BACKGROUND: Advancing the retrograde microcatheter (MC) into the antegrade guide catheter during retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can be challenging or impossible, preventing guidewire externalization. OBJECTIVES: To detail and evaluate all the techniques focused on wiring to achieve intubation of the distal tip of a microcatheter, balloon, or stent with an antegrade or retrograde guidewire, aiming to reduce complications by minimizing tension on fragile collaterals during externalization and enabling rapid antegrade conversion in various clinical scenarios. METHODS: We describe the two main techniques, tip-in and rendezvous, and their derivatives such a facilitated tip-in, manual MC-tip modification, tip-in the balloon, tip-in the stent, deep dive rendezvous, catch-it and antegrade microcatheter probing. We provide case studies that demonstrate the effectiveness of these techniques in complex scenarios involving extreme vessel angulation, severe calcification, fragile collaterals, and challenging retrograde MC crossing without externalization. CONCLUSION: The development of advanced variants along with traditional techniques to establish retrograde guidewire connection and antegrade conversion has led to the establishment of a cohesive group of methods known as portal techniques. These approaches serve as strategic advantages in retrograde CTO-PCI, providing a valuable and feasible alternative to conventional retrograde connection techniques, particularly when those techniques fail. Their ability to avoid the externalization process reduces potential damage to collateral channels and the ostium of the donor artery, potentially leading to a reduction in complication rates.
- MeSH
- Angioplasty, Balloon, Coronary instrumentation adverse effects MeSH
- Chronic Disease MeSH
- Equipment Design MeSH
- Percutaneous Coronary Intervention instrumentation adverse effects MeSH
- Coronary Occlusion * diagnostic imaging therapy physiopathology MeSH
- Humans MeSH
- Miniaturization MeSH
- Cardiac Catheters * MeSH
- Stents * MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Review MeSH
BACKGROUND: Patients with severe aortic stenosis present frequently (∼50%) with concomitant obstructive coronary artery disease. Current guidelines recommend combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) as the preferred treatment. Transcatheter aortic valve implantation (TAVI) and fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) represent a valid treatment alternative. We aimed to test the non-inferiority of FFR-guided PCI plus TAVI versus SAVR plus CABG in patients with severe aortic stenosis and complex coronary artery disease. METHODS: This international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial was conducted at 18 tertiary medical centres across Europe. Patients (aged ≥70 years) with severe aortic stenosis and complex coronary artery disease, deemed feasible for percutaneous or surgical treatment according to the on-site Heart Team, were randomly assigned (1:1) to FFR-guided PCI plus TAVI or SAVR plus CABG according to a computer-generated sequence with random permuted blocks sizes stratified by site. The primary endpoint was a composite of all-cause mortality, myocardial infarction, disabling stroke, clinically driven target-vessel revascularisation, valve reintervention, and life-threatening or disabling bleeding at 1 year post-treatment. The trial was powered for non-inferiority (with a margin of 15%) and if met, for superiority. The primary and safety analyses were done per an intention-to-treat principle. This trial is registered with ClinicalTrials.gov (NCT03424941) and is closed. FINDINGS: Between May 31, 2018, and June 30, 2023, 172 patients were enrolled, of whom 91 were assigned to the FFR-guided PCI plus TAVI group and 81 to the SAVR plus CABG group. The mean age of patients was 76·5 years (SD 3·9). 118 (69%) of 172 patients were male and 54 (31%) patients were female. FFR-guided PCI plus TAVI resulted in favourable outcomes for the primary endpoint (four [4%] of 91 patients) versus SAVR plus CABG (17 [23%] of 77 patients; risk difference -18·5 [90% CI -27·8 to -9·7]), which was below the 15% prespecified non-inferiority margin (pnon-inferiority<0·001). FFR-guided PCI plus TAVI was superior to SAVR plus CABG (hazard ratio 0·17 [95% CI 0·06-0·51]; psuperiority<0·001), which was driven mainly by all-cause mortality (none [0%] of 91 patients vs seven (10%) of 77 patients; p=0·0025) and life-threatening bleeding (two [2%] vs nine [12%]; p=0·010). INTERPRETATION: The TCW trial is the first trial to compare percutaneous treatment versus surgical treatment in patients with severe aortic stenosis and complex coronary artery disease, showing favourable primary endpoint and mortality outcomes with percutaneous treatment. FUNDING: Isala Heart Centre and Medtronic.
- MeSH
- Aortic Valve Stenosis * surgery complications MeSH
- Heart Valve Prosthesis Implantation methods MeSH
- Fractional Flow Reserve, Myocardial * MeSH
- Percutaneous Coronary Intervention * methods MeSH
- Coronary Artery Bypass * methods MeSH
- Humans MeSH
- Coronary Artery Disease * surgery complications therapy MeSH
- Prospective Studies MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Transcatheter Aortic Valve Replacement * methods MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Equivalence Trial MeSH
- Multicenter Study MeSH
- Comparative Study MeSH
BACKGROUND: Mineralocorticoid receptor antagonists have been shown to reduce mortality in patients after myocardial infarction with congestive heart failure. Whether routine use of spironolactone is beneficial after myocardial infarction is uncertain. METHODS: In this multicenter trial with a 2-by-2 factorial design, we randomly assigned patients with myocardial infarction who had undergone percutaneous coronary intervention to receive either spironolactone or placebo and either colchicine or placebo. The results of the spironolactone trial are reported here. The two primary outcomes were a composite of death from cardiovascular causes or new or worsening heart failure, evaluated as the total number of events; and a composite of the first occurrence of myocardial infarction, stroke, new or worsening heart failure, or death from cardiovascular causes. Safety was also assessed. RESULTS: We enrolled 7062 patients at 104 centers in 14 countries; 3537 patients were assigned to receive spironolactone and 3525 to receive placebo. At the time of our analyses, the vital status was unknown for 45 patients (0.6%). For the first primary outcome, there were 183 events (1.7 per 100 patient-years) in the spironolactone group as compared with 220 events (2.1 per 100 patient-years) in the placebo group over a median follow-up period of 3 years (hazard ratio adjusted for competing risk of death from noncardiovascular causes, 0.91; 95% confidence interval [CI], 0.69 to 1.21; P = 0.51). With respect to the second primary outcome, an event occurred in 280 of 3537 patients (7.9%) in the spironolactone group and 294 of 3525 patients (8.3%) in the placebo group (hazard ratio adjusted for competing risk, 0.96; 95% CI, 0.81 to 1.13; P = 0.60). Serious adverse events were reported in 255 patients (7.2%) in the spironolactone group and 241 (6.8%) in the placebo group. CONCLUSIONS: Among patients with myocardial infarction, spironolactone did not reduce the incidence of death from cardiovascular causes or new or worsening heart failure or the incidence of a composite of death from cardiovascular causes, myocardial infarction, stroke, or new or worsening heart failure. (Funded by the Canadian Institutes of Health Research and others; CLEAR ClinicalTrials.gov number, NCT03048825.).
- MeSH
- Mineralocorticoid Receptor Antagonists * therapeutic use adverse effects MeSH
- Stroke mortality MeSH
- Double-Blind Method MeSH
- Myocardial Infarction * mortality drug therapy MeSH
- Kaplan-Meier Estimate MeSH
- Cardiovascular Diseases mortality prevention & control MeSH
- Percutaneous Coronary Intervention MeSH
- Middle Aged MeSH
- Humans MeSH
- Aged MeSH
- Spironolactone * therapeutic use adverse effects MeSH
- Heart Failure * drug therapy mortality MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
- Randomized Controlled Trial MeSH
BACKGROUND AND AIM: Diabetes has been shown in last decades to be associated with a significantly higher mortality among patients with ST-segment elevation myocardial infarction (STEMI) treated with primary PCI (PPCI). Therefore, the aim of current study was to evaluate the impact of diabetes on times delays, reperfusion and mortality in a contemporary STEMI population undergoing PPCI, including treatment during the COVID pandemic. METHODS AND RESULTS: The ISACS-STEMI COVID-19 is a large-scale retrospective multicenter registry involving PPCI centers from Europe, Latin America, South-East Asia and North-Africa, including patients treated from 1st of March until June 30, 2019 and 2020. Primary study endpoint of this analysis was in-hospital mortality. Secondary endpoints were postprocedural TIMI 0-2 flow and 30-day mortality. Our population is represented by 16083 STEMI patients. A total of 3812 (23,7 %) patients suffered from diabetes. They were older, more often males as compared to non-diabetes. Diabetic patients were less often active smokers and had less often a positive family history of CAD, but they were more often affected by hypertension and hypercholesterolemia, with higher prevalence of previous STEMI and previous CABG. Diabetic patients had longer ischemia time, had more often anterior MI, cardiogenic shock, rescue PCI and multivessel disease. They had less often out-of-hospital cardiac arrest and in-stent thrombosis, received more often a mechanical support, received less often a coronary stent and DES. Diabetes was associated with a significantly impaired postprocedural TIMI flow (TIMI 0-2: 9.8 % vs 7.2 %, adjusted OR [95 % CI] = 1.17 [1.02-1.38], p = 0.024) and higher mortality (in-hospital: 9.1 % vs 4.8 %, Adjusted OR [95 % CI] = 1.70 [1.43-2.02], p < 0.001; 30-day mortality: 10.8 % vs 6 %, Adjusted HR [95 % CI] = 1.46 [1.26-1.68], p < 0.001) as compared to non-diabetes, particularly during the pandemic. CONCLUSIONS: Our study showed that in a contemporary STEMI population undergoing PPCI, diabetes is significantly associated with impaired epicardial reperfusion that translates into higher in-hospital and 30-day mortality, particularly during the pandemic.
- MeSH
- Time-to-Treatment MeSH
- Time Factors MeSH
- COVID-19 * mortality epidemiology MeSH
- Diabetes Mellitus * mortality diagnosis epidemiology MeSH
- Risk Assessment MeSH
- ST Elevation Myocardial Infarction * mortality therapy diagnosis MeSH
- Percutaneous Coronary Intervention * mortality adverse effects MeSH
- Middle Aged MeSH
- Humans MeSH
- Hospital Mortality MeSH
- Registries MeSH
- Retrospective Studies MeSH
- Risk Factors MeSH
- Aged MeSH
- Treatment Outcome MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
BACKGROUND: Hypertension is the most prevalent cardiovascular risk factor, with several detrimental effects on the cardiovascular system. Contrasting results have been reported so far on its prognostic role in patients admitted for ST-segment elevation myocardial infarction (STEMI). Therefore, we investigated the impact of hypertension on short-term mortality in a large multicenter contemporary registry of STEMI patients, including patients treated during COVID-19 pandemic. METHODS: The ISACS-STEMI COVID-19 was a retrospective registry that included STEMI patients treated with primary percutaneous coronary intervention (PCI) between March and June of 2019 and 2020 in 109 high-volume primary PCI centers from 4 continents. We collected data on baseline, clinical and procedural characteristics, in-hospital outcome and 30-day mortality. For this analysis patients were grouped according to history of hypertension at admission. RESULTS: A total of 16083 patients were assessed, including 8813 (54.8%) with history of hypertension. These patients were more often elderly, with a worse cardiovascular risk profile, but were less frequently active smoker. Some procedural differences were observed between the two groups, including lower rate of thrombectomy and use of glycoprotein IIb/IIIa inhibitors or cangrelor but more extensive coronary disease in patients with hypertension. Between patients with and without hypertension, there was no significant difference in SARS-CoV-2 positivity. Hypertensive patients had a significantly higher in-hospital and 30-day mortality, similarly observed in both pre-COVID-19 and COVID-19 era, and confirmed after adjustment for main baseline differences and propensity score (in-hospital mortality: adjusted odds ratio (OR) [95% confidence interval (CI)] =1.673 [1.389-2.014], P < 0.001; 30-day mortality: adjusted hazard ratio (HR) [95% CI] = 1.418 [1.230-1.636], P < 0.001). CONCLUSION: This is one of the largest and contemporary study assessing the impact of hypertension in STEMI patients undergoing primary angioplasty, including also the COVID-19 pandemic period. Hypertension was independently associated with significantly higher rates of in-hospital and 30-day mortality.
- MeSH
- COVID-19 * complications mortality MeSH
- Hypertension * complications mortality MeSH
- ST Elevation Myocardial Infarction * mortality complications therapy MeSH
- Percutaneous Coronary Intervention * MeSH
- Middle Aged MeSH
- Humans MeSH
- Hospital Mortality MeSH
- Registries * MeSH
- Retrospective Studies MeSH
- Risk Factors MeSH
- SARS-CoV-2 MeSH
- Aged MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
Cíl: Zjistit, zda by detekce subklinického městnání ultrazvukovým vyšetření plic (lung ultrasound, luS) pacientů se SteMi mohla pomoci předpovědět rozvoj srdečního selhání a systolické, nebo diastolické dysfunkce levé komory. Metody: Do studie bylo zařazeno 150 pacientů. u všech byla provedena úspěšná revaskularizace a při příjmu u nich nebylo z klinického hlediska přítomno srdeční selhání. Během prvních 24 hodin od příjmu u nich bylo provedeno luS s 28 plicními body a byly spočítány B-linie. Pacienti byli rozděleni do dvou skupin: 64 pacientů do skupiny luS pozitivní (se 6 nebo více B-liniemi) a 86 jedinců do skupiny luS negativní; po tříměsíčním sledování byli vyšetřeni na přítomnost srdečního selhání stupně ii nebo vyššího podle klasifikace nYhA, ejekční frakci (ef) ≤40%, a celková longitudinální deformace myokardu (global longitudinal strain, GlS) ≤–16 %. Výsledky: K rozvoji klinického srdečního selhání došlo u většího počtu pacientů ve skupině luS pozitivní (17 vs. 2 ve skupině luS negativní; p < 0,01); totéž platilo pro ef ≤ 40 % (34 vs. 3; p < 0,01) i GlS ≤ –16 % (60 vs. 58; p < 0,01). Křivky operační charakteristiky přijímače (receiver-operating characteristic, roc) prokázaly, že optimální mezní hodnota počtu B-linií pro predikci rozvoje klinického srdečního selhání i poruchy systolické funkce je 6 nebo více (senzitivita = 89,47 %, specificita = 64,62 %, resp. senzitivita = 91,89 %, specificita = 74,11 %). Analýza podskupin podle počáteční diagnózy prokázala, že predikční hodnota luS byla statisticky významná pouze v případě SteMi přední stěny. Závěry: ultrazvukové vyšetření plic u pacientů se SteMi, provedené do 24 hodin od příjmu, dokáže předpovědět rozvoj klinického srdečního selhání nebo systolické dysfunkce do tří měsíců, zvláště v případě infarktu přední stěny.
Aim: To see if the detection of subclinical congestion in STEMI patients by lung ultrasound (LUS) could be helpful in predicting the development of future heart failure, systolic dysfunction or diastolic dysfunction. Methods: 150 patients were included. All patients were successfully revascularized and were not suffering from clinical heart failure on admission. The patients had a 28-point LUS study within the first 24 hours of admission, and B-lines were counted. Patients were divided into two groups: 64 patients into the LUS positive group (with 6 or more B-lines) and 86 into the LUS negative group. They were followed-up after 3 months, looking for heart failure NYHA II or greater, ejection fraction (EF) ≤40%, and global longitudinal strain (GLS) ≤-16%. Results: More patients from the LUS positive group developed clinical heart failure (17 vs 2 in the LUS negative group, p <0.01), EF ≤40% (34 vs 3, p <0.01), GLS ≤-16% (60 vs 58, p <0.01). Optimal cutoff derived from ROC curves revealed that the best B-line number cutoff to predict clinical heart failure as well as impaired systolic function was 6 or greater (sensitivity = 89.47%, specificity = 64.62% and sensitivity = 91.89%, specificity = 74.11%, respectively). Subgroup analysis by initial diagnosis revealed that the predictive power of LUS was significant only in anterior STEMI. Conclusions: LUS in STEMI patients, performed within 24 hours of admission, is able to predict the occurrence of clinical heart failure or systolic dysfunction at 3 months, especially in anterior infarctions.
The prevalence of left-sided valvular heart disease (VHD) increases with age, but data on the impact of pre-existing VHD in patients with acute myocardial infarction (AMI) are limited. We aimed to define the clinical characteristics and outcomes of AMI patients with pre-existing left VHD. The analysis is based on data from three merged national registries. The dataset included 47,436 patients admitted with AMI over a 5year period at all Cath Labs nationwide. Pre-existing VHD was diagnosed in 1,445 patients (3.0%), moderate-to-severe mitral regurgitation (MR) in 510 patients (35.3%), and moderate-to-severe aortic stenosis (AS) in 869 patients (60.1%). Patients with VHD had worse baseline characteristics, pre-existing coronary artery disease, more complicated in-hospital course with higher Killip class, lower left ventricular ejection fraction, and more comorbidities. Angiographically more frequent left main stenosis, TIMI flow 3 before PCI, less frequent stent implantation. Patients with pre-existing VHD had significantly higher 7-day (10.1% vs. 4.5%, p < 0.001), 30-day (16.0% vs. 7.0%, p < 0.001) and 1-year mortality (28.7 vs. 12.7%, p < 0.001) compared to patients without. Conclusions. Patients with pre-existing VHD and AMI are characterized by complicated in-hospital course with higher Killip class, lower ejection fraction, angiographically less severe stenosis, TIMI flow 3 prior to PCI, and less frequent stent implantation. This is a high-risk group with higher short - and long-term mortality and earlier intervention should be considered.
- MeSH
- Aortic Valve Stenosis * complications epidemiology MeSH
- Myocardial Infarction * complications mortality MeSH
- Middle Aged MeSH
- Humans MeSH
- Mitral Valve Insufficiency * complications epidemiology MeSH
- Registries MeSH
- Risk Factors MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
Monotherapy with a potent P2Y12 receptor antagonist after 1 month of dual antiplatelet therapy (DAPT) may reduce bleeding in the absence of increased ischaemic events compared to 12-month DAPT in patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI). PCI guidance with optical coherence tomography (OCT) may enhance stent expansion. COMPARE STEMI ONE is an international, multicentre, open-label, randomised controlled trial. In 1,656 ST-segment elevation myocardial infarction (STEMI) patients, prasugrel monotherapy after 1 month of DAPT, as compared to standard 12-month prasugrel-based DAPT, will be tested for non-inferiority for the primary composite endpoint of net adverse clinical events - defined as all-cause death, myocardial infarction, stroke, or Bleeding Academic Research Consortium Type 3 or 5 bleeding events - at 11 months after randomisation. Furthermore, an ancillary substudy will test the superiority of OCT-guided versus angiography-guided staged complete revascularisation in achieving a larger minimal stent area (MSA) in non-culprit lesions during staged procedures. COMPARE STEMI ONE is the first randomised controlled trial assessing an abbreviated 1-month DAPT regimen followed by prasugrel monotherapy in the context of STEMI. The trial will also study the value of OCT-guided PCI in terms of the MSA of non-culprit lesions and may elucidate potential synergies between intravascular imaging-guided PCI and abbreviated DAPT regimens. (ClinicalTrials.gov: NCT05491200).
- MeSH
- Purinergic P2Y Receptor Antagonists * therapeutic use MeSH
- ST Elevation Myocardial Infarction * therapy drug therapy diagnostic imaging surgery MeSH
- Platelet Aggregation Inhibitors * therapeutic use MeSH
- Coronary Angiography methods MeSH
- Percutaneous Coronary Intervention * methods MeSH
- Humans MeSH
- Tomography, Optical Coherence * methods MeSH
- Prasugrel Hydrochloride * therapeutic use MeSH
- Randomized Controlled Trials as Topic MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
- Clinical Trial Protocol MeSH
- Randomized Controlled Trial MeSH
- Comparative Study MeSH
OBJECTIVES: The aim of the study was to analyse the role of conservative treatment and regional differences in 30-day hospital mortality for acute myocardial infarction (AMI) patients in the Czech Republic. METHODS: Using administrative data from Czech health insurance companies for 2018-2020, we employed a probit model to examine factors influencing mortality across 13 complex cardiovascular centres, calculating average marginal effects to ensure interpretable results. RESULTS: Conservative treatment was associated with a 4.7 percentage point increase in 30-day mortality compared to percutaneous coronary intervention (PCI) treatment (95% CI: 3.6-5.7). This effect varied significantly across different types of AMI and healthcare providers, with regional variations in mortality ranging from 0 to 4.3 percentage points relative to the best-performing centre. CONCLUSIONS: Higher proportions of conservative treatment significantly contribute to increased 30-day mortality in complex cardiovascular centres. The persistent regional variations after controlling for patient characteristics suggest the need for standardized treatment protocols and improved data collection systems to reduce disparities in outcomes.
- MeSH
- Myocardial Infarction * mortality therapy MeSH
- Conservative Treatment * statistics & numerical data mortality MeSH
- Percutaneous Coronary Intervention statistics & numerical data mortality MeSH
- Middle Aged MeSH
- Humans MeSH
- Hospital Mortality * trends MeSH
- Aged MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Geographicals
- Czech Republic MeSH
BACKGROUND: There is a lack of evidence to guide treatment of patients with a concomitant indication for transcatheter aortic valve implantation (TAVI) and complex, high-risk percutaneous coronary intervention (PCI). AIMS: We aimed to assess different strategies of PCI timing in this high-risk TAVI cohort. METHODS: The ASCoP registry retrospectively included patients with a clinical indication for both TAVI and PCI with at least 1 criterion of complex or high-risk PCI. The primary endpoint was a composite of all-cause death and unplanned rehospitalisation for cardiovascular causes. The secondary endpoint was a composite of all-cause death, stroke, acute myocardial infarction, major bleeding, major vascular complication and unplanned revascularisation. Multivariable analysis was used to adjust for possible confounders. RESULTS: A total of 519 patients were included: 363 (69.9%) underwent staged procedures and 156 (30.1%) concomitant TAVI and PCI. After 441 (interquartile range 182-824) days, the primary endpoint occurred in 151 (36.5%) cases, without any significant difference between the 2 groups (p=0.98), while the secondary endpoint occurred more frequently in the concomitant group (n=36 [25.8%] vs n=57 [17.4%]; p=0.014). CONCLUSIONS: In patients undergoing TAVI and complex/high-risk PCI, a concomitant strategy is associated with a higher rate of adverse events and increased procedural risk. (ClinicalTrials.gov: NCT05750927).
- MeSH
- Aortic Valve Stenosis * surgery mortality MeSH
- Percutaneous Coronary Intervention * methods adverse effects MeSH
- Humans MeSH
- Registries MeSH
- Retrospective Studies MeSH
- Risk Factors MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Severity of Illness Index MeSH
- Transcatheter Aortic Valve Replacement * methods adverse effects MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
- Clinical Trial MeSH