0.19, 95% CI: 0.04 to 0.89). CONCLUSIONS SVD was evident at a low but detectable rate at 5-year follow-up. Further understanding of TAVR biomechanics as well as continued longer-term follow-up will be essential for informing patient-specific risk of SVD.
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Affiliation(s)
- Rachel Yang
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA
| | - Aaron F. Grober
- Division of Cardiology, University of
California San Francisco and San Francisco VA Medical Center, CA, USA
| | - Ramon Riojas
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA
| | - Vimala Ponna
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA
| | - Kendrick A. Shunk
- Division of Cardiology, University of
California San Francisco and San Francisco VA Medical Center, CA, USA
| | - Jeffrey M. Zimmet
- Division of Cardiology, University of
California San Francisco and San Francisco VA Medical Center, CA, USA
| | - Joshua Gustafson
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA,Uniformed Services University of the
Health Sciences, Bethesda, MD, USA
| | - Liang Ge
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA
| | - Elaine E. Tseng
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA,Elaine E. Tseng, MD, Division of
Cardiothoracic Surgery, University of California San Francisco and San Francisco
VA Medical Center, 500 Parnassus Ave, Ste 405W, Box 0118, San Francisco, CA
94143, USA.
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3
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Dissemination of Transcatheter Aortic Valve Replacement in the United States. J Am Coll Cardiol 2021; 78:794-806. [PMID: 34412813 DOI: 10.1016/j.jacc.2021.06.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Societal guidelines and payor coverage decisions for transcatheter aortic valve replacement (TAVR) attempt to strike a balance between providing access and maintaining quality. The extent to which dissemination of TAVR has achieved these ideals remains unknown. OBJECTIVES This study sought to define patterns of TAVR dissemination in the United States and their influence on outcomes. METHODS Using data from the TVT (Transcatheter Valvular Therapy) registry, this study identified TAVR sites from 2011 to 2018 and calculated drive-times from existing to new sites. In a contemporary cohort, this study compared site and patient characteristics by annual case volume and density of sites per million Medicare beneficiaries. Using hierarchical regression and Cox methods, this study determined the association between case volumes, site density, and changes in volume and density with patient risk profiles and outcomes. RESULTS TAVR sites participating in the TVT registry increased from 198 to 556 from 2011 to 2018. Median drive-time from existing to new sites decreased from 403 minutes (interquartile range: 211-587 minutes) to 26 minutes (interquartile range: 17-48 minutes). In a contemporary cohort, higher site density was associated with lower procedural risk as well as with an increased hazard of 30-day risk-adjusted mortality (P = 0.017). Similarly, longitudinal increases in site density over time were associated with a higher hazard of 30-day (P = 0.011) and 1-year (P = 0.013) mortality. CONCLUSIONS TAVR has expanded significantly over time, but with regional clustering of sites. Although procedural risk is lower at higher density sites, these sites demonstrate an increased hazard of mortality. These findings suggest that the expansion of TAVR services in the United States may have had unintended consequences on procedural quality.
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4
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Patel V, Jneid H, Cornwell L, Kherallah R, Preventza O, Rosengart TK, Amin A, Khalid M, Paniagua D, Denktas A, Patel A, McClafferty A, Jimenez E. Left Ventricle Mass Regression After Surgical or Transcatheter Aortic Valve Replacement in Veterans. Ann Thorac Surg 2021; 114:77-83. [PMID: 34416227 DOI: 10.1016/j.athoracsur.2021.07.039] [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: 04/26/2021] [Revised: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Differences in left ventricular mass regression (LVMR) between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have not been studied. We present clinical and echocardiographic data from veterans who underwent TAVR and SAVR, evaluating the degree of LVMR and its association with survival. METHODS We retrospectively reviewed TAVR (n = 194) and SAVR (n = 365) procedures performed in veterans from 2011 to 2019. After 1:1 propensity matching, we evaluated mortality and secondary outcomes. Echocardiographic data (median follow-up 957 days, interquartile range 483-1652 days) were used to evaluate LVMR, its association with survival, and predictors of LVMR. RESULTS There was no difference between SAVR and TAVR patients in mortality (for up to 8 years), stroke at 30 days, myocardial infarction, renal failure, prolonged ventilation, reoperation, or structural valve deterioration. SAVR patients (67.3% [101 of 150]) were more likely to have LVMR than TAVR patients (55.7% [44 of 79], P = .11). The magnitude of LVMR was greater for the SAVR patients (median, -23.3%) than for the TAVR patients (median, -17.8%, P = .062). SAVR patients with LVMR had a survival advantage over SAVR patients without LVMR (P = .016). However, LVMR was not associated with greater survival in TAVR patients (P = .248). CONCLUSIONS SAVR patients were more likely to have LVMR and had a greater magnitude of LVMR than TAVR patients. LVMR was associated with better survival in SAVR patients, but not in TAVR patients.
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Affiliation(s)
- Vivek Patel
- Department of Cardiothoracic Surgery, Texas Heart Institute, Houston, Texas; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Hani Jneid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Lorraine Cornwell
- Department of Cardiothoracic Surgery, Texas Heart Institute, Houston, Texas; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Riyad Kherallah
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ourania Preventza
- Department of Cardiothoracic Surgery, Texas Heart Institute, Houston, Texas; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Todd K Rosengart
- Department of Cardiothoracic Surgery, Texas Heart Institute, Houston, Texas; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Arsalan Amin
- Department of Cardiothoracic Surgery, Texas Heart Institute, Houston, Texas; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Mirza Khalid
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - David Paniagua
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ali Denktas
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ashley Patel
- Department of Cardiothoracic Surgery, Texas Heart Institute, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Anthony McClafferty
- Department of Cardiothoracic Surgery, Texas Heart Institute, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ernesto Jimenez
- Department of Cardiothoracic Surgery, Texas Heart Institute, Houston, Texas; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
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5
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Damschroder LJ, Knighton AJ, Griese E, Greene SM, Lozano P, Kilbourne AM, Buist DSM, Crotty K, Elwy AR, Fleisher LA, Gonzales R, Huebschmann AG, Limper HM, Ramalingam NS, Wilemon K, Ho PM, Helfrichfcr CD. Recommendations for strengthening the role of embedded researchers to accelerate implementation in health systems: Findings from a state-of-the-art (SOTA) conference workgroup. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100455. [PMID: 34175093 DOI: 10.1016/j.hjdsi.2020.100455] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 05/15/2020] [Accepted: 07/14/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Traditional research approaches do not promote timely implementation of evidence-based innovations (EBIs) to benefit patients. Embedding research within health systems can accelerate EBI implementation by blending rigorous methods with practical considerations in real-world settings. A state-of-the-art (SOTA) conference was convened in February 2019 with five workgroups that addressed five facets of embedded research and its potential to impact healthcare. This article reports on results from the workgroup focused on how embedded research programs can be implemented into heath systems for greatest impact. METHODS Based on a pre-conference survey, participants indicating interest in accelerating implementation were invited to participate in the SOTA workgroup. Workgroup participants (N = 26) developed recommendations using consensus-building methods. Ideas were grouped by thematic clusters and voted on to identify top recommendations. A summary was presented to the full SOTA membership. Following the conference, the workgroup facilitators (LJD, CDH, NR) summarized workgroup findings, member-checked with workgroup members, and were used to develop recommendations. RESULTS The workgroup developed 12 recommendations to optimize impact of embedded researchers within health systems. The group highlighted the tension between "ROI vs. R01" goals-where health systems focus on achieving return on their investments (ROI) while embedded researchers focus on obtaining research funding (R01). Recommendations are targeted to three key stakeholder groups: researchers, funders, and health systems. Consensus for an ideal foundation to support optimal embedded research is one that (1) maximizes learning; (2) aligns goals across all 3 stakeholders; and (3) implements EBIs in a consistent and timely fashion. CONCLUSIONS Four cases illustrate a variety of ways that embedded research can be structured and conducted within systems, by demonstrating key embedded research values to enable collaborations with academic affiliates to generate actionable knowledge and meaningfully accelerate implementation of EBIs to benefit patients. IMPLICATIONS Embedded research approaches have potential for transforming health systems and impacting patient health. Accelerating embedded research should be a focused priority for funding agencies to maximize a collective return on investment.
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Affiliation(s)
- Laura J Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2800 Plymouth Rd. Building 16, Floor 3, (152), Ann Arbor, MI, 48105, USA.
| | - Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Healthcare, 5026 South State Street, 3rd Floor, Murray, UT, 84107, USA.
| | - Emily Griese
- Sanford Research, Sanford Health, 2301 E 60th Street, N Sioux Falls, SD, 57106, USA.
| | - Sarah M Greene
- Health Care Systems Research Network, 1249 NE 89th Street, Seattle, WA, 98115, USA.
| | - Paula Lozano
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.
| | - Amy M Kilbourne
- Quality Enhancement Research Initiative (QUERI), U.S. Dept of Veterans Affairs, 810 N Vermont Avenue (10X2), Washington, DC, 20420, USA; Learning Health Science, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Bldg 16 Ann Arbor, MI, 48198, USA.
| | - Diana S M Buist
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.
| | - Karen Crotty
- RTI International, 3040 E. Cornwallis Road, Hobbs 139 P.O. Box 12194, Durham, NC, 27709, USA.
| | - A Rani Elwy
- VA Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road (152), Bedford, MA, 01730, USA; Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Box G-BH, Providence, RI, 02912, USA.
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, Leonard Davis Institute of Health Economics, University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA, 19104, USA.
| | - Ralph Gonzales
- Division of General Internal Medicine, Department of Medicine, UCSF, 350 Parnassus Avenue, Box 0361, San Francisco, CA, 94117-0361, USA.
| | - Amy G Huebschmann
- University of Colorado (CU) School of Medicine, Department of Medicine, Division of General Internal Medicine, 12631 E. 17th Ave., Mailstop, B180, Aurora, CO, 80045, USA.
| | - Heather M Limper
- Vanderbilt University Medical Center, 2525 West End Ave, Nashville, TN, 37203, USA.
| | - NithyaPriya S Ramalingam
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Park Rd, Portland, 97239, USA.
| | - Katherine Wilemon
- 680 East Colorado Boulevard, Suite #180, Pasadena, CA 91101-6144, USA.
| | - P Michael Ho
- Cardiology Section, Rocky Mountain Regional VA Medical Center, 1700 N. Wheeling St, Aurora, CO 80045, USA.
| | - Christian D Helfrichfcr
- Seattle-Denver Center of Innovation for Veteran-Centered Value-Driven Care, 1660 South Columbian Way, S-152, Seattle, WA, 98108, USA.
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6
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Lum MY, Wang SX, Wisneski AD, Liang NE, Zimmet J, Shunk KA, Stechert M, London MJ, Ge L, Tseng EE. Development of the Minimalist Approach for Transcatheter Aortic Valve Replacement at a Veterans Affairs Medical Center. THE JOURNAL OF INVASIVE CARDIOLOGY 2021; 33:E108-E114. [PMID: 33531442 PMCID: PMC8589465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES While a minimalist transcatheter aortic valve replacement (TAVR) approach has shown safety and efficacy at civilian hospitals, limited data exist regarding developing this approach at Veterans Affairs (VA) medical centers (VAMCs). We implemented TAVR with minimalist approach (MA) using conscious sedation (CS) with transthoracic echocardiography (TTE) and compared safety and outcomes with general anesthesia (GA) with transesophageal echocardiography (TEE) at a university-affiliated VAMC. METHODS A total of 258 patients underwent transfemoral TAVR at a VAMC between November 2013 and October 2019. Ninety-three patients underwent GA/TEE and 165 patients underwent CS/TTE with dexmedetomidine and remifentanil. Propensity-score matching with nearest-neighbor matching was used to account for baseline differences, yielding 227 participants (81 GA, 146 CS). RESULTS MA-TAVR had no effect on 30-day mortality or paravalvular leakage. No differences were found in permanent pacemaker implantation, major vascular complications, or postoperative hemodynamics. In this population, MA-TAVR did not reduce procedural time, hospital length of stay, or intensive care unit length of stay. CONCLUSIONS Unlike civilian hospitals, MA with CS/TTE did not reduce overall length of stay in the veteran population; however, it was safe and effective for transfemoral TAVR without impacting clinical outcomes of mortality, major vascular complications, and paravalvular leakage.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Elaine E Tseng
- University of California San Francisco Medical Center, Cardiothoracic Surgery, San Francisco VA Medical Center, 4150 Clement St. 112D, San Francisco, CA 94121 USA.
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7
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Messenger JC. The Veterans Affairs Transcatheter Aortic Valve Experience: Putting the CART Before the Horse! JACC Cardiovasc Interv 2019; 12:2195-2197. [PMID: 31473242 DOI: 10.1016/j.jcin.2019.06.021] [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: 06/03/2019] [Accepted: 06/11/2019] [Indexed: 11/17/2022]
Affiliation(s)
- John C Messenger
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.
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