Transatlantic editorial on transcatheter aortic valve replacement
2017; Elsevier BV; Volume: 154; Issue: 1 Linguagem: Inglês
10.1016/j.jtcvs.2017.03.047
ISSN1097-685X
AutoresVinod H. Thourani, Michael A. Borger, David R. Holmes, Hersh S. Maniar, Fausto J. Pinto, D. Craig Miller, Josep Rodés‐Cabau, Friedrich-Wilhelm Mohr, Holger Schröfel, Neil Moat, Friedhelm Beyersdorf, G. Alexander Patterson, Richard D. Weisel,
Tópico(s)Aortic Disease and Treatment Approaches
ResumoCentral MessageThe treatment of aortic stenosis is changing rapidly, and sharing ideas from across the Atlantic will help us provide the most optimal care for our patients.PerspectiveThe management of aortic stenosis has expanded to include both surgical and transcatheter options. It remains important for the heart team to decide the most optimal patients for each treatment strategy. The treatment of aortic stenosis is changing rapidly, and sharing ideas from across the Atlantic will help us provide the most optimal care for our patients. The management of aortic stenosis has expanded to include both surgical and transcatheter options. It remains important for the heart team to decide the most optimal patients for each treatment strategy. Aortic stenosis (AS) is the most common acquired valve disease in elderly patients, with a prevalence of 2.8% in those 75 years or older.1Go A.S. Go A.S. Mozaffarian D. Roger V.L. Benjamin E.J. Berry J.D. et al.Heart disease and stroke statistics—2014 update: a report from the American Heart Association.Circulation. 2014; 129: e28-e292Crossref PubMed Scopus (4482) Google Scholar As the general population ages,2Ortman JMO, Guarneri CE. United States Population Projections: 2000 to 2050. Available at: http://www.census.gov/population/projections/files/analytical-document09.pdf. Accessed May 14, 2012.Google Scholar it is reasonable to expect that the number of patients seeking treatment for AS also will increase in the coming years. Surgical aortic valve replacement (SAVR) remains the most effective treatment of AS and can be performed with excellent results.3Thourani V.H. Myung R. Kilgo P. Thompson K. Puskas J.D. Lattouf O.M. et al.Long-term outcomes after isolated aortic valve replacement in octogenarians: a modern perspective.Ann Thorac Surg. 2008; 86: 1458-1464Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 4Grossi E.A. Schwartz C.F. Yu P.J. Jorde U.P. Crooke G.A. Grau J.B. et al.High-risk aortic valve replacement: are the outcomes as bad as predicted?.Ann Thorac Surg. 2008; 85: 102-106Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar, 5Brennan J.M. Edwards F.H. Zhao Y. O'Brien S.M. Douglas P.S. Peterson E.D. et al.Long-term survival after aortic valve replacement among high-risk elderly patients in the United States: insights from the Society of Thoracic Surgeons Adult Cardiac Surgery Database, 1991 to 2007.Circulation. 2012; 126: 1621-1629Crossref PubMed Scopus (122) Google Scholar, 6Iung B. Cachier A. Baron G. Messika-Zeitoun D. Delahaye F. Tornos P. et al.Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery?.Eur Heart J. 2005; 26: 2714-2720Crossref PubMed Scopus (916) Google Scholar, 7Thourani V.H. Suri R.M. Gunter R.L. Sheng S. O'Brien S.M. Ailawadi G. et al.Contemporary real-world outcomes of surgical aortic valve replacement in 141,905 low-risk, intermediate-risk, and high-risk patients.Ann Thorac Surg. 2015; 99: 55-61Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar However, elderly patients increasingly are presenting with multiple comorbidities, making them either high- or extreme-risk surgical candidates. Transcatheter aortic valve replacement (TAVR) was developed as an alternative to SAVR for patients at high operative risk. Since the introduction of this transformative technology in 2002, TAVR has been found to be superior to standard medical therapy at 5 years in inoperable patients.8Kapadia S.R. Leon M.B. Makkar R.R. Tuzcu E.M. Svensson L.G. Kodali S. et al.5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): A randomised controlled trial.Lancet. 2015; 385: 2485-2491Abstract Full Text Full Text PDF PubMed Scopus (618) Google Scholar In addition, mid-term results have revealed that TAVR is equivalent or has superior survival compared with SAVR in high-risk operative patients.9Mack M.J. Leon M.B. Smith C.R. Miller D.C. Moses J.W. Tuzcu E.M. et al.5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial.Lancet. 2015; 385: 2477-2484Abstract Full Text Full Text PDF PubMed Scopus (1180) Google Scholar, 10Reardon M.J. Adams D.H. Kleiman N.S. Yakubov S.J. Coselli J.S. Deeb G.M. et al.2-year outcomes in patients undergoing surgical or self-expanding transcatheter aortic valve replacement.J Am Coll Cardiol. 2015; 66: 113-121Abstract Full Text Full Text PDF PubMed Scopus (327) Google Scholar These findings, combined with the minimal invasive nature of TAVR, have resulted in an explosion in the number of these procedures performed in North America and Europe.11Walther T. Hamm C.W. Schuler G. Berkowitsch A. Kötting J. Mangner N. et al.Perioperative results and complications in 15,964 transcatheter aortic valve replacements, prospective data from the GARY Registry.J Am Coll Cardiol. 2015; 65: 2173-2180Abstract Full Text Full Text PDF PubMed Scopus (300) Google Scholar, 12Holmes Jr., D.R. Nishimura R.A. Grover F.L. Brindis R.G. Carroll J.D. Edwards F.H. et al.Annual outcomes with transcatheter valve therapy: from the STS/ACC TVT Registry.J Am Coll Cardiol. 2015; 66: 2813-2823Crossref PubMed Scopus (200) Google Scholar A similar marked experience in the number of TAVR-related clinical studies also has been observed in the last few years, with several recent clinical trials even investigating the use of TAVR in intermediate- and low-risk patients.13Leon M.B. Smith C.R. Mack M.J. Makkar R.R. Svensson L.G. Kodali S.K. et al.Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2016; 374: 1609-1620Crossref PubMed Scopus (3203) Google Scholar, 14Thourani V.H. Kodali S. Makkar R.R. Herrmann H.C. Williams M. Babaliaros V. et al.Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis.Lancet. 2016; 387: 2218-2225Abstract Full Text Full Text PDF PubMed Scopus (783) Google Scholar With such a rapidly developing landscape in the management of patients with severe AS, recommendations that have been published by various medical societies may no longer accurately reflect current clinical practice. For example, valve guidelines produced by the European Society of Cardiology/European Association for Cardio-Thoracic Surgery in 2012 listed bicuspid aortic valve disease and untreated coronary artery disease requiring intervention as relative contraindications for TAVR.15Vahanian A. Alfieri O. Andreotti F. Antunes M.J. Barón-Esquivias G. Baumgartner H. et al.Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).Eur J Cardiothorac Surg. 2012; 42: S1-S44Crossref PubMed Scopus (2) Google Scholar However, increasing clinical experience suggest that TAVR can be performed in both of these scenarios (combined with percutaneous coronary intervention for the latter) with good results.16Kochman J. Rymuza B. Huczek Z. Transcatheter aortic valve replacement in bicuspid aortic valve disease.Curr Opinion Cardiol. 2015; 30: 594-602Crossref PubMed Scopus (15) Google Scholar, 17Penkalla A. Pasic M. Drews T. Buz S. Dreysse S. Kukucka M. et al.Transcatheter aortic valve implantation combined with elective coronary artery stenting: a simultaneous approach.Eur J Cardiothorac Surg. 2015; 47: 1083-1089Crossref PubMed Scopus (40) Google Scholar As another example, the American Heart Association/American College of Cardiology guidelines from 2014 recommend SAVR as the procedure of choice for intermediate-risk patients with AS (class of recommendation I, level of evidence A).18Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Guyton R.A. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Thorac Cardiovasc Surg. 2014; 148: e1-e132Abstract Full Text Full Text PDF PubMed Scopus (803) Google Scholar However, recent data have suggested that transfemoral (TF) balloon-expandable TAVR may be superior to SAVR in intermediate-risk patients.13Leon M.B. Smith C.R. Mack M.J. Makkar R.R. Svensson L.G. Kodali S.K. et al.Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2016; 374: 1609-1620Crossref PubMed Scopus (3203) Google Scholar, 14Thourani V.H. Kodali S. Makkar R.R. Herrmann H.C. Williams M. Babaliaros V. et al.Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis.Lancet. 2016; 387: 2218-2225Abstract Full Text Full Text PDF PubMed Scopus (783) Google Scholar Another randomized, prospective trial using the self-expanding TAVR valve compared with surgery in intermediate-risk patients is forthcoming. In addition to the rapidly changing landscape for patients with AS, significant variations in clinical practice patterns—for a variety of causes—also can be observed between North America and Europe. For example, TAVR was being performed at a much more frequent rate in Germany than in the United States over the last few years. However, TAVR has increased rapidly in the United States and currently is being performed in 44.4% of patients requiring isolated aortic valve procedures, compared with 46.7% in Germany. With this background, the current document aims to evaluate the similarities and differences in the indications and patient populations currently undergoing SAVR and TAVR in Europe and North America. In addition, our multidisciplinary, international writing group aims to present an up-to-date overview of the current state of TAVR to further guide practice patterns and future areas of research within the greater cardiovascular community. The Heart Team has become a central concept in modern cardiovascular disease. Team-based care has been a widely used approach in many medical and surgical fields such as oncology, solid-organ transplants, and neurovascular disease. However, it has reached a more integrated level with the inclusion of the Heart Team in the United States as a requirement by the Center for Medicare/Medicaid Services for reimbursement. In addition, in Europe it is codified in guidelines as a Class I indication for revascularization of patients with chronic stable angina and structural heart disease. The concept of bringing together a multidisciplinary team to reach a consensus in managing complex patients and thereby optimizing outcome is straightforward. Less straightforward is the make-up of and implementation of this multidisciplinary team in daily practice. Equally less straightforward are the metrics that can be used to judge the efficacy in clinical care. With TAVR, the Heart Team seems intuitively obvious because the care of patients with structural heart disease such as AS crosses the boundaries of cardiac surgery and cardiology, each of which bring different expertise and experience to these complex patients. This is particularly true because both catheter-based as well as surgical skills are needed for patient selection, procedural techniques, and periprocedural management of complications should they occur. Both the U.S. and European guidelines are proponents of the Heart Team, with specific performance of TAVR in hospitals with cardiac surgery on-site. Components of the TAVR Heart Team vary. At the present time, the core consists of the partnership between the interventional cardiologist and cardiac surgeon. As mentioned, this relationship has been codified for reimbursement but in actual fact provides merit. Other members of the Heart Team should include imaging specialists experienced with echocardiography and computed tomography (CT), cardiac anesthesia, nonprocedural cardiologists whose role will be to manage the patients pre- and postoperatively and also in terms of longer term care, as well as nursing care specialists and advanced practice providers for these high-risk patients with multiple comorbidities. Occasionally neurologists are required to help determine levels of preoperative dementia. The addition of a patient (or family advocate) may be very valuable in some circumstances to help synergize physician and patient expectations. There are multiple areas and needs for interaction (Figure 1). Some of these may either occur or be met in structural space, others in the virtual reality of telemedicine. Essential points of contact include:1.Evaluation of the patient with AS for the potential need for mechanical intervention. This requires evaluation of clinical patient demographics and the baseline assessment of hemodynamics as well as the degree, severity, and extent of comorbidities.2.After evaluation as a candidate, the surgeon and cardiologist should decide on the risk benefit ratio of the relative merits for medical therapy or aortic valve replacement via the TAVR or SAVR techniques.3.Discussion with the patient and family by both surgeon and cardiologist about options available and educating the patient about the risk benefit ratio for SAVR versus TAVR as well as specific access routes, prosthetic type, and type of anesthesia.4.Performance of the procedure. This will include details of the place of the procedure that is hybrid operating rooms or catheterization laboratory, types of anesthesia (general vs moderate intravenous sedation), access route (TF or non-TF), selection of device size culminating in optimizing placement of the TAVR prosthesis documenting its stable position, and hemodynamic results.5.Periprocedural care and follow-up. In this group the Heart Team will need to include general cardiology as a bridge to the primary care giver of the patient which is essential for continuity. The potential advantages can be seen in Table 1. These relate to patient centric care, resource use, professional satisfaction, procedural reimbursement, and generation of new knowledge in the field to optimize results in the future as well as develop new approaches to treatment.Table 1Potential outcomes of effective heart team interventionsPatientClinicianHealth systemImproved knowledgeXXReduced decisional conflictXGreater satisfaction (with care delivery process)XXInvolvement in shared decision makingXXImproved QoLXXExpanded clinical and procedural skill setXReduction in variability both in access and outcomeXGreater adherence to guidelinesXLower readmission ratesXShorter length of stayXFaster time to decisionXLower costXImproved care coordination and communicationXQoL, Quality of life. Open table in a new tab QoL, Quality of life. The success with the appropriate use of the Heart Team has transformed the culture of management of AS in the United States. Patients have benefited with expeditious decision making with the comanagement of these complex patients, while maintaining equipoise regarding patient care. In contrast, some centers in Europe performed TAVR without integration of a full Heart Team, particularly in the early years of this transformative technology. The future role and preservation of the Heart Team is critical as cardiologists and cardiac surgeons should continue to maintain this check and balance system for providing optimal care not only for those with AS but in the widening field of transcatheter mitral valve technologies. The German Aortic Valve Registry (GARY) was founded by both the German Society of Cardiology and the German Society of Cardiothoracic and Vascular Surgery in 2010. The idea of this all-comers registry is to capture surgical and transcatheter interventions in Germany with a 5-year follow-up. Financial support was given by both societies, the German Heart Foundation, and generous support by various industry partners. Hospital outcomes were reported to the independent research institute, BQS Institute, which performs the follow-up and statistical analyses. The GARY registry was very well accepted by 90 participating German institutions, and more than 100,000 patients have agreed to participate in this unique registry. Patients collected within the GARY registry include those undergoing isolated SAVR, SAVR combined with coronary artery bypass grafting (SAVR + CABG), and TAVR with TF-TAVR or transapical access (TA-TAVR).11Walther T. Hamm C.W. Schuler G. Berkowitsch A. Kötting J. Mangner N. et al.Perioperative results and complications in 15,964 transcatheter aortic valve replacements, prospective data from the GARY Registry.J Am Coll Cardiol. 2015; 65: 2173-2180Abstract Full Text Full Text PDF PubMed Scopus (300) Google Scholar, 19Hamm C.W. Möllmann H. Holzhey D. Beckmann A. Veit C. Figulla H.R. et al.The German Aortic Valve Registry (GARY): in-hospital outcome.Eur Heart J. 2014; 35: 1588-1598Crossref PubMed Scopus (269) Google Scholar, 20Mohr F.W. Holzhey D. Möllmann H. Beckmann A. Veit C. Figulla H.R. et al.The German Aortic Valve Registry: 1-year results from 13 680 patients with aortic valve disease.Eur J Cardiothorac Surg. 2014; 46: 808-816Crossref PubMed Scopus (150) Google Scholar, 21Holzhey D. Mohr F.W. Walther T. Möllmann H. Beckmann A. Kötting J. et al.Current results of surgical aortic valve replacement: insights from the German Aortic Valve Registry.Ann Thorac Surg. 2016; 101: 658-666Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar The first report published in the European Heart Journal by Hamm and colleagues19Hamm C.W. Möllmann H. Holzhey D. Beckmann A. Veit C. Figulla H.R. et al.The German Aortic Valve Registry (GARY): in-hospital outcome.Eur Heart J. 2014; 35: 1588-1598Crossref PubMed Scopus (269) Google Scholar demonstrated that 98.5% of the patients could be followed and hospital mortalities were depicted for SAVR, SAVR + CABG, and TAVR. In this early series the surgical results seemed to be better in all groups with low, intermediate, and greater European System for Cardiac Operative Risk Evaluation (euroSCORE) score, whereas in the highest risk scores TF-TAVR had similar outcomes.19Hamm C.W. Möllmann H. Holzhey D. Beckmann A. Veit C. Figulla H.R. et al.The German Aortic Valve Registry (GARY): in-hospital outcome.Eur Heart J. 2014; 35: 1588-1598Crossref PubMed Scopus (269) Google Scholar One of the primary aims of this database is to compare transcatheter with conventional surgical treatment. Based on the newly created German Aortic Valve Score that stratifies patients into 4 risk groups with low (0%-20%), moderate (20%-40%), intermediate (40%-60%), and high ( 200 aortic valve replacement (AVR) per year, experience in balloon aortic valvuloplasty and/or TAVR, and a geographic distribution throughout the country. The registry was under the authority of the French Societies of Cardiology and Thoracic and Cardio-Vascular Surgery. A unique aspect of this registry included the evaluation of both balloon- and self-expanding TAVR prostheses. For all patients, the Society of Thoracic Surgeons (STS) predicted risk of operative mortality was 18.9 ± 12.8%, with a mean age of 82.3 ± 7.3%. There was a 30-day mortality of 12.7% and an initial stroke rate of 3.6%.23Eltchaninoff H. Prat A. Gilard M. Leguerrier A. Blanchard D. Fournial G. et al.Transcatheter aortic valve implantation: early results of the FRANCE (FRench Aortic National CoreValve and Edwards) registry.Eur Heart J. 2011; 32: 191-197Crossref PubMed Scopus (459) Google Scholar Subsequently, in January 2010, a total of 34 centers were authorized to perform TAVR by the French Ministry of Health and named the French Aortic National CoreValve and Edwards (FRANCE 2) TAVR Registry.24Gilard M. Eltchaninoff H. Iung B. Donzeau-Gouge P. Chevreul K. Fajadet J. et al.Registry of transcatheter aortic-valve implantation in high-risk patients.N Engl J Med. 2012; 366: 1705-1715Crossref PubMed Scopus (1042) Google Scholar Gilard and colleagues24Gilard M. Eltchaninoff H. Iung B. Donzeau-Gouge P. Chevreul K. Fajadet J. et al.Registry of transcatheter aortic-valve implantation in high-risk patients.N Engl J Med. 2012; 366: 1705-1715Crossref PubMed Scopus (1042) Google Scholar evaluated 3195 patients from 2010 to 2011 with a mean age of 82.7 ± 7.2 years and a STS score of 14.4 ± 11.9%. They noted a remarkable 96.9% procedural success rate, as well as a 9.7% 30-day and 24.0% 1-year mortality. At 30 days, there was greater mortality in those undergoing TA-TAVR compared with TF (13.9% vs 8.5%), but no difference between the balloon- and self-expanding valves (9.6% vs 9.4%). The major stroke rate had decreased from previous studies to 2.3%. Since the initial report from the FRANCE 2 registry, these investigators have contributed importantly to this burgeoning field with reports such as those on the predictive factors to risk assessment,25Iung B. Laouénan C. Himbert D. Eltchaninoff H. Chevreul K. Donzeau-Gouge P. et al.Predictive factors of early mortality after transcatheter aortic valve implantation: individual risk assessment using a simple score.Heart. 2014; 100: 1016-1023Crossref PubMed Scopus (155) Google Scholar outcomes related to pacemaker implantation,26Mouillet G. Lellouche N. Yamamoto M. Oguri A. Dubois-Rande J.L. Van Belle E. et al.Outcomes following pacemaker implantation after transcatheter aortic valve implantation with CoreValve(®) devices: results from the FRANCE 2 Registry.Catheter Cardiovasc Interv. 2015; 86: E158-E166Crossref PubMed Scopus (57) Google Scholar and prognostic value of pre-existing and new onset atrial fibrillation.27Chopard R. Teiger E. Meneveau N. Chocron S. Gilard M. Laskar M. et al.Baseline Characteristics and Prognostic Implications of Pre-Existing and New-Onset Atrial Fibrillation After Transcatheter Aortic Valve Implantation: results From the FRANCE-2 Registry.JACC Cardiovasc Interv. 2015; 8: 1346-1355Crossref PubMed Scopus (96) Google Scholar, 28Furuta A. Lellouche N. Mouillet G. Dhanjal T. Gilard M. Laskar M. et al.Prognostic value of new onset atrial fibrillation after transcatheter aortic valve implantation: A FRANCE 2 registry substudy.Int J Cardiol. 2016; 210: 72-79Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The U.K. TAVR registry initiated in 2007 with centers performing TAVR in England and Wales. The Society of Cardiothoracic Surgery in Great Britain and Ireland and the British Cardiovascular Intervention Society established the dataset on short term outcomes, whereas longer term mortality was tracked via the National Health Service Central Registry. The initial publication from the U.K. registry by Moat and colleagues29Moat N.E. Ludman P. de Belder M.A. Bridgewater B. Cunningham A.D. Young C.P. et al.Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis. The U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry.J Am Coll Cardiol. 2011; 58: 2130-2138Abstract Full Text Full Text PDF PubMed Scopus (770) Google Scholar was unique in that it captured all 870 TAVR procedures performed in this region, with 100% follow-up, and encompassed implants from both the original SAPIEN and CoreValve devices. In a high-risk patient cohort, they noted a 30-day survival of 92.9%, very similar to other national databases. The learning curve was quite dramatic, such that over a 2-year time period, the authors noted an approximately 96% 30-day survival in those patients undergoing TAVR in 2009. This was also one of the first reports to evaluate patients with at least a 1-year follow-up; they noted a 78.6% and 73.7%, 1- and 2-year survival, respectively.29Moat N.E. Ludman P. de Belder M.A. Bridgewater B. Cunningham A.D. Young C.P. et al.Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis. The U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry.J Am Coll Cardiol. 2011; 58: 2130-2138Abstract Full Text Full Text PDF PubMed Scopus (770) Google Scholar In a follow-up study of the same patients, Duncan and colleagues30Duncan A. Ludman P. Banya W. Cunningham D. Marlee D. Davies S. et al.Long-term outcomes after transcatheter aortic valve replacement in high-risk patients with severe aortic stenosis: the U.K. transcatheter aortic valve implantation registry.JACC Cardiovasc Interv. 2015; 8: 645-653Crossref PubMed Scopus (95) Google Scholar reported an acceptable 3- and 5-year survival rates of 61.2% and 45.5%, respectively. Since then, the U.K. TAVR registry has been very productive in evaluating all aspects of this burgeoning treatment for AS. Fröhlich and colleagues31Fröhlich G.M. Baxter P.D. Malkin C.J. Scott D.J. Moat N.E. Hildick-Smith D. et al.Comparative survival after transapical, direct aortic, and subclavian transcatheter aortic valve implantation (data from the UK TAVI registry).Am J Cardiol. 2015; 116: 1555-1559Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar recently noted that TA and transaortic TAVR had similar results and were worse than those undergoing TF-TAVR. However, they also noted that mortality in those patients undergoing subclavian access was similar to TF-TAVR and may represent the safest nonfemoral access route. Most recently, Ludman and colleagues32Ludman P.F. Moat N. de Belder M.A. Blackman D.J. Duncan A. Banya W. et al.Transcatheter aortic valve implantatio
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