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臝腯腳腣腵腫腹膄臭膊膰膶 Vol. 34, pp. 359368, 2006 腓腏腎腂腀腁腄腓腌腗腑腕腒腋腍腔腈腇腆腉腊腅腃腖腘腐 腜腐 腗腨 腣腏 腗腥 1 腒腃腤 腡腑 腛腌 1 腠腥 腍腨 腋腩 腃腔 腧腄 1 腒腇 腙腏 腛腧 1 腒腇 腙腏 腞腍 腕腦 1 腈腟 臇膲 腐腢腩腌 1 腡腞 腡腑 腂腉 1 腆腆 腙腏 腛腖 1 腏腠 腎腨 腘腝 腛腌 1 腍腇腃腘 腒腇 1 腙腊 腨腤 腅腃 腃腔 腧腄 1 腒腇 腜腟 1 腞腑 腣腏 腛腧 1 腌腚腡腏 腖腏 2 : 18 8 21 臃臍臁臯膍腕腃腂腐腖臯臒臞central venous pressure: CVP腕腳 pulmonary artery wedge pressure: PAWP腔腓腢膴腒腉腎臆膌膍腕腄腡腞腕腁膐膾腕腜腞臹腝腠腟 膚膪臺膠腽腢腬膴臘 intrathoracic blood volume index: IT- BVI膠膍膈臖腌腬膴臘 extravascular lung water index: EVLWI腍腉腐膠膍臶膆臙膴臘 permeability index: PI腅臆膌膍腖膴腒腉腐臰腈腠腐腂腟腕腁膐膾腱腬腨腳腵腦腢臖膿 pulmonary edema: PE8 腕膻膵腉腍腖臙腢膣臵腉腎臩臎腢臞臖腷臔膝臖膿 hydrostatic pulmonary edema: hydr. PE2 腒膠膍臶膆臙臔膝臖膿 increased permeability pulmonary edema: perm. PE6 腌腮 膜腖ITBVI, EVLWI, PI 膉腉腎ITBVI hydr. PE perm. PE 腙膫臮腢膺腉腎EVLWI 膜腕膭腗腔腄腏腎PI perm. PE 膜腅膫臮腢膺腉腎hydr. PE perm. PE 腒腖膎ITBVI, EVLWIPI 腕腜腞膃腑腁腏腎自腕 腾腊腎臖腅腇腠腝腮腲腰腀腨腀腢膴腒腋腟腇腒腕腜腞膃腑腁腟腇腄腊腆 膔臙臥臉 ALIARDS腕腁膐膾臖膿膠膍膈臖腌腬臆膌臷自腱腬腨腀 腂腀腃腁 1996 Connors 腥腩腀腩腴 pul- monary artery catheter: PA 腥腩腀腩腴腂腎膋 膼腖臁臯膍腗膋膼腖膧膇臡腕膏腉腔腂腘腄腞 臜臤腢腶膁腈腌腟腒膬腉腎 1腍腖膧Sandham 2Richard 3PA 腩腀腩腴腢腂腎膋膼膍腖臧至臙腢臦膵臟膗臸膤 膖腑膣臵腉腎膟膅膋膼腖膧腢腶膁腈腌腟腇腒 腗腔腂腅PA 腥腩腀腩腴腕腜腞臹腎腪腀腨腢膴腒腉腎膋膼膍臱腗腔腂腇腒腢膬腉腎臃臍膋膼腕臩腋腟臁臯膹腒腗腭腤腨腴腧腤腵腸 膸腛臋臢臐臬膽腸膸腖腎腚腖臆膌膠腽臨腽 腒臒腖腸膸腛臈腅膮臠腈腠腟臆膌膠腽腬腉膂腖膴腒腉腐腆腎 CVP PA 腩腀腩腴腕腜腟 PAWP 腖臑臙腕膓腅臄腐腆 腎膦膯腇腠腕臬腡腏腐腕腁膐膾腕腜腟 膚膪臺膠腽ITBV: intra-thoracic blood volume膠膍膈臖腌腬 EVLW: extra vascular lung wa- 臝腯腳腣腵腫腹膄臭膊 膕膔腹膊 臝腯腳腣腵腫腹膄臭膊 膈膄膊臒臣膠膍膈膄359 147

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Page 1: ˘ˇ - St. Marianna University School of Medicineigakukai.marianna-u.ac.jp/idaishi/www/344/16-34-04Yoshinari Hujinawa.pdfVol. 34, pp. 359 368, 2006 ˘ˇ 1 1 1 1 ˇ ˘ ˆ˙ 1 ˇ ˆ

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� �/�) 01234�5678) 9�:3;<�= �central venous pressure: CVP�) �>��

�= �pulmonary artery wedge pressure: PAWP� ?@AB�CDEFG4�5HIJ) �K�>��LM�5NJOPQR STUVW��BX �intrathoracic blood volume index: IT-BVI�) �V4YZ��BX �extravascular lung water index: EVLWI� [D8V4\]^BX�permeability index: PI� _FG4�:B�CD8`�aQ87R*�K�>��LM�bcd��eA�Zf �pulmonary edema: PE� 81 5ghD) [:!"^AijDE* klA<Z=#mn�Zf �hydrostatic pulmonary edema: hydr. PE� 2 )CV4\]^#mn�Zf �increased permeability pulmonary edema: perm. PE� 6 5�$D) %o:) ITBVI, EVLWI, PI A&pDE*ITBVI q hydr. PE _ perm. PE 5&r�sAtDE* EVLWI q%o5uq?HvE*PI q perm. PE o_�sAtDE*hydr. PEC perm. PE C:w'_) ITBVI, EVLWI) PI 5NJx(yzvE* ){5

|}EZ�4�_~QP����d�AB�C�R~C5NJx(yzR*

�����^��� �ALI�ARDS�) �K�>��LM�) �Zf) �V4YZ��) FG>{bcd�

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1996� Connors P q�>������ �pul-monary artery catheter: PA������A"7E��:234�q��:*���5�+D?7�HJH) *�) ��,A��a�RC-�DE1�*[:�) Sandham P2�) Richard P3�q) PA �

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�yijDE* � ) ��:*�A��a�R~Cq?7_) PA �����5NJOE¡�dAB�CDE��4�:.¢q?7~CA-�DE*01��5k�R23£/Cq¤¥d�¦¥�§¨©0ª«¬­®§¨:E¯:) FGVW�) °W�4�C;�±(:§¨©1²_³2´aQR*FGVW�3µ:B�CD8¶E CVP © PA �����5NR PAWP :"4^5·5_¸8¶E¹º) ~Q5­Iv8�K�>��LM�5NRSTUVW� �ITBV: intra-thoracic blood volume�C�V4YZ�� �EVLW: extra vascular lung wa-

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147

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ter� ���������� ITBV ��� � ������������ EVLW ������������������� !���"�"#$%&��'(� )*� ITBV,EVLW +,� PI ��,-� ./0012345 ICU /,-��� 8$� �6�7 �89����-��7����:�� +���;�<=,-�

�����

0012345>/,� ���?@AB"���7����-��6�7 �89� �PiCCOmonitor, Pulsion Medical Systems, AG, Munich,

Germany� C���7����:D- 8��EF?,-� GH� �6�7 �89�� PiCCO?I��JK�%&�EF?,-�L�MNO retrospec-

tive study ���� %&�PQ� #$�'(� )*�R��ST5TU��VWX�Y�?,�Z-�%&��� !� �Table 1�� ALI�ARDS [

�B"���\J;�]��� �increased perme-ability pulmonary edema: G^ perm. PE ?��� 6�?_;��� [�B"�`�a�]b����increased hydrostatic pulmonary edema: G ^hydr. PE ?��� 2 ����� perm. PE 6 �ARDS�ALI � 4 c�@Ade� 1� 1;�$� 2�f� Xg��hijk� 3� P�F ratio�300� 4� l

�amn���� ��-,��-� o-_pq%�� rs?4�� 3�� �tu>��v wx�y�����z{ �direct injury type� �|� } ;�|� ~!������ +,� 3�� sepsis �� �p,� |$;���S�3�� humoral mediator

��z{�_p?�����z{ �indirect injurytype� ��D-4��8��%& � �� 85�� PiCCO C����:���EF?,-� �������%&�Y�,����� ��Y" 2��_�?,� %&�#��$�,-?� ���y��,-� ���%� ��������&�� �Mm����('�ALI �ARDS �� P �F ratio 300 Gm� +,�PiCCO C����()?*AB"-��?,-� ¡��� Unpaired T-test ���-�PiCCO���_� 1� a+¢��? 2� �8

9����� ��B"�£¤¥545�� 2 !��Table 2�� �89 C��� Swan-Ganz Cathe-ter C�+"?_�P¦���� -§,�PiCCO �� ¨©23�5�ª,,-'` ¤�3��«¬UU5¥3ST5TU� 1312-8TG� "�­®5¯°±����,--��²³� �7` � l³�6�� ´�7 V,-ST5TU �5Fr. thermodilution catheter, PV4046, PulsionMedical Systems AG�¨©23�5���¨©�µ¶,� 2����89 C·R��£¤¥545��������.¸¹�¹ 1 !� �Fig. 1��

Table 1. Characteristics of Study Patients

º/»0 1 ¼2 �360

148

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CV �������� 15 ml 3�� �� ������������PiCCO ��������� ! 2�"#� $

��%�&� ��'�()�*�*�+�,���-� ITBV ���./ ITBVI ��ITBV�0!12�� EVLW ���./ EVLWI ��EVLW�03����4 EVLW� ITBV��567��89:;<./ �permeability index: PI�EVLW�ITBV� (=��$��5��� �>?@ 2�AB�C��4"# �Fig. 2��56DE�FG4-H�I�J(=�� KL-CV ������� �� M�NO�P ��Q�R�(STUV�� WXYZ[�� $�WXYZ[��\]�%�&� �56#�5��\]�5�-�� ^� PiCCO _0+`Na�56�b1�!"#��ITTV�CO�MTT

PTV�CO�Te�pdecGEDV�ITTV�PTVITBV�a�GEDV�b �cd�eG4- a�1.16� b�86 ml�m2�EVLW�ITTV�ITBV

ITTV: intrathoracic thermal volume �fghWij�MTT: mean transit time �k;lm�CO: cardiac output �nopj�PTV: pulmonary thermal volume �qhWij�Texpdec: exponential decay time �./r/astum�GEDV: global end-diastolic volume �nvwxyuij�ITBV: intrathoracic blood volume �fgh8zj�EVLW: extra vascular lung water �89{|j�

Table 2. The PiCCO Measures the Following Parameters

Fig. 1. Transpulmonary thermodilution method �PiCCO systems�.

q}~NOWXYE����� ��� 361

149

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� �

�� ITBV � EVLW ����perm. PE�� hydr. PE�� ITBV �EVLW �

����� 3� � �Fig. 3�� perm. PE ����ITBV �������EVLW������������� ITBVI �intrathoracic blood volume index�ITBIVI�ITBV����� ����� ����700� 1000 ml �m2 �� � ITBVI � hydr. PE

�group B� 1183.5�160.7 ml�m2 perm. PE �groupA� 966.4�260.5 ml�kg� hydr. PE ���!��Fig. 4, p�0.01���� EVLWI �extravascular lung water index�EVLWI�EVLW��" ���� � ����10.0 ml�kg #$�� � perm. PE �group A�: 13.9�5.2 ml�kg, hydr. PE �group B�: 14.9�5.3 ml�kg�EVLWI �%&��'��()*�+,�� �Fig.5���� PI �permeability index�

Fig. 2. A schema of volumetric parameters obtained by PiCCO.

Fig. 3. A scatter diagram of ITBV and EVLW in permeability PE and hydrostatic PE.

�: permeability PE. : hydrostatic PE.

-./0 1 23 4362

150

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PI � EVLW �ITBV ������� perm. PE�group A�: 0.60�0.28� hydr. PE �group B�: 0.41�0.14 � perm. PE ��� �� �Fig. 6, p�0.01��

� �

�� ����������������� hydrostatic pul-monary edema �hydr. PE: ����� ���� �increased permeability pulmonary edema �perm.PE: !"#�� ���� �$%���� &��'(����)*��$%+,-.� /01234�5��67,-��89:;� hydr. PE ��<=�>?��$@��A(���� �B�C�,-.DE#����FG���� H1 perm. PE ��� �IJKLMN�B.C�IJO�PQA(�9.IJKRS�$@����,-.� ALI�ARDS �FG���� perm. PE ��S��T� UV#�T9W��XYPQZ:.[\8� direct injury �XYPQ� ALI�ARDS � sepsis 9W��]^_���`

Fig. 4. Comparison of ITBVI between group A �perme-ability PE� and group B �hydrostatic PE�. ITBVIwas significantly higher in hydrostatic PE than

those in permeability PE �p�0.01�.

Fig. 5. Comparison of EVLWI etween group A �perme-ability PE� and group B �hydrostatic PE�. Therewas no significant di#erence between group A

and B.

Fig. 6. Comparison of PI between group A �permeabi-lity PE� and group B �hydrostatic PE�. PI inpermeability PE was significantly higher than

those in hydrostatic PE �p�0.01�.

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151

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�������� humoral mediator ���indirect injury � ���� ����������������������������

�� �� CVP� PAWP �PAOP� �� ������!"�#�$� perm. PE � hydr. PE ��%���&'( �� �)*+","������-�.��������/,��"� 0�0�1#�$�)����2��,� CVP, PAWP ���.�+3 �!"4#�5���6���7�+89� �:�;�<����� �<�=)���2�+>?��"� @#�A�"�4 ITBV� B EVLW +C�� !�!�"#�D�� #��$"EFG��;��H���IJ���Marik 5�� CVP �%�<�������&K�� CVP ��<����� ��L�MN1OPQR� PAWP 1$"STU'VW���2����:X���JY"� ��0Z PAOP �STU'VW[ �LVEDP� �2��D:� STU'VW���LVEDV� �2������ #�(\�)4 PA �]�EFG+2��,"�������*I�^��_�D��$�JY���6���� ALI�ARDS ����ARDS �`�abc+�,+��de�� ALI �`�

���� ��� 1967- Ashbaugh 57�4f�g������4� hijkB=����./,�`�ab�0+1���2+/3,� @�I Petty 58�4�labc+�de �Adult respiratory distress syn-drome� �45,"�1992-� 6mn7g�op �ATS� �qrs8.

�op �ESICM� ����t9u:p �AECC� ����� ALI�ARDS �!v� w;xy� /<z{�*I� �&|}�~?=��4$�?5�"9��ARDS�ALI�����>�?�<��@� �>'@��A��B~�x��Cf_��)*�D�10����2�1� perm. PE2 �ALI�ARDS�����PI 4D��+1 ���+�,� hydr. PE ��<�?A�����+E;��,"��� ����� �ITBV� �������EVLW�1992-� Lichtwarck-Ascho#511�� CI� � CVP@,� PCWP �PAWP� ��MN�5� CVP �PCWP �PAWP��fFGH��2��,��IJ�D:� ITBV4DK�2��D�#�+K�,"�

@�I9L�K�4.!� �-fF�GH�2��,� CVP B PAWP �M0:� n��<����ITBV� ��;�4�N�����12������������ <������1��<�=)��� !�� �����s8.�����-�O�P��)*� ab�0�/<+QR�S���H)����.�=�+�!,� @�TJ�+U�'�%���D�� ,�, PAWP �Cf_�@,�f_���)*�2��,��v4V�#�4���"13�15��#�$� PAWP 4Sf��GH�2��,�W�5��!"�XPY����#����� ��0Z� <��P+��SfT���GH��STU'ZW���D�4� fT�[���MN4[��D���!���STU'ZW[�MW�!�� �5�� \]^g�4�-��STU'ZW[�_�S`[�MW�!�� PCWP D��� PAOP �� �ab�4c��dt+��VZ<���D�#�+eW,� fgD���� F�h¡��:�ab�[ij+¢;���� _�S`[�£¤_¥��#�+�XPY��,���16�� ��0Z[���MN4[��D���!,�STU'ZW[�5GH���+¦!,��"� �#§4�&2��kR,1[�MN4�l,��#�4�m�D��Mitchell 517�� PAWP �M0 ��<�=)�

� �EVLW� +2��,"����4���ab¨noW ��© ICU ªTp«+¬­�Q��K�,"��)*�w;����� EVLW �n7®��¯�°��:18±�4�� 18�� $" EVLW ��2��qr���� EVLW ������*I2���:²��1K���"19��0�0�1"#��:�)*�"��D�

EVLW+G�³´F�U�#�4�!� n7 X [���#���� �)*�sªP�ytµ�BuW/<+U�#�4�!� �&P�v!�wl ���� ¶·��� ITBV,� EVLW� IP+ !,� )�x¸�� y���Mz�¹ J":�{|�� {|}����~º��»º������+�!,������ EVLW ����������� �� ������� �: single transpulmonary thermodi-lution ��)*�!�P��#�,� gravimetric ��

��¼� _ �� 5364

152

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��� gold standard ������� ���� ������ ��� �������EVLW������������� double indicator������ �������� � !"��� EVLW��"�#���$�� %""� �&��'�()��*������ ���+ � ,!��-����� "��.�������: singletranspulmonary thermodilution � �PiCCO, Pul-sion Medical Systems, Munich, Germany� ����2004�� Katzenelson � 5����"/0123

�� 4567839� perm. PE 9� ,�� hydr.PE9"�:�;��%� PiCCO�� EVLWI�� gold standard ���<=���EVLW �����)�>��!��?� ��� perm.PE� hydr. PE���� ITBV, EVLW�PI

ITBVI � CVP @ PAWP �A�#�� !B�?�������12������"28C�%� " 3 ?� ���perm. PE 9�� ITBV �,�DEF��?�:�% EVLW �F)� G " 6�?� �� PI �hydr. PE 9#HF��?� � !�� perm. PE9;�����$%� !B�?� ITBVI �I&�� ���'JK�� ��(L�I) �PI������M"��*N �456783��!��O+��A� perm. PE ",-�����./P�(L�01�23��Q4�"56��R)?S���2004 �� Katzenelson �5���7/0�� perm.PE "89T�/P"��"U:��V" EVLWI� hydr. PE " EVLWI �#W� perm. PE ;��F��?�!��?� �X�Y�"��28C��� EVLWI � perm.PE � hydr. PE ;9Z���+ � !��� [0<� perm. PE 989,��\9T�/P�]^!��_`�=���� ,"ab�>cd�e+���fg"?�� U:h`��89T�/P" EVLWI �@"89T;�i\9T�/P#H�AjF��?�!��BC����� ��� ��k����Dl� �X9"E-�]�� EVLW� PI m��,�n�FG�?��op���� qr� perm. PE ��� ALI�ARDS �%_`E-�A ITBV, @ EVLW �FG"����?�!��HI��� !��gC��!��Q

4JK�sL���op� tMu�����./P"I&�����.(L�: PI ��

perm. PE9� hydr. PE9#H�AjZ�%+�F��?� � Nv�wx�O Py�� !�G���<;����"zE-"{�� PI �AQC� R|��)� ����"R|�}~�������perm. PE "�E-��5�6��5� ��6��5� S�����C8��E����.$����� ,��p��$%@�"�����:��%Tp�!��U���$%��\�� �VM"*NM8���� X�� hydr. PE����.�������� �E-�����."�%�W�)Tp L��%� �!B�A�~���$J��*N���op���� !"!����(L�/P"I&��� PI �� perm. PE ;�� hydr.PE �AF��?�_`�op������������ hydr. PE X����7���� �5��E"YZ�[\���� Q4��perm. PE �YZ���%]�^(���" ~" 3¡�5_�[\� ¢?����C8�`�a[\�E�� ITBV, EVLW� IP"28C�£e+���� J�� perm. PE �,",-�����(L��sL��Q4��56�op���� PiCCO�� hemodynamic monitoring� ����,�"Yb�� 1� ���$M�¤8¤3�cd�6¥:� ef�� g/P� ���h¦�ij"�k��)lm§���� 2� ��",-����������EVLW�"��¨n���� 3�EVLW ��%��$%�o©�� ITBV ��¨n��A� ª«�-�'� p¬�'W�)­\���®b� 1� #W�q�r¯��M"�¤8¤3st�6�� �¬°±� �u�v"²_³�HI���� 2� �¤8¤3h`´w³� 3� µ²x��¶ yz{��e¨n� �E��·�������"�!¸� ¹|"����¤8¤3�#W

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�PiCCO� ���������� ��� ��������� ���������� ��!���"#$� �%��!�2� �&'�()�*+,-.�� perm. PE "hydr. PE / ITBVI 0 PI ���123-4�56�/789:��3� perm. PE �;!1�� ITBV �<=">�?@AB�CDEF� �G-��&'�HI�JK-.�� LMN-.�?OPQ��M�RS�TU�HIV�WX/YZ-.�["�78U��4� ARDS�ALI"��&'�\]�^N">))_� `a�MN�bc 1 )�def-.�� ghperm. PE � 2)�*+,� direct injury type "indirect injury type�;!1� ITBV, EVLW, PI�i�9j�klU�YZ/.�� [:��m ALI�ARDS �n��MN�TU��o/pqm� HIrs�tu/vjw���56�/.��

� �

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Abstract

The Usefulness of Transpulmonary Thermodilution Method for

Hemodynamic Monitoring in Pulmonary Edema

Yosinari Fujinawa1, Yasuhiko Taira1, Kenichirou Morisawa1,

Hiroo Takahashi1, Masateru Takahashi1, Yoriko Egami1,

Yasuaki Koyama1, Hitoshi Ohashi1, Nobuhiko Shimozawa1,

Takashi Sakaino1, Eiichiro Hagiwara1, Tkahumi Wada1,

Yoshihiro Masui1, and Toshiya Kobayashi2

In recent years, the utility of hemodynamic monitoring by PiCCO systems �Pulsion Co. � Germany� forcritically ill patients has received attention.

Pulmonary edema �PE� is a common finding in many critically ill patients.The pathophysiological mechanism leading to PE is accumulation of fluid in the interstitial and alveolar

space in the lungs, termed extravascular lung water index �EVLWI�.The principles of PiCCO systems are pulse contour and single thermodilution methods. Especially,

single tehrmodilution method provides intrathoracic blood volume index: ITBVI and extravascular lung

water: EVLWI.

The purpose of this study was to investigate the utility of ITBVI and EVLWI as the parameters for

hemodynamic management for patients with pulmonary edema.

Eight patients with pulmonary edema received intensive care, including hemodynamic monitoring by

PiCCO systems, in our ICU were included. The eight patients were classified into group A: increased

permeability pulmonary edema, n�6 and group B: hydrostatic pulmonary edema, n�2.ITBVI, EVLWI and permeability index �PI� obtained by PiCCO were compared between group A and

group B.

ITBV values were indexed by the predicted body weight: ITBVI. EVLW values were indexed by the

predicted body surface: EVLWI. PI was shown as EVLW divided by ITBV. ITBVI was significantly higher

in hydrostatic PE �group B� than in increased permeability PE �group A�.There was no statisticallysignificant di#erence in EVLWI between group A and B. PI was significantly higher in group A than ingroup B.

ITBVI, EVLWI, and PI obtained by PiCCO can allow di#erentiation between increased permeabilityPE and hydrostatic PE. These parameters may play an important role for hemodynamic management in

critically ill patients.

Key Words

ALI�ARDS, pulmonary edema, ITBV �intrathoracic blood volume�,EVLW �extaravascular lung awter�, PI �permeability index�

1 Department of Emergemcy Clitical Care Medicine, St Marianna University School of Medicine2 Department of Cardiovascular Surgery, St Marianna University School of Medicine

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