Author + information
- Received December 5, 2016
- Revision received January 23, 2017
- Accepted January 24, 2017
- Published online April 3, 2017.
- Rebecca T. Hahn, MDa,b,∗ (, )
- Christopher U. Meduri, MDc,
- Charles J. Davidson, MDd,
- Scott Lim, MDe,
- Tamim M. Nazif, MDa,
- Mark J. Ricciardi, MDd,
- Vivek Rajagopal, MDd,
- Gorav Ailawadi, MDe,
- Mani A. Vannan, MBBSc,
- James D. Thomas, MDd,
- Dale Fowler, MDe,
- Stuart Rich, MDd,
- Randy Martin, MDc,
- Geraldine Ong, MDb,
- Adam Groothuis, PhDf and
- Susheel Kodali, MDa
- aDepartment of Medicine, Division of Cardiology/New York Presbyterian Hospital, New York-Presbyterian/Columbia University Medical Center, New York, New York
- bCardiovascular Research Foundation, New York, New York
- cMarcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia
- dBluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- eUniversity of Virginia, Charlottesville, Virginia
- fMitralign, Inc., Tewksbury, Massachusetts
- ↵∗Address for correspondence:
Dr. Rebecca T. Hahn, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, New York, New York 10032.
Background The SCOUT (Percutaneous Tricuspid Valve Annuloplasty System for Symptomatic Chronic Functional Tricuspid Regurgitation) trial is a prospective, single-arm, multicenter, early feasibility study of a novel transcatheter device to plicate the tricuspid annulus (TA) and reduce tricuspid regurgitation (TR).
Objectives This study tested the feasibility and safety of a novel transcatheter device and assessed its early performance and functional outcomes.
Methods Between November 2015 and June 2016, 15 patients with New York Heart Association (NYHA) functional class ≥II and moderate or greater functional TR were enrolled. Primary performance and safety endpoint outcomes were technically successful at 30 days with no reintervention. Echocardiographic measurements (TA diameter, effective regurgitant orifice area [EROA], left ventricular stroke volume [LVSV]) and quality-of-life (QoL) measurements (NYHA functional class, Minnesota Living with Heart Failure Questionnaire [MLHFQ], and 6-min walk test [6MWT]) were performed at baseline and 30 days.
Results All patients (mean 73.2 ± 6.9 years of age, 87% female) underwent successful device implantation with no deaths, strokes, bleeding, tamponade, or valve reintervention. Technical success rate at 30 days was 80%, with 3 single-pledget annular detachments without reintervention. In the remaining 12 patients, there were significant reductions in TA (12.3 ± 3.1 cm2 to 11.3 ± 2.7 cm2, respectively; p = 0.019) and EROA (0.51 ± 0.18 cm2 vs. 0.32 ± 0.18 cm2, respectively; p = 0.020), with significant increase in LVSV (63.6 ± 17.9 ml vs. 71.5 ± 25.7 ml, respectively; p = 0.021). In the intention-to-treat cohort, there were significant improvements in NYHA functional class (≥1 class, p = 0.001), MLHFQ (47.4 ± 17.6 to 20.9 ± 14.8; p < 0.001), and 6MWT (245.2 ± 110.1 to 298.0 m ± 107.6 m; p = 0.008).
Conclusions The 30-day results of the SCOUT trial confirmed the safety of the novel transcatheter device, which reduced TA and EROA, increased LVSV, and improved QoL. (Early Feasibility of the Mitralign Percutaneous Tricuspid Valve Annuloplasty System (PTVAS) Also Known as TriAlign [SCOUT]; NCT02574650.)
Interest in functional or secondary tricuspid valve regurgitation (TR) has increased in recent years (1) due to its high prevalence (2), progressive nature (3), and impact on outcomes (4–6). According to the American Heart Association/American College of Cardiology guidelines, the only class 1 indication for TR repair is during concomitant left heart surgery (Level of Evidence: C) (7). Despite the benefits of tricuspid repair (8,9), a large number of patients undergoing left-sided valve surgery do not undergo treatment of concomitant significant TR. In patients who develop severe TR late after left-sided heart valve surgery, operative mortality may be as high as 10% to 20% (2,10,11). In addition, an increasing number of patients are currently being treated with transcatheter therapies, and severe TR has been shown to affect outcomes in these patients (12,13). Thus, there is significant interest in development of a transcatheter therapy for TR.
Although the original Kay bicuspidization procedure is infrequently used (14), the Trialign system (Mitralign Inc., Tewksbury, Massachusetts) attempts to replicate the results of the current modified Kay procedure, which has shown efficacy and long-term outcomes similar to those of other surgical repair methods (15,16). Since its first-in-human implantation (17), numerous other investigators have reported using this device successfully for TR (18,19). The SCOUT (Percutaneous Tricuspid Valve Annuloplasty System [PTVAS] for Symptomatic Chronic Functional Tricuspid Regurgitation) trial (NCT02574650) is a prospective, single-arm, multicenter, early feasibility study of this novel device. The following 30-day results of the SCOUT trial constitute the first report of an early feasibility trial for a transcatheter tricuspid valve device.
Patient selection, study design, and management
Between November 2015 and June 2016, 15 patients with New York Heart Association (NYHA) functional class ≥II and greater than or equal to moderate functional TR, with no indication of left-sided valve surgery, were enrolled at 4 sites in the United States. Exclusion criteria were >85 years of age, pacemaker implantation, systolic pulmonary artery pressure >60 mm Hg, left ventricle ejection fraction <35%; tricuspid annular plane systolic excursion (TAPSE) <13 mm; or tricuspid effective regurgitant orifice area (EROA) >1.2 cm2. Online Table 1 lists the complete inclusion/exclusion criteria.
Echocardiography core laboratory analysis
All echocardiograms were analyzed at an independent core laboratory that followed the American Society of Echocardiography standards for echocardiography core laboratories (20). Pre- and post-procedural transthoracic echocardiograms (TTE) were performed according to specific core laboratory protocols for assessment of tricuspid valve and ventricular and atrial functions, and core laboratory measurements were performed according to previously published guidelines (21,22). Right ventricular function was assessed by using TAPSE, fractional area change, and tricuspid annulus tissue Doppler systolic velocity (S′) (23,24). TR was assessed using standard color Doppler methods, as described in American Society of Echocardiography guidelines (25), with minimum and maximum vena contracta diameters also recorded (Figure 1). The ellipticity of the vena contracta was calculated as minimum/maximum diameters.
The following echocardiographic measurements and calculations were performed (see Figure 2 for calculations):
1. Proximal isovelocity surface area (PISA) (26–28): A PISA EROA was calculated using color Doppler Nyquist baseline shift, recording aliasing velocity and maximum PISA radius view, where TR jet was parallel to the insonation beam, peak TR velocity, and TR velocity time integral.
2. Quantitation of TR by relative stroke volumes (26,29,30):
a. The forward stroke volume was calculated using left ventricular outflow tract radius and velocity time integral. In the setting of greater mild aortic regurgitation, the forward stroke volume was calculated using the right ventricular outflow tract radius and velocity time integral.
b. Quantitative Doppler method for calculating tricuspid stroke volume as the product of the tricuspid annular area (TAA) and pulsed-wave Doppler annular velocity time integral.
i. TAA: orthogonal plane annular diameters (inflow and 4-chamber views) in early diastole (1 frame after initial valve opening) were used in an ellipse formula to calculate TAA. If a simultaneous biplane image of the annulus was obtained, the orthogonal diameters were obtained from that image.
ii. The tricuspid annular velocity time integral was obtained by averaging 5 to 10 sequential pulsed-wave diastolic spectral waveforms from the view with flow most parallel to the insonation beam (typically the apical view).
c. Regurgitant volume was calculated as [tricuspid valve diastolic stroke volume minus forward stroke volume].
TA plication procedure
Implantation of the device was previously described (Figure 3) (17). Before device implantation, a guidewire is placed in the right coronary artery to help identify its location relative to the tricuspid annulus (TA). Two 14-F gauge sheaths are introduced into the right jugular vein for delivery of the device. A deflectable guide catheter is introduced to position a wire delivery catheter beneath the annulus, between the posterior and septal tricuspid leaflet commissures (posteroseptal position). Before crossing the annulus, transesophageal echocardiographic (TEE) imaging is used to visualize the wire delivery catheter and confirm that: 1) adequate annular depth (2 to 4 mm from the base of the leaflet); 2) distance from the right coronary artery; and 3) direction (into the right atrium). An insulated radiofrequency (20 to 30 W for ∼3 s) wire is passed through the tissue of the annulus, and the wire’s position is confirmed by TEE. The wire is snared in the right atrium, exteriorized, and a pledget delivery catheter is introduced over the wire and across the annulus. Fluoroscopy and TEE guide withdrawal of the pledget delivery catheter and seating of the ventricular side of the pledget. The proximal (atrial) side of the pledgeted suture is deployed and cinched onto the annulus. After placement of the first pledget, a second wire is positioned between 2.4 and 2.8 cm from the first site, near the commissure, between the posterior and anterior tricuspid valve leaflets (anteroposterior position), and a second pledgeted suture is placed using the same technique. A dedicated plication lock device is used to bring the 2 sutures together, drawing the anteroposterior pledget toward the posteroseptal pledget (Central Illustration). Using fluoroscopic and TEE imaging, maximal plication of the TA is performed. Completion of a right coronary artery angiogram is performed following implantation.
The primary safety and performance endpoint of the early feasibility trial was a technical success at 30 days. Secondary endpoints are listed in Online Table 1. Patient quality of life (QoL) was assessed by using NYHA functional class assessment, 6-min walk test (6MWT) results, and Minnesota Living with Heart Failure Questionnaire (MLHFQ) responses.
Data are summarized and reported for the intention-to-treat population and the as-treated population of subjects, as appropriate, with technical success at 30 days. Categorical variables are summarized using frequency tables, and continuous variables are presented as mean ± SD. Statistical comparisons of characteristics collected at baseline and at 30 days were performed using paired data, using the Student t test or the Wilcoxon signed rank test when the assumption of normality was violated (as assessed by the Shapiro-Wilk test of the distribution of change scores).
Baseline demographics are listed in Table 1. The mean age was 73.6 ± 6.6 years, and 87% were women. All patients were symptomatic and in NYHA functional class II (33%) or III (67%). The majority of patients had a history of hypertension (80%) or pulmonary hypertension (60%) or had undergone prior mitral valve intervention (67%) and were in atrial fibrillation (67%). All patients were treated with diuretic agents, and the majority (93%) were also receiving a beta-blocker agent. Additional medications are shown in Online Table 2.
All 15 patients underwent successful implantation of the device, in the intended position, with successful plication. Procedural data are listed in Table 2. There were no instances of death, stroke, bleeding or access site complications, cardiac tamponade, or valve reintervention. In 1 subject, the completion angiogram obtained post-implantation showed tenting of the distal right coronary artery in the region of the plication with significant narrowing confirmed by fractional flow reserve of 0.57, which was associated with ST-segment elevations on electrocardiogram. These changes resolved with right coronary stent placement with post-procedure peak troponin concentration of 1.79 μg/l, which decreased to 0.7 μg/l.
At 30 days (Table 3), 3 patients had echocardiographic evidence of a single pledget detachment from the annulus. The detached pledget was posteroseptal in 1 patient and anteroposterior in 2 patients. All detached pledgets remained securely attached to the remaining pledgeted suture and did not require reintervention or result in adverse events.
Echocardiographic measurements for the intention-to-treat population are listed in Table 4 (complete list of measurements are in Online Table 3). Right ventricular function by TAPSE and tissue Doppler was unchanged (p = 0.46 and 0.48, respectively). In the intention-to-treat cohort, there was a significant reduction in TA diameter (4.0 ± 0.5 cm vs. 3.9 ± 0.5 cm, respectively; p = 0.017) and a trend to reduction in TAA (12.3 ± 2.8 cm2 vs. 11.5 ± 2.5 cm2, respectively; p = 0.061). The mean vena contracta diameter (1.3 ± 0.3 vs. 1.1 ± 0.4, respectively; p = 0.13) and EROA by both PISA (0.51 ± 0.16 vs. 0.41 ± 0.27, respectively; p = 0.19) and quantitative Doppler (0.93 ± 0.27 vs. 0.93 ± 0.74, respectively; p = 0.53) were not significantly reduced. Left ventricular stroke volume was significantly increased (67.1 ± 18.1 ml vs. 72.8 ± 23.2 ml, respectively; p = 0.04) in the setting of stable left ventricular ejection fraction (p = 0.85) and right ventricular function by TAPSE (p = 0.46).
The TTE findings from the 12 patients without pledget detachment or as-treated population are listed in Table 5 (complete list of measurements is in Online Table 4). Of note, there was a significant reduction in mean vena contracta diameter (1.3 ± 0.4 vs. 1.0 ± 0.3, respectively; p = 0.022), TAA (12.3 ± 3.1 cm2 vs. 11.3 ± 2.7 cm2, respectively; p = 0.019), EROA by PISA (0.51 ± 0.18 cm2 vs. 0.32 ± 0.18 cm2, respectively; p = 0.020) and quantitative Doppler (0.85 ± 0.22 cm2 vs. 0.63 ± 0.29 cm2, respectively; p = 0.045). There were no changes in left ventricular ejection fraction (p = 0.90) or right ventricular TAPSE (p = 0.31). There was, again, a significant increase in left ventricular stroke volume (63.6 ± 17.9 ml to 71.5 ± 25.7 ml, respectively; p = 0.021).
In the as-treated patients with pledgets in the intended positions, the ellipticity of the regurgitant orifice showed no significant change (0.6 ± 0.2 vs. 0.6 ± 0.2, respectively; p = 0.92). In the setting of an elliptical orifice, the EROA by PISA method was significantly less than the EROA by quantitative Doppler, both at baseline (0.5 ± 0.2 vs. 0.9 ± 0.2, respectively; p < 0.001) and after device implantation (0.3 ± 0.2 vs. 0.6 ± 0.3, respectively; p < 0.001).
In the 3 patients with single-pledget detachment, there were no significant differences between baseline and 30 days for TAA (12.18 ± 1.34 cm2 vs. 12.54 ± 1.27 cm2, respectively; p = 1.00), EROA by PISA (0.51 ± 0.06 cm2 vs. 0.76 ± 0.28 cm2, respectively; p = 0.18), or quantitative Doppler (1.22 ± 0.31 cm2 vs. 2.00 ± 0.98 cm2, respectively; p = 0.18).
In the as-treated population (Table 6, Central Illustration), there were significant improvements in NYHA functional class (all patients ≥1 class; p = 0.001), MLHFQ (49.6 ± 15.7 to 18.8 ± 12.0, respectively; p < 0.001) and 6MWT (236.5 ± 107.4 m to 305.1 ± 106.5 m, respectively; p = 0.003). Quality of life for the intention-to-treat group is listed in Online Table 5. Compared with their baseline values, these patients experienced significant improvement in NYHA functional class (≥1 class, p = 0.001), MLHFQ (47.4 ± 17.6 to 20.9 ± 14.8, respectively; p < 0.001), and 6MWT results (245.2 ± 110.1 m to 298.0 ± 107.6 m, respectively; p = 0.008).
In the 3 patients with single-pledget detachment, there were no significant differences between baseline and 30 day values for NYHA functional class (≥1 class; p = 0.17), MLHFQ (38.7 ± 25.5 to 29.7 ± 24.3, respectively; p = 0.75), and 6MWT (279.7 ± 138.3 m to 269.7 ± 130.8 m, respectively; p = 1.00).
This is the first early feasibility trial to complete enrollment for an investigational tricuspid repair device. In this study, we report that the transcatheter plication device achieved 93% procedural success with no procedural mortality or stroke, successful delivery, and retrieval of the device delivery system with proper device placement in all patients; quantitative reduction of TA measurements and TR severity, with concomitant increase in LV forward stroke volume; and improvement in QoL measurements.
Although functional or secondary TR is the most common cause of severe TR in the Western world (31), it remains undertreated. The presence of functional TR, either isolated or in combination with left heart disease, is associated with an unfavorable prognosis (4,32–34). Surgical mortality for isolated tricuspid valve interventions remains higher than for any other single valve surgery (35,36). Combined tricuspid repair at the time of the left-sided disease treatment is not associated with a significant increase in mortality (37) and is recommended in the setting of significant annular dilation and TR (7,38). Nonetheless, moderate-to-severe TR is present in 1.6 million U.S. individuals, and only a small portion (<0.5%) of this population currently undergoes surgical tricuspid valve repair or replacement (39). Similarly, despite the benefits of tricuspid repair (8,9), a large number of patients undergoing left valve surgery do not have concomitant treatment of significant TR. This could be explained by an underestimation of TR severity under anesthesia (40); or the misconception that TR resolves following mitral valve surgery (9,41,42); and the overestimation of surgical risk when concomitant tricuspid valve surgery is performed at the time of mitral valve surgery (43–45). As more left-sided valve disease is treated with transcatheter therapies, the negative impact of TR on survival in these patients has underscored the importance of developing transcatheter solutions to this disease (12,13,46).
The transcatheter plication system attempts to replicate the results of the modified Kay bicuspidization procedure described by Ghanta et al. (16) in 2007. This suture bicuspidization technique is performed by placing a double pledget-supported mattress suture from the anteroposterior commissure to the posteroseptal commissure along the posterior annulus and tying the suture down on an obturator to reduce the stress on the annulus. In their follow-up in 237 patients, Ghanta et al. (16) demonstrated that bicuspidization annuloplasty and ring annuloplasty for functional TR were equally durable and efficacious for reducing TR up to 3 years post-operatively.
The high procedural success achieved in this study by 4 different heart teams speaks to the generalizability of this procedure. All patients had the device placed in the intended position, and all achieved annular plication with no mortality and only 1 unplanned right coronary artery stent implanted without adverse consequences. At 30 days, in 3 patients, 1 of the 2 pledgeted sutures was no longer attached to the annulus but remained attached to the remaining annular suture, and importantly, no patient required reintervention. The first patient detachment occurred in the first patient entered into the trial and could be explained by excessive manipulation of the annulus during initial pledget delivery and cinching. Refinement in operator technique resulted in 4 subsequently successful implantation procedures at this site. The second and third device detachments occurred at a single site, and determination of cause is being investigated. Modeling and improved characterization of TA tissue and variables that affect the degree of stress on the tissue generated by the plication process may improve technical success.
Echocardiography plays an integral role in the successful pre-procedural, intraprocedural, and post-procedural analysis of tricuspid valve morphology and function. This is the first study to use not only multiparametric methods for assessing tricuspid regurgitant severity but multiple quantitative measures as well. We purposefully elected to avoid using the labels mild, moderate, or severe TR when reporting the results of this trial. Unfortunately, the current guideline-suggested grading scheme for TR (25) fails to take into account its “torrential” nature in patients we are currently treating. A vena contracta qualifies as severe at ≥0.7 cm; however, our patients, on average, had a vena contracta width of 1.3 cm. Likewise, an EROA of ≥0.40 cm2 qualifies as severe; however, our patients had an average quantitative EROA of 0.85 cm2, more than double what the guidelines consider severe. If just the reduction in EROA is evaluated, the transcatheter plication system reduced the quantitative EROA, on average, by >0.20 cm2, which according to the current guidelines, would be the equivalent of 1 to 2 grades. The PISA method is simple and easy to perform (26); however, the complex relationship of the isovelocity shell to the often elliptical shape (47,48) and enlarged size of the TR EROA results in a significant underestimation of the true EROA (49). If one uses the PISA EROA only, the patients in this trial had TR EROA reduced from severe (0.51 ± 0.18 cm2) to moderate (0.32 ± 0.18 cm2). Although the accuracy of the quantitative method should be validated, both methods performed in a core laboratory before and after device deployment showed significant reductions in TR EROA, are associated with an increase in forward stroke volume, and resulted in significant improvements in QoL measures.
The main objectives of any treatment of heart valve disease are to improve QoL and survival. Tricuspid regurgitation does not have the same immediate impact on short-term mortality as other heart valve diseases, and thus, QoL measurements, such as the disease-specific MLHFQ (50), may play a significant role in future trial designs. In the SCOUT trial, the as-treated population experienced an improvement in average MLHFQ score from 50 (poor health) to 19 (good health), with this change of 31 points substantially exceeding the 5-point change considered to be a large effect (51). In addition to patient-reported symptoms, tests such as the 6MWT, according to American Thoracic Society guidelines (52), have been used to objectify QoL and can predict morbidity and mortality in some patients. Improvement in 6MWT has been shown to be reflect clinically important changes in symptoms and health status in cohorts of patients with cardiac disease (53,54). In a small study of patients with chronic heart failure, changes in 6MWTD of 25 to 50 m were associated with clinically meaningful changes in health status (54). In this study, a significant improvement in patient-reported symptoms was associated with objective improvement in 6MWT (increase of 52.9 ± 72.6 m). The substantial improvements in both MLHFQ and 6MWT results support the findings of significant improvements in echocardiographic measurements of disease severity and show that a reduction of even 1 grade of TR is enough to improve QoL.
The 1 patient with failure to remodel the annulus did not improve in QoL measures. At the time of the procedure, the EROA was significantly larger than on qualifying TTE (>2 cm2), with marked dilation of the right ventricle. In this patient, the lack of response might have been due to the persistent and/or ongoing ventricular dilation that was greater than could be effectively treated with a single-pledget annular device. A current modification of the SCOUT I protocol now includes the possibility of implanting 2 pairs of pledgets, potentially allowing greater annular reduction.
The relatively small number of patients in this early feasibility trial make conclusions about efficacy less robust; however, the consistent reduction in TR and annular dimensions associated with a consistent improvement in QoL measures is promising. The quantitation of TR has not been extensively validated, but the methods of this study show the feasibility of preforming repeat quantitation by multiple techniques and show a change in these parameters that correlates with clinical outcomes. Further studies comparing these echocardiographic methods with cardiac magnetic resonance should be performed. Finally, optimal medical therapy in this study was determined by the referring physician, and medication changes throughout the study could have influenced the results.
The SCOUT trial is the first multicenter early feasibility study of a novel transcatheter device for functional TR to complete enrollment in the United States. The 30-day results of the SCOUT trial confirmed that the device was safe, successfully reduced annular area and regurgitant orifice, and improved left ventricular forward stroke volume. These changes were associated with improvements in functional status and QoL measures.
COMPETENCY IN PATIENT CARE AND PROCEDURAL SKILLS: In selected patients, functional TR can be reduced by transcatheter plication of the valve annulus.
TRANSLATIONAL OUTLOOK: Larger trials of transcatheter tricuspid repair are needed to confirm the efficacy and safety of this technology, quantify its impact on echocardiographic and hemodynamic measurements of TR severity, and assess the outcome and durability of the intervention in terms of symptoms and QoL.
For supplemental tables, please see the online version of this article.
Dr. Hahn is a speaker for Edwards Lifesciences, Abbott Vascular, Boston Scientific, and GE Medical; is an unpaid national principal investigator for the SCOUT Trial; and is an uncompensated director of Echo Core for multiple industry-sponsored trials. Dr. Meduri is a consultant and proctor for and has received a research grant from Medtronic; is an advisory board member, consultant, and proctor for Boston Scientific; and has received research grants from Edwards Lifesciences. Dr. Nazif is a consultant for Edwards Lifesciences. Dr. Rajagopal is a consultant for Boston Scientific, Abbott Vascular, Medtronic, and Edwards Lifesciences.
Dr. Alawadi is a consultant for Abbott Vascular, Edwards Lifesciences, Medtronic, St. Jude Medical, and Atricure. Dr. Vannan is a speaker for and has research support from Abbott Vascular and Siemens Healthcare. Dr. Thomas has received honoraria from and is a consultant for Siemens, GE Medical, and Edwards Lifesciences. Dr. Martin is a speaker for Medtronic, Edwards Lifesciences, and Abbott Vascular; and holds stock/ownership in BayLabs. Dr. Groothuis is an employee of and holds ownership stock in Mitralign. Dr. Kodali is a consultant for Dura Biotech; consults for and has received research support from Edwards Lifesciences, Medtronic, and Abbott Vascular; and holds equity in Thubrikar Aortic Valve and BioTrace. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- 6-min walk test
- effective regurgitant orifice area
- Minnesota Living with Heart Failure Questionnaire
- New York Heart Association
- proximal isovelocity surface area
- quality of life
- tricuspid annular plane systolic excursion
- transesophageal echocardiography
- tricuspid regurgitation
- transthoracic echocardiography
- Received December 5, 2016.
- Revision received January 23, 2017.
- Accepted January 24, 2017.
- 2017 American College of Cardiology Foundation
- Rogers J.H.,
- Bolling S.F.
- Antunes M.J.,
- Barlow J.B.
- Nath J.,
- Foster E.,
- Heidenreich P.A.
- Topilsky Y.,
- Nkomo V.T.,
- Vatury O.,
- et al.
- Taramasso M.,
- Vanermen H.,
- Maisano F.,
- et al.
- Nishimura R.A.,
- Otto C.M.,
- Bonow R.O.,
- et al.
- Mangoni A.A.,
- DiSalvo T.G.,
- Vlahakes G.J.,
- et al.
- Lindman B.R.,
- Maniar H.S.,
- Jaber W.A.,
- et al.
- Ohno Y.,
- Attizzani G.F.,
- Capodanno D.,
- et al.
- Schofer J.,
- Bijuklic K.,
- Tiburtius C.,
- et al.
- Latib A.,
- Ancona M.B.,
- Agricola E.,
- et al.
- Malasa M.,
- Werner N.,
- Nickenig G.,
- et al.
- Douglas P.S.,
- DeCara J.M.,
- Devereux R.B.,
- et al.
- Haddad F.,
- Hunt S.A.,
- Rosenthal D.N.,
- et al.
- Loeber C.P.,
- Goldberg S.J.,
- Allen H.D.
- Meijboom E.J.,
- Horowitz S.,
- Valdes-Cruz L.M.,
- et al.
- Voelkel N.F.,
- Quaife R.A.,
- Leinwand L.A.,
- et al.
- Badhwar V.,
- Rankin J.S.,
- He M.,
- et al.
- Gosev I.,
- Yammine M.,
- McGurk S.,
- et al.
- Di Mauro M.,
- Bivona A.,
- Iacò A.L.,
- et al.
- Frangieh A.H.,
- Gruner C.,
- Mikulicic F.,
- et al.
- Rodriguez L.,
- Anconina J.,
- Flachskampf F.A.,
- et al.
- Holmes C.,
- Briffa N.
- O'Keeffe S.T.,
- Lye M.,
- Donnellan C.,
- et al.