1
|
Sá MP, Jacquemyn X, Van den Eynde J, Chu D, Serna‐Gallegos D, Ebels T, Clavel M, Pibarot P, Sultan I. Impact of Prosthesis-Patient Mismatch After Surgical Aortic Valve Replacement: Systematic Review and Meta-Analysis of Reconstructed Time-to-Event Data of 122 989 Patients With 592 952 Patient-Years. J Am Heart Assoc 2024; 13:e033176. [PMID: 38533939 PMCID: PMC11179750 DOI: 10.1161/jaha.123.033176] [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: 10/17/2023] [Accepted: 02/28/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND It remains controversial whether prosthesis-patient mismatch (PPM) impacts long-term outcomes after surgical aortic valve replacement. We aimed to evaluate the association of PPM with mortality, rehospitalizations, and aortic valve reinterventions. METHODS AND RESULTS We performed a systematic review with meta-analysis of reconstructed time-to-event data of studies published by March 2023 (according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Sixty-five studies met our eligibility criteria and included 122 989 patients (any PPM: 68 332 patients, 55.6%). At 25 years of follow-up, the survival rates were 11.8% and 20.6% in patients with and without any PPM, respectively (hazard ratio [HR], 1.16 [95% CI, 1.13-1.18], P<0.001). At 20 years of follow-up, the survival rates were 19.5%, 12.1%, and 8.8% in patients with no, moderate, and severe PPM, respectively (moderate versus no PPM: HR, 1.09 [95% CI, 1.06-1.11], P<0.001; severe versus no PPM: HR, 1.29 [95% CI, 1.24-1.35], P<0.001). PPM was associated with higher risk of cardiac death, heart failure-related hospitalizations, and aortic valve reinterventions over time (P<0.001). Statistically significant associations between PPM and worse survival were observed regardless of valve type (bioprosthetic versus mechanical valves), contemporary PPM definitions unadjusted and adjusted for body mass index, and PPM quantification method (in vitro, in vivo, Doppler echocardiography). Our meta-regression analysis revealed that populations with more women tend to have higher HRs for all-cause death associated with PPM. CONCLUSIONS The results of the present study suggest that any degree of PPM is associated with poorer long-term outcomes following surgical aortic valve replacement and provide support for implementation of preventive strategies to avoid PPM after surgical aortic valve replacement.
Collapse
Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| | | | | | - Danny Chu
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| | - Derek Serna‐Gallegos
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, University Medical Center GroningenUniversity of GroningenThe Netherlands
| | - Marie‐Annick Clavel
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of Medicine, Faculty of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Philippe Pibarot
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of Medicine, Faculty of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Ibrahim Sultan
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| |
Collapse
|
2
|
Matkovic M, Aleksic N, Bilbija I, Antic A, Lazovic JM, Cubrilo M, Milojevic A, Zivkovic I, Putnik S. Clinical Impact of Patient-Prosthesis Mismatch After Aortic Valve Replacement With a Mechanical or Biological Prosthesis. Tex Heart Inst J 2023; 50:e228048. [PMID: 37867308 PMCID: PMC10658167 DOI: 10.14503/thij-22-8048] [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] [Indexed: 10/24/2023]
Abstract
BACKGROUND Patient-prosthesis mismatch (PPM) may impair functional capacity and survival after aortic valve replacement. This study aimed to investigate the impact of PPM on long-term survival and quality of life after mechanical and biological aortic valve replacement. METHODS This study included 595 consecutive patients who had undergone isolated aortic valve replacement. Patients were divided into 2 groups according to prosthesis type. The baseline and operative characteristics, survival rates, complications, and quality of life of the groups with and without PPM were compared for up to 6 years. The PPM calculation was performed using the effective orifice area value provided by the manufacturer divided by the patient's body surface area. RESULTS The moderate to severe PPM rates were 69.8% and 3.7% after biological and mechanical prosthesis implantation, respectively. Mean survival for patients in the biological group who had PPM was statistically significantly shorter (50.2 months [95% CI, 45.2-55.3]) than for patients in the biological group without PPM (60.1 months [95% CI, 55.7-64.4]; P = .04). In the mechanical prosthesis group, there was no difference in mean survival between the subgroup with PPM (66.6 months [95% CI, 58.3-74.9]) and the subgroup without PPM (64.9 months [95% CI, 62.6-67.2]; P = .50). A quality-of-life questionnaire's scores did not differ between the groups. CONCLUSION Mismatch is common after biological valve implantation and statistically significantly affects long-term survival and quality of life. If the risk of PPM after implantation of a biological prosthesis is suspected, adopting strategies to avoid PPM at the time of surgery is warranted.
Collapse
Affiliation(s)
- Milos Matkovic
- Department for Cardiac Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nemanja Aleksic
- Department for Cardiac Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ilija Bilbija
- Department for Cardiac Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ana Antic
- Department for Cardiac Surgery, Clinical Centre of Serbia, Belgrade, Serbia
| | - Jelena Milin Lazovic
- Department for Biostatistics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Cubrilo
- Department for Cardiac Surgery, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Igor Zivkovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Department for Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Svetozar Putnik
- Department for Cardiac Surgery, Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
3
|
Aitaliyev S, Rumbinaitė E, Mėlinytė-Ankudavičė K, Nekrošius R, Keturakis V, Benetis R. Early outcomes of patient-prosthesis mismatch following aortic valve replacement. Perfusion 2021; 37:692-699. [PMID: 34080457 PMCID: PMC9500169 DOI: 10.1177/02676591211023286] [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: 11/15/2022]
Abstract
INTRODUCTION Patient-prosthesis mismatch (PPM) has been associated with numerous short- and long-term adverse events. This study aimed to evaluate the effect of PPM on early postoperative results after aortic valve replacement (AVR) in daily practice. METHODS In this single-centre retrospective study, 150 non-consecutive patients from March 2019 to January 2020 with clinically indicated AVR with/without concomitant surgery were analysed. The study protocol included operative mortality, complication rate, and pre- and postoperative echocardiographic data. PPM was considered severe with indexed effective orifice area at <0.65 cm2/m2, moderate at 0.65-0.85 cm2/m2 and none at >0.85 cm2/m2. RESULTS Moderate PPM was observed in 16 patients (10.6%). No patient had severe PPM. PPM was not related to early mortality (r = 0.40, p = 0.630), intra- (r = -0.076, p = 0.352) and postoperative (r = -0.0134, p = 0.102) events. CONCLUSION In this study, moderate PPM was a frequent finding after AVR, whereas severe PPM was not observed. PPM did not affect the early results after AVR. A long-term follow-up study in a large patient population is required to assess the actual influence of residual PPM.
Collapse
Affiliation(s)
- Serik Aitaliyev
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Egle Rumbinaitė
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Rokas Nekrošius
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vytenis Keturakis
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Benetis
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| |
Collapse
|
4
|
Marsico R, Zakkar M, Bruno VD, Mansour S, Bryan AJ, Angelini GD. The impact of patient-prosthesis mismatch on early and long-term survival after aortic replacement with the Edwards Perimount valve: A propensity score-matched analysis. J Card Surg 2021; 36:2269-2276. [PMID: 33821500 DOI: 10.1111/jocs.15534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND To investigate the impact of severe patient-prosthesis mismatch (PPM) related to the Edwards Lifesciences Perimount (EP) bioprosthesis in the aortic position on early in-hospital outcomes and long-term survival. METHODS A total of 5964 consecutive patients underwent aortic valve replacement at the Bristol Heart Institute between 1998 and 2014, 2667 representing the cohort of this study received EP. PPM was defined severe as EOAi < 0.65 cm2 /m2 . To minimize bias, propensity score matching was conducted and two groups A and B (without and with severe PPM) of 320 patients with similar preoperative characteristics were matched. We assessed early in-hospital outcomes including CVA, re-exploration for bleeding, low cardiac output, wound infection, acute renal injury, length of hospital stay, and long-term survival for both groups in unmatched and matched populations. RESULTS In the unmatched analysis, 18.3% of patients had severe PPM. Severe PPM was not associated with increased in-hospital mortality (4.5% vs. 2.9%, respectively, p = .09) or any other early adverse outcomes except increased length of hospital stay (10.57 ± 8.2 vs. 11.7 ± 9.4, respectively, p = .01). Long-term survival differed significantly between groups at 2 and 8 years (91.8% vs. 91.4% and 60.5% vs. 55.7%, respectively, p = .02). Matched analysis showed no differences between the groups in early health outcomes and overall survival at 2 and 8 years was also similar (89.7% vs. 91% and 57.3% vs. 58%, group A vs. B, respectively p = .9). CONCLUSION Presence of PPM does not seem to affect early in-hospital outcomes or late survival when using EP in patients undergoing aortic valve replacement.
Collapse
Affiliation(s)
- Roberto Marsico
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Mustafa Zakkar
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Vito D Bruno
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Sherif Mansour
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Alan J Bryan
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Faculty of Health Sciences, Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| |
Collapse
|
5
|
Dell'Aquila AM, Welp H, Rukosujew A. Prosthesis-Patient Mismatch: When Should It Be Determined for Prognosis Implications? Ann Thorac Surg 2018; 106:315. [PMID: 29937220 DOI: 10.1016/j.athoracsur.2017.10.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 10/30/2017] [Indexed: 10/28/2022]
Affiliation(s)
- Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg A1, Muenster D-48149, Germany.
| | - Henryk Welp
- Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg A1, Muenster D-48149, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Bldg A1, Muenster D-48149, Germany
| |
Collapse
|
6
|
Reply. Ann Thorac Surg 2017; 106:315-316. [PMID: 29253465 DOI: 10.1016/j.athoracsur.2017.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/14/2017] [Indexed: 11/22/2022]
|
7
|
Impact of mild patient prosthesis mismatch on quality of life in patients with preserved ejection fraction after isolated aortic valve replacement for aortic stenosis. Int J Cardiol 2017; 227:225-228. [DOI: 10.1016/j.ijcard.2016.11.138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 11/06/2016] [Indexed: 11/21/2022]
|
8
|
Foroutan F, Guyatt GH, O'Brien K, Bain E, Stein M, Bhagra S, Sit D, Kamran R, Chang Y, Devji T, Mir H, Manja V, Schofield T, Siemieniuk RA, Agoritsas T, Bagur R, Otto CM, Vandvik PO. Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies. BMJ 2016; 354:i5065. [PMID: 27683072 PMCID: PMC5040922 DOI: 10.1136/bmj.i5065] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To determine the frequency of survival, stroke, atrial fibrillation, structural valve deterioration, and length of hospital stay after surgical replacement of an aortic valve (SAVR) with a bioprosthetic valve in patients with severe symptomatic aortic stenosis. DESIGN Systematic review and meta-analysis of observational studies. DATA SOURCES Medline, Embase, PubMed (non-Medline records only), Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to June 2016. STUDY SELECTION Eligible observational studies followed patients after SAVR with a bioprosthetic valve for at least two years. METHODS Reviewers, independently and in duplicate, evaluated study eligibility, extracted data, and assessed risk of bias for patient important outcomes. We used the GRADE system to quantify absolute effects and quality of evidence. Published survival curves provided data for survival and freedom from structural valve deterioration, and random effect models provided the framework for estimates of pooled incidence rates of stroke, atrial fibrillation, and length of hospital stay. RESULTS In patients undergoing SAVR with a bioprosthetic valve, median survival was 16 years in those aged 65 or less, 12 years in those aged 65 to 75, seven years in those aged 75 to 85, and six years in those aged more than 85. The incidence rate of stroke was 0.25 per 100 patient years (95% confidence interval 0.06 to 0.54) and atrial fibrillation 2.90 per 100 patient years (1.78 to 4.79). Post-SAVR, freedom from structural valve deterioration was 94.0% at 10 years, 81.7% at 15 years, and 52% at 20 years, and mean length of hospital stay was 12 days (95% confidence interval 9 to 15). CONCLUSION Patients with severe symptomatic aortic stenosis undergoing SAVR with a bioprosthetic valve can expect only slightly lower survival than those without aortic stenosis, and a low incidence of stroke and, up to 10 years, of structural valve deterioration. The rate of deterioration increases rapidly after 10 years, and particularly after 15 years.
Collapse
Affiliation(s)
- Farid Foroutan
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8 Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Kathleen O'Brien
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Eva Bain
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Madeleine Stein
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sai Bhagra
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Daegan Sit
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Rakhshan Kamran
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Yaping Chang
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Tahira Devji
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Hassan Mir
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8
| | - Veena Manja
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8 Department of Internal Medicine, State University of New York at Buffalo, Buffalo, USA VA WNY Health Care System at Buffalo, Department of Veterans Affairs, USA
| | - Toni Schofield
- Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Reed A Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Agoritsas
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario, Canada L8S 4L8 Division of General Internal Medicine, and Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Rodrigo Bagur
- Division of Cardiology, London Health Sciences Centre and Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada N6A 5W9
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Per O Vandvik
- Department of Internal Medicine, Innlandet Hospital Trust-division Gjøvik, Norway Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway
| |
Collapse
|
9
|
Predictors and Outcomes of Prosthesis-Patient Mismatch After Aortic Valve Replacement. JACC Cardiovasc Imaging 2016; 9:924-33. [DOI: 10.1016/j.jcmg.2015.10.026] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 10/15/2015] [Indexed: 11/22/2022]
|
10
|
Shahzeb KM, Imran BF, Asadullah K, Mehwish H. Prosthesis-patient mismatch causes a significantly increased risk of operative mortality in aortic valve replacement. Heart Surg Forum 2015; 17:E127-31. [PMID: 25002387 DOI: 10.1532/hsf98.2013304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Small aortic prosthesis can lead to prosthesis-patient mismatch (PPM). Implanting such small prosthesis remains a controversial issue. This study was done to investigate whether or not PPM causes an increased operative mortality in aortic valve replacement (AVR). METHODS Two-hundred-two consecutive patients undergoing primary AVR in a tertiary hospital were included. The sample was grouped according to the aortic valve prosthesis size: ≤21 mm (small) and >21 mm (standard). The effect of variables on outcomes was determined by univariate and multivariable regression analyses. RESULTS PPM was found significantly more among patients with AVR ≤ 21 mm (P < 0.0001). Moreover, the likelihood of mortality also was significantly higher in these patients (P < 0.0001). Univariate analysis demonstrated small prosthesis size, urgent operation, PPM, female gender, and NYHA Class IV as significant predictors of mortality. Multivariate regression identified female gender, PPM, and urgent operation as the key independent predictors of mortality. CONCLUSION PPM and female gender are significant predictors of mortality. Care should be taken to prevent PPM by implanting larger prosthesis especially in females.
Collapse
Affiliation(s)
| | | | - Khan Asadullah
- MBBS- Cardiac Surgery Department, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, Pakistan
| | | |
Collapse
|
11
|
Amorim P, Diab M, Färber G, Kirov H, Gonzales-Lopes D, Doenst T. Hämodynamische Ergebnisse nach Aortenklappenersatz. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-014-1109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|