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Archives of cardiovascular diseases
Volume 106, n° 4
pages 209-219 (avril 2013)
Doi : 10.1016/j.acvd.2013.01.006
Received : 10 December 2012 ;  accepted : 15 January 2013
Cost of transcatheter aortic valve implantation and factors associated with higher hospital stay cost in patients of the FRANCE (FRench Aortic National CoreValve and Edwards) registry
Coûts de l’implantation des valves aortiques percutanées et facteurs associés aux coûts des séjours chez les patients du registre FRANCE (FRench Aortic National CoreValve and Edwards)
 

Karine Chevreul a, , b , Matthias Brunn a, b, Benjamin Cadier a, b, Georges Haour a, b, Hélène Eltchaninoff c, Alain Prat d, Alain Leguerrier e, Didier Blanchard f, Gérard Fournial g, Bernard Iung h, Patrick Donzeau-Gouge i, Christophe Tribouilloy j, Jean-Louis Debrux k, Alain Pavie l, Martine Gilard m, Pascal Gueret n
on behalf of

the FRANCE registry investigators

a URC Eco, AP–HP, Hôtel-Dieu, 1, place du Parvis-Notre-Dame, 75004 Paris, France 
b UPEC EA 4393, Créteil, France 
c Cardiology Department, Charles-Nicolle Hospital, University of Rouen, INSERM U 644, Rouen, France 
d Department of Cardiovascular Surgery, University Hospital, Lille, France 
e Department of Cardiovascular Surgery, University Hospital, Rennes, France 
f Department of Cardiology, Georges-Pompidou European Hospital, AP–HP, Paris, France 
g Department of Cardiovascular Surgery, Rangueil University Hospital, Toulouse, France 
h Department of Cardiology, Bichat-Claude-Bernard Hospital, AP–HP, Paris, France 
i Department of Cardiovascular Surgery, Jacques-Cartier Institute, Massy, France 
j Department of Cardiology, University Hospital, Amiens, France 
k Department of Cardiovascular Surgery, University Hospital, Angers, France 
l Department of Cardiovascular Surgery, Pitié-Salpêtrière Hospital, AP–HP, Paris, France 
m Department of Cardiology, La-Cavale-Blanche Hospital, Brest, France 
n Department of Cardiology, Henri-Mondor Hospital, AP–HP, Créteil, France 

*Corresponding author. Fax: +33 1 40 27 41 41.
Summary
Background

Currently, several anatomical approaches and intervention sites can be used to perform transcatheter aortic valve implantations (TAVIs), often with no clinical indications for choosing one or another. While these choices can have an impact on resource consumption, no costing study is available in the European context to provide information on resource use and assist decision-making.

Aims

To provide comparative data on the cost of the TAVI procedure, depending on anatomical approach and intervention site used, from a hospital perspective, and to analyze factors associated with cost of hospital stay.

Methods

Multicentre national registry data were collected in 16 centres between January and October 2009. For 287 patients, a descriptive costing study and a multivariable analysis of hospital stay cost were performed.

Results

The mean cost of the TAVI procedure was €22,876 and the mean initial hospital stay cost was €35,164. The procedure cost, excluding valve cost, did not differ between anatomical approaches and was highest in the hybrid room and lowest in the catheterization laboratory. Factors associated with higher hospital stay cost were transapical approach, Society of Thoracic Surgeons score>10%, warfarin use at inclusion, complications during procedure and pacemaker implantation following valve implantation.

Conclusions

If clinical considerations do not interfere, hospital staff may find it economically favorable to opt for the catheterization laboratory and against the hybrid room. The mean hospital stay cost is higher than the tariff paid in 2011, a difference that has grown since the change in tariff in 2012, representing an economic disincentive for the uptake of TAVI in France.

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Résumé
Contexte

Il n’existe souvent aucune indication clinique permettant de faire le choix entre les différents types de salle et de voies d’abord disponibles pour effectuer une implantation de valve aortique par voie percutanée (TAVI). Bien que ces choix aient un impact en termes de consommation de ressources, aucune étude ne permet de le quantifier et d’apporter une aide à la décision dans le contexte européen.

Objectifs

L’objectif était de fournir des données comparatives de coût de la procédure TAVI du point de vue de l’hôpital en fonction de la voie d’abord et du type de salle utilisés ainsi que de déterminer les facteurs associés au coût de séjour.

Méthodes

Les données utilisées proviennent d’un registre national multicentrique correspondant à 16 centres et à la période allant de janvier à octobre 2009. Une étude descriptive de coût ainsi qu’une analyse multivariée du coût de séjour ont été effectuées sur une population de 287 patients.

Résultats

Les coûts moyens de la procédure TAVI et de l’hospitalisation initiale étaient respectivement de 22 876€ et 35 164€. Les coûts de la procédure ne différaient pas en fonction de la voie d’abord et étaient les plus élevés en salle hybride et les moins élevés en salle de cardiologie interventionnelle. Les facteurs associés à une augmentation de coût de séjour sont la voie transapicale, un score STS supérieur à 10 %, l’utilisation d’antivitamines K à l’inclusion, la présence de complications lors de la procédure et la pose d’un pacemaker à la suite de l’intervention.

Conclusion

Si les conditions cliniques du patient le permettent, le personnel hospitalier pourrait être amené à trouver l’utilisation de la salle de cardiologie interventionnelle économiquement plus avantageuse que celle de la salle hybride. Le coût moyen de l’hospitalisation est supérieur au tarif remboursé en 2011. Cet écart s’est amplifié depuis le changement de règle tarifaire survenue en août 2012 représentant un frein au développement de l’utilisation de TAVI en France.

The full text of this article is available in PDF format.

Keywords : Aortic stenosis, Transcatheter aortic valve implantation, TAVI, Costing study, Factors associated with higher costs

Mots clés : Sténose aortique, Bioprothèse aortique par voie percutanée, Étude de coût, Facteurs associés à un coût élevé

Abbreviations : CRF, GHM, LES, SC, STS, TA, TAVI, TF


Background

In 2002, the first transcatheter aortic valve implantation (TAVI) was performed in a patient with severe aortic stenosis and cardiogenic shock, as a therapeutic alternative to cardiac surgery for patients at high surgical risk. Since then, over 50,000 patients are estimated to have been treated by TAVI worldwide [1].

The safety and efficacy of TAVI have been repeatedly demonstrated [1, 2, 3] and 1-year as well as 2-year survival rates were recently reported to be similar to those for patients undergoing surgical valve replacement [4, 5]. The quality of life of patients has been shown to improve after TAVI [6] and studies based on a randomized trial in the USA using only the Edwards SAPIEN valve suggest that the cost-effectiveness and cost-utility of TAVI are favourable in inoperable patients [7, 8]. However, no costing study is available in the European context to provide information on resource utilization and assist decision-making at the national and hospital level, especially in countries where payment is based on activity. Indeed, physicians and hospital managers face the choice of several TAVI devices, anatomical approach types (arterial or transapical) and intervention sites (catheterization laboratory, operating room or hybrid room) but lack comparative cost data in order to make informed decisions when the choice is not clinically driven.

The purpose of this study is therefore to provide these comparative data for the cost of the TAVI procedure and the hospital stay excluding the procedure cost, from a hospital perspective, and to analyse factors associated with higher cost.

Methods
Study design and population

Our study is based on the FRANCE registry, which has been described in detail in previous publications [2]. In short, it involved symptomatic adults requiring TAVI due to severe degenerative valvular aortic stenosis and who were very-high-risk patients for aortic valve replacement at the time of enrolment. The registry is exhaustive because TAVI may only be performed in France in authorized participating centres.

The FRANCE registry case report form (CRF) was designed to collect detailed information on the resource requirements for the TAVI procedure and initial hospital stay, in addition to the collection of clinical and quality of life data. The subsequent FRANCE2 registry currently collects long-term data on follow-up and adverse events [1]. The present study presents the findings of the FRANCE registry, allowing sound cost analysis; it reports on a total of 295 patients included in 16 French centres between January and October 2009, of whom 287 patients underwent TAVI implantation and were included. For the costing study, 11 patients were excluded due to missing data (anatomical approach type, device type, length of stay). For the analysis of hospital stay cost predictors, 31 patients were excluded because death occurred during the hospital stay and nine patients were excluded due to missing data (anatomical approach type, device type, length of stay).

Devices, procedure and intervention sites

Patients received one of two models of prosthesis: the Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA, USA) or the CoreValve (Medtronic, Minneapolis, MN, USA). The Edwards SAPIEN valve (the SAPIEN XT valve was not available at the time of the study) is a bioprosthetic valve made of bovine pericardial tissue mounted into a balloon-expandable stainless steel open-cell stent. The valve can be implanted using the transfemoral (TF) or transapical (TA) approach, depending on the peripheral access. The CoreValve consists of a trileaflet bioprosthetic porcine pericardial tissue valve mounted into a self-expandable nitinol frame. It is generally implanted using the TF arterial approach or, less frequently at the time of data collection, the subclavian approach (SC). There were no prespecified recommendations regarding the TF, SC or TA anatomical approaches or for intervention sites used to implant either valve, which included the catheterization laboratory, the operating room and the hybrid room (a multiusage site equipped with both catheterization and anaesthesia devices).

Data collection

After informed consent, data were recorded using a standardized e-CRF and sent to a central database via the internet. Recorded data included demographic and clinical patient data, data on the devices and other materials used for the TAVI procedure, information about which anatomical approach and intervention site had been used, the duration and staffing required for the procedure, the length of hospital stay and the homogenous patient group code (groupe homogène de malades ; GHM), which is the accounting system code used for depicting the level of hospital resource consumption for a patient stay.

Costing

A hospital perspective was taken for costing. Unit costs have been applied to the materials and staffing resources used in order to estimate the cost of the TAVI procedure, which also included overhead costs depending on the intervention site. As these costs are not available on a national basis, Paris hospital consortium average unit costs were used. The cost of the hospital stay was estimated based on the cost of the procedure and on direct and overhead cost items related to the patient's GHM as identified in the national cost scale for the medicine, surgery and obstetrics sector (ENC MCO, which features a detailed accounting system that evaluates the total cost of each hospital stay). As only GHM data for patients in hospitals with accounting systems were available (47% of the study population), we calculated the mean daily hospital costs excluding procedure cost for these patients. To determine the cost of each hospital stay, this daily amount was then multiplied by the patient length of stay. Subgroup analysis distinguished patients by arterial (TF and SC) or transapical (TA) approaches and by intervention site. Costs are expressed in 2009 Euros (€) and are displayed with and without the valve price included.

Factors potentially associated with hospital stay cost
Outcome

What was of interest was understanding the factors associated with higher hospital stay cost. As the cost of the valve represented a high fixed-cost component (close to €20,000 which is over 62% of the tariff offer to hospitals for TAVI hospital stays in 2011), it was not integrated and the outcome studied was the hospital stay cost on top of the cost of the valve.

Predictors: factors potentially associated with higher hospital stay cost

Variables analysed include sociodemographic and clinical patient characteristics and treatment at inclusion, as described previously [2]. Variables related to the procedure included the type of anaesthesia (general/local), device type (Edwards/Medtronic), anatomical approach chosen (arterial/TA), intervention site (catheterization laboratory/operating room/hybrid room) and occurrence of complications during the procedure (yes/no). As clinical scores assessing overall severity seemed likely to be overall cost predictors, we constructed our analysis around two mortality risk scores widely used in TAVI: the Society of Thoracic Surgeons (STS) score and the logistic Euroscore (LES). An STS score>10% and an LES>20% are commonly used in the literature to define high-risk patients in valvular surgery so we chose these values as thresholds for categorical analysis [9, 10].

Statistical analyses

Because of the skewed distribution of the cost, we used a gamma distribution with a log link in a generalized linear model. As the data have a hierarchical structure, the unconditional means model was first fitted to test for centre effects, which were not detected.

Because classifications of patients in high-risk groups using the STS score and the LES are highly correlated, two different models were then tested with gamma regression: the STS score and all other variables except those used for its calculation; and the LES and all other variables except those used for its calculation. Variables were selected using the backward elimination method. Gamma coefficients generated by the regression models were exponentiated to retransform them into rate ratio estimates.

All statistical tests were two-sided. Statistical significance was accepted at P <0.05. All data were analysed using SAS software version 9.3 (SAS Institute Inc., Cary, NC, USA). Results are expressed as means±standard deviations while dichotomous variables are presented as frequencies and percentages.

Sensitivity analysis

A one-way sensitivity analysis was performed on the results of the costing study to estimate the effect of potential variation in main variables. Hypotheses tested included a decrease in the valve price that may follow an increase in uptake of the TAVI, a decrease in the duration of the procedure as a result of a learning effect after the diffusion of TAVI and, similarly, a decrease in the length of hospital stay (−10% and−20%, respectively). For the study of cost predictors, the sensitivity analysis tested the effect of including the patients who died during the hospital stay. A model was also performed that excluded the severity scores LES and STS, replacing them with variables available in the e-CRF (described elsewhere [2]).

Results
Population baseline characteristics

Detailed baseline characteristics of the FRANCE registry population have been described elsewhere [2]. In short, patients undergoing TAVI by the TA approach did not differ significantly from those undergoing the arterial approach in terms of age, sex, hypertension, diabetes, bypass surgery, peripheral artery surgery, New York Heart Association class, creatinine, warfarin treatment, LES, STS score and ejection fraction. However, they exhibited an aortic abdominal aneurysm more frequently (Table 1).

Procedural results

The arterial approach was performed more often than the TA approach (73% vs. 27%) and an Edwards valve was more frequently used than a CoreValve (66% vs. 34%). The combination of an Edwards valve and the arterial approach accounted for 38% of patients. The catheterization laboratory was the most frequently used intervention site (67%), regardless of the valve and approach type. The operating room was most frequently used to perform the TA approach, while the hybrid room was predominantly chosen to carry out TAVI using an Edwards valve by arterial approach.

Staffing and duration of the procedure

The TAVI procedure required, on average, 10 hospital staff. The duration, with a mean of 182±85min (median, 167min), decreased during the study period of 10months from a median of 177min to a median of 150min. The mean duration did not differ significantly when the arterial approach was chosen (185±87min) compared with the TA approach (175±80min; P =0.40). The mean duration of the arterial procedure was significantly longer for patients with an Edwards valve (193±77min) compared with those with a CoreValve (174±96min; P =0.009), which was not linked to a difference in the choice of intervention site. The mean duration for patients treated in the catheterization laboratory (165±58min) was significantly lower than the mean duration for patients treated in the operating room (229±128min; P <0.0001) or the hybrid room (220±84min; P <0.0001). The mean duration of the procedure did not differ significantly between the hybrid room and the operating room (P =0.9206).

Length of hospital stay

The average length of stay was 14.83±11.04days (median, 12days) and decreased from a median of 13days for the first third of patients (by order of implantation date) to a median of 11days for the last third. Mean length of stay did not significantly differ between the subgroups distinguishing approach and intervention site.

Cost of the procedure

The total average cost of the TAVI procedure was €22,876, of which 85% was attributable to the valve price, 7% to other material, 7% to staffing and 1% to logistics (Table 2).

When the price of the valve was excluded, the average procedure cost was €3305. For patients treated in the catheterization laboratory, the cost was significantly lower than in the other two settings (P <0.001 for each) and it was significantly higher in the hybrid room than in the operating room (P <0.001). No significant cost difference was observed between the subgroups distinguishing approach type and brand name of the valve. However, when the cost of the valve was included, the cost of using Edwards for the arterial approach was significantly higher (+€1160; P <0.001) (Table 3).

Cost of hospital stay

The total average cost of the initial hospital stay associated with the TAVI procedure was €35,164. When the price of the valve was not included, the cost of the procedure was 21% of the average hospital stay cost, which amounted to €15,593 and was 44.3% of the total hospital cost. There was no significant cost difference between the subgroups distinguishing approach type and intervention site (Table 4).

Factors associated with higher hospital stay cost

For the robustness of the models, three patients with extreme length of stay (90, 87 and 65days) were excluded. We therefore performed the analysis on 244 patients.

Regardless of the variable included to assess severity (i.e. in both the STS and the LES models), hospitals cost modelling results were quite similar. However, while an STS score>10% at inclusion was associated with increased hospital stay cost, an LES>20% was not significant.

In both models, patients treated with warfarin at inclusion, the TA approach, complications during procedure and pacemaker implantation during hospital stay following valve implantation were significantly associated with higher hospital stay cost. Receiving a pacemaker was associated with a 36% increase in cost and this effect was approximately double that of other factors associated with cost.

In the model assessing patient severity using the LES, the use of the hybrid room was associated with increased hospital stay cost (Table 5).

No significant association with cost was found for the following patient characteristics at inclusion: age, sex, use of platelet inhibitors, New York Heart Association class, ejection fraction, severe aortic insufficiency, creatinine, atrial fibrillation, left bundle branch block, previous cardiac surgery, previous mitral replacement surgery, abdominal aortic aneurism, peripheral arterial disease, smoking status, diabetes, hypertension, high cholesterol; nor for the procedural variables device type and type of anaesthesia.

Sensitivity analysis

As anticipated, one-way sensitivity analysis for the costing study revealed a major impact of the valve price on the procedure cost: a 20% reduction in the price would lead to a 17% decrease in the procedure cost. Further, learning effects leading to a decrease in procedure time by 20% would reduce the procedure cost by almost 11%, excluding the valve cost. The hospital stay cost excluding the valve cost would decrease by 7% if the valve price was 20% lower and would decrease by 15% if the length of stay was 20% shorter (Figure 1).



Figure 1


Figure 1. 

Sensitivity analysis for the procedure and hospital stay costing study, with and without valve price. How to read this graph: for instance, a 20% reduction in the valve price leads to a 17% decrease in total procedure cost.

Zoom

When the patients who died during the hospital stay were included in the multivariable analysis, all variables significantly associated with increased hospital stay cost in the initial analysis remained significant. The model without severity scores but with their constituent variables found similar factors associated with higher cost (pacemaker implantation, warfarin use at inclusion, the TA approach, the hybrid room and complications during the procedure).

Discussion

This is the first study to provide a comparative cost assessment of the TAVI procedure and hospital cost and an analysis of factors associated with higher hospital stay cost, from a hospital perspective. The average total cost of the TAVI procedure was €22,876, which is nearly two-thirds of the total hospital stay cost.

When the valve cost was excluded, the average procedure cost was 15% of the total procedure cost and did not differ between patients undergoing TAVI by the arterial or TA approach. However, regarding the intervention site, cost was highest in the hybrid room and lowest in the catheterization laboratory. This is mainly explained by the difference in duration reflected in higher staffing costs and, to a lesser extent, in logistical costs.

Hospital stay cost excluding the procedure cost did not differ between patients undergoing TAVI by the arterial or TA approach or by intervention site used. However, the TA approach was associated with a higher hospital stay cost in the modelling. This may be due to the fact that this approach is used in a greater number of patients with worse health status. Indeed, clinical data show that patients undergoing the TA approach have higher mortality rates [1]. While limited research evidence suggests that the steep learning curve for the TA approach may be responsible for higher mortality [11], it is very likely that the risk profile of these patients, as reflected in a higher LES at inclusion, plays a determining role [2, 12].

While it was not the case at the time of data collection, the arterial approach is now considered the ‘first-line treatment’, which means that patients undergoing the TA approach show contraindications for the arterial approach [2].

A similar explanation may be given concerning the hybrid room's significance in the model using the LES, while it is not associated with higher cost in model using the STS score. Indeed, among both severity score models, higher risk is associated with higher cost only when using the STS score and not the LES.

Despite the fact that the LES was found to be linked to increased 1-year mortality in the FRANCE2 registry [1], its lack of statistical significance is likely to be explained by the way both scores were calculated. While both scores were not specifically designed and calibrated for TAVI patients but for patients undergoing cardiac surgery in general [10], the STS score takes operation-related factors into account much more precisely than the LES does, including factors specific to valve surgery [13]. Moreover, evidence suggests that in high-risk patients with severe aortic stenosis, the STS score is superior to the LES in predicting mortality [14].

The association of the hybrid room usage with higher cost in the LES model should therefore be qualified by the fact that 90% of patients treated in a hybrid room have STS scores higher than 10% versus only 59% among patients treated in another type of room. This leads us to believe that the hybrid room's significance was determined by the higher STS severity scores of the patients who were operated on in such rooms.

Warfarin use at inclusion was also associated with higher hospital stay cost in our study. We tested whether atrial fibrillation as a frequent reason for warfarin use explained this phenomenon but did not find a significant effect of atrial fibrillation at inclusion in our multivariable model. Our findings are, however, consistent with a study showing that in patients with atrial fibrillation, warfarin use was the main predictor of hospital stay cost [15].

Finally, when compared with the specific TAVI DRG tariff (code 1522) established by the statutory social health insurance in 2010 to pay hospitals for TAVIs, average total hospital stay cost was higher taking into account supplemental payments for intensive care (mean duration: 4.6days) and pacemakers. With the growing use of TAVI, more recent clinical data (2010–2011) on the follow-up registry FRANCE2 suggest a nearly 10% decrease (€31,863) in total hospital stay cost and a 27% decrease (€11,444) in hospital stay cost excluding the valve cost. This is due to a decrease in the mean length of stay (by 0.9days) and in pacemaker implantations (by 3.9%) and an increase in the share of patients treated in the catheterization laboratory (by 7.7%) [2]. When using this estimate, total hospital stay cost was then very close to the applicable tariff (−1.6%) until changes were made in August 2012. Since then, the specific TAVI DRG tariff has been abolished and the valve price is now paid on top of generic DRG tariffs for therapeutic procedures with endovascular access except endoprosthesis (codes 1716, 1717, 1718, 1455). With an estimated average tariff of €8381, the hospital stay cost is more than €3000 higher than the tariff paid. The average tariff excluding valve was estimated by weighting each tariffs (codes 1716, 1717, 1718, 1455), taking into account their frequency of use from August to November 2012 and by adding supplemental payment for intensive care and pacemaker.

Study limitations

The FRANCE registry represents the first experience with TAVI on French soil, limited to 16 hospital centres. Learning curves are steep at the introduction of such innovations, as implied by the measured decrease in TAVI procedure duration and length of stay. Therefore, our evaluation may have overestimated total cost, which is why alternative cost scenarios are provided in the sensitivity analysis.

With regard to data availability, staffing, device and logistic unit costs were based on Parisian hospital consortium costs, which may not be similar in other settings (12 centres were outside of Paris). However, while wage mix can differ across hospitals, French public hospital wages are set at the national level and thus the average national wages presumably are very close to the amounts we used. Moreover, device (excluding the valve) and logistic costs comprise 7% and 1% of the total procedure cost, respectively, which means that a variation in the cost of these items is unlikely to have a major effect on total procedure cost.

Further, the accounting system codes (GHM) were only available for 47% of patients, which may have decreased the accuracy of the hospital stay costing study. Nevertheless, the cost dispersion (mean, €784; median €754; standard deviation, €201) and 95% confidence interval (€750–818) of the available GHMs were small, which leads us to hypothesise that the missing data only had a minor impact.

Our hospital stay costing analysis used mean daily costs weighted by length of stay, which is why hospital stay cost is directly proportional to length of stay. As the marginal hospital stay cost generally decreases during a hospital stay [16], our study is likely to overestimate the cost of long stays and, vice versa, to underestimate the cost of short stays. Also, the multivariable analysis of hospital stays is equivalent to a model in which length of stay is used as the outcome variable. Indeed, performing the multivariable analysis with length of stay as the outcome yielded similar results to those reported above (data not shown).

Finally, our multivariable analysis included variables that were chosen based on clinical assumptions and the availability of data. The adjusted R2 of 0.13 and 0.14, respectively, indicate that a main share of variation in hospital cost is linked to variables that were not available for analysis.

Conclusions

Based on the results of this study, assuming there are no clinical reasons for choosing one option over another, hospital staff may find it economically favourable to opt for the use of a catheterization laboratory as opposed to a hybrid room, regardless of the approach chosen, However, when considering this choice within a broader perspective, one must consider that in France, with the current tariff for TAVI hospital stays below the cost incurred by the hospital, there is an economic disincentive for the continued uptake of TAVI.

Disclosure of interest

H. Eltchaninoff has received lecture fees and was proctor for Edwards Lifesciences. B. Iung has received consultancy fees from Servier, Boehringer Ingelheim, Bayer, Valtech and Abbott, and speaker's fees from Edwards Lifesciences and Sanofi-Aventis.


Acknowledgements

We wish to thank François Hémery, Henri-Mondor Hospital, for providing cost data and valuable advice. This work was supported by the ministère de la Santé (Paris, France), Edwards Lifesciences and Medtronic.


Appendix. FRANCE registry investigators

P. Leprince, F. Beygui and J.-P. Collet: Pitié-Salpêtrière Hospital, Paris. D. Himbert, P. Nataf and A. Vahanian: Bichat-Claude-Bernard Hospital, Paris. T. Lefevre and M. Romano: Institut Jacques-Cartier, Massy. H. Eltchaninoff, P.-Y. Litzler, J.-P. Bessou and A. Cribier: Rouen University Hospital and Inserm U644, Rouen. J. Fajadet: Clinique Pasteur, Toulouse. D. Carrie, P. Berthoumieu, N. Dumonteil and G. Fournial: Rangueil Hospital, Toulouse. E. Teiger, J.-L. Dubois Randé and M. Kirsch: Henri-Mondor Hospital, Créteil. D. Blanchard and J.-N. Fabiani: European Georges-Pompidou Hospital, Paris. A. Sudre and T. Modine: University Hospital, Lille. P. Dos Santos, J.-P. Guibaud and X. Roques: Haut-Levêque Hospital, Bordeaux. M. Gilard, J. Boschat and E. Bezon: La-Cavale-Blanche Hospital, Brest. F. Schiele, S. Chocron, N. Meneveau and J.-P. Bassand: Jean-Minjoz Hospital, Besançon. G. Rioufol and J.-F. Obadia: Louis-Pradel Hospital, Lyon. A. Tirouvanziam, J.-C. Roussel and D. Crochet: Laennec Hospital, Nantes. F. Collard, J.-L. Bonnet and T. Cuisset: La Timone Hospital, Marseille. J.-E. Wolf and O. Bouchot: Bocage Hospital, Dijon.

Scientific committee:

chairmen: P. Gueret: Henri-Mondor Hospital, Creteil. A. Pavie: Pitié-Salpêtrière Hospital, Paris.
members: D. Blanchard: European Georges-Pompidou Hospital, Paris. J.-L. Debrux: University Hospital, Angers. P. Donzeau-Gouge: Institut Jacques-Cartier, Massy. H. Eltchaninoff: University of Rouen, Rouen. M. Gilard: La-Cavale-Blanche Hospital, Brest. B. Iung: Bichat-Claude-Bernard Hospital, Paris. A. Leguerrier: University Hospital, Rennes. A. Prat: University Hospital, Lille. C. Tribouilloy: University Hospital, Amiens. K. Chevreul: Henri-Mondor Hospital, Créteil.

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