Przezskórna lub chirurgiczna naprawa zastawki mitralnej (PRIMARY)
Przezskórna lub chirurgiczna naprawa wypadania mitralnego i niedomykalności u osób w wieku ≥65 lat (PODSTAWOWE)
This is a prospective, multicenter, open-label, randomized trial comparing mitral valve (MV) transcatheter edge-to-edge repair (TEER) to surgical repair (1:1 ratio) in patients with primary, degenerative mitral regurgitation (MR). The trial will be conducted in the U.S., Canada, Germany, Spain, and the United Kingdom, and is designed as a strategy trial. Thus, all devices legally marketed for TEER of primary degenerative MR in a particular country are eligible to be used in this trial.
Przegląd badań
Status
Status
Warunki
Warunki
Interwencja / Leczenie
Interwencja / Leczenie
Szczegółowy opis
The primary aim of this study is to evaluate the long-term effectiveness and safety of MV TEER compared with surgical repair in patients with primary, degenerative MR. The secondary aim is to analyze the relationship between the adequacy of MR correction at one-year post intervention and longer-term clinical outcomes (death, heart failure hospitalizations/urgent care visits, valve re-interventions, and quality of life). The tertiary aim of this trial is to evaluate a range of patient-centered outcomes (quality of life, functional status, and discharge location) of transcatheter edge-to-edge MV repair compared with MV surgical repair in patients with primary, degenerative mitral regurgitation. This study is closely integrated with the PRIMARY Ancillary Substudy (NCT07103733)
The patient population for this trial consists of adult patients with severe, primary degenerative MR for whom the local heart team has verified that an indication for MV intervention is present and for whom both transcatheter edge-to-edge and surgical repair strategies are anatomically feasible.
Because the use of the commercial edge-to-edge mitral repair device in the U.S. is approved only in patients considered to be at prohibitive risk of MV surgery by a heart team, use of such devices in this trial is considered investigational by the FDA. As such, this trial will be conducted under an Investigational Device Exemption (IDE).
Outcomes will be measured from randomization over a period of 5 years post intervention. The estimated enrollment period is 36 months, and all patients will be followed from randomization for up to 10 years post intervention for particular endpoints. Long-term follow-up will include leveraging administrative datasets linked to clinical trial data.
Typ studiów
Typ studiów
Zapisy (Rzeczywisty)
Zapisy
Faza
Faza
- Nie dotyczy
Kontakty i lokalizacje
Lokalizacje studiów
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Barcelona, Hiszpania, 08036
- Hospital Clinic De Barcelona
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Madrid, Hiszpania, 28040
- Hospital Clínico San Carlos
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Oviedo, Hiszpania, 33011
- Hospital Central de Asturias
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Balearic Islands
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Palma de Mallorca, Balearic Islands, Hiszpania, 07120
- Hospital Universitari Son Espases.
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Galacia
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Vigo, Galacia, Hiszpania, 36204
- Hospital Alvaro Cunqueiro
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British Columbia
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Vancouver, British Columbia, Kanada, BC V6E 1M7
- University of British Columbia, Providence Health Care, St. Paul's Hospital
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Ontario
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London, Ontario, Kanada, ON N6A 5W9
- London Health Sciences
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Ottawa, Ontario, Kanada, K1Y 4W7
- University of Ottawa Heart Institute
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Toronto, Ontario, Kanada, M5B 1W8St
- Unity Health Toronto (St. Michael's Hospital)
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Quebec
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Québec, Quebec, Kanada, QC G1V 4G5
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (Laval University)
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Bad Nauheim, Niemcy, 61231
- Kerckhoff Klinik Bad Nauheim
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Bad Rothenfelde, Niemcy, 49214
- Schüchtermann-Klinik Bad Rothenfelde
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Berlin, Niemcy, 13353
- Deutsches Herzzentrum der Charité
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Frankfurt, Niemcy, 60590
- Universitätsklinikum Frankfurt
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Freiburg im Breisgau, Niemcy, 79106
- Universitätsklinikum Freiburg
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Hamburg, Niemcy, 20099
- Asklepios Klinik St. Georg Hamburg
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Hamburg, Niemcy, 20246
- Universitätsklinikum Hamburg Eppendorf
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Heidelberg, Niemcy, 69120
- Universitätsklinikum Heidelberg
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Jena, Niemcy, 07747
- Universitätsklinikum Jena
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Kiel, Niemcy, 24105
- Universitätsklinikum Schleswig-Holstein Campus Kiel
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Leipzig, Niemcy, 04289
- Herzzentrum Leipzig
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Lübeck, Niemcy, 23538
- Universitätsklinikum Schleswig-Holstein Campus Lübeck
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München, Niemcy, 80636
- Deutsches Herzzentrum München
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Berlin-kölnische Allee
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Cologne, Berlin-kölnische Allee, Niemcy, 50969
- Universitätsklinikum Köln
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North Rhine-Westphalia
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Cologne, North Rhine-Westphalia, Niemcy, 50937
- Universitätsklinikum Köln
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California
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Los Angeles, California, Stany Zjednoczone, 90048
- Cedars Sinai Medical Center
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Los Angeles, California, Stany Zjednoczone, 90033
- Keck Hospital of the University of Southern California
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San Francisco, California, Stany Zjednoczone, 94143
- University of California San Francisco
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Stanford, California, Stany Zjednoczone, 94305
- Stanford University
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Georgia
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Atlanta, Georgia, Stany Zjednoczone, 30308
- Emory University Hospital Midtown
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Atlanta, Georgia, Stany Zjednoczone, 30322
- Emory University
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Atlanta, Georgia, Stany Zjednoczone, 30309
- Piedmont Heart Institute
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Louisiana
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New Orleans, Louisiana, Stany Zjednoczone, 70121
- Ochsner Clinic
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Maine
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Portland, Maine, Stany Zjednoczone, 04102
- Maine Medical Center
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Maryland
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Baltimore, Maryland, Stany Zjednoczone, 21287
- The Johns Hopkins Hospital
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Massachusetts
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Boston, Massachusetts, Stany Zjednoczone, 02114
- Massachusetts General Hospital
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Boston, Massachusetts, Stany Zjednoczone, 02115
- Brigham and Women's
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Michigan
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Ann Arbor, Michigan, Stany Zjednoczone, 48109
- University of Michigan Hospital
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Missouri
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Kansas City, Missouri, Stany Zjednoczone, 64111
- Saint Luke's Hospital of Kansas City/MidAmerica Heart and Lung Surgeons
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New Hampshire
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Lebanon, New Hampshire, Stany Zjednoczone, 03756
- Dartmouth Hitchcock Medical Center
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New York
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Bay Shore, New York, Stany Zjednoczone, 11706
- Northwell - South Shore
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Manhasset, New York, Stany Zjednoczone, 11030
- Northwell Health - North Shore
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New York, New York, Stany Zjednoczone, 10032
- New York-Presbyterian/Columbia University Medical Center
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New York, New York, Stany Zjednoczone, 10075
- Northwell Health - Lenox Hill
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New York, New York, Stany Zjednoczone, 10065
- Weill Cornell Medicine/ New York-Presbyterian Hospital
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Staten Island, New York, Stany Zjednoczone, 10305
- Northwell Staten Island University Hospital
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North Carolina
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Durham, North Carolina, Stany Zjednoczone, 27710
- Duke University Hospital
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Ohio
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Cleveland, Ohio, Stany Zjednoczone, 44195
- Cleveland Clinic
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Pennsylvania
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Philadelphia, Pennsylvania, Stany Zjednoczone, 19104
- Hospital of the University of Pennsylvania
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South Carolina
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Charleston, South Carolina, Stany Zjednoczone, 29425
- Medical University of South Carolina
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Texas
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Dallas, Texas, Stany Zjednoczone, 75246
- Baylor, Scott and White
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Virginia
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Charlottesville, Virginia, Stany Zjednoczone, 22903
- University of Virginia Medical Center
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West Virginia
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Morgantown, West Virginia, Stany Zjednoczone, 26506
- West Virginia University Hospital
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Birmingham, Zjednoczone Królestwo, B15 2TH
- University Hospitals Birmingham NHS Foundation Trust
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Bristol, Zjednoczone Królestwo, BS1 3NU
- University Hospital Bristol and Weston NHS Foundation Trust
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Clydebank, Zjednoczone Królestwo, G81 4DY
- Golden Jubilee University National Hospital
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Headington, Zjednoczone Królestwo, OX3 9DU
- Oxford University Hospitals NHS Foundation Trust
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London, Zjednoczone Królestwo, E1 8PR
- Barts Health NHS Trust
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Middlesbrough, Zjednoczone Królestwo, TS4 3BW
- South Tees Hospitals NHS Foundation Trust
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England
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Cambridge, England, Zjednoczone Królestwo, CB2 0AY
- Royal Papworth Hospital NHS Foundation Trust
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Leeds, England, Zjednoczone Królestwo, LS1 3EX
- The Leeds Teaching Hospitals NHS Trust
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London, England, Zjednoczone Królestwo, SE5 9RS
- King's College Hospital NHS Foundation Trust
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London, England, Zjednoczone Królestwo, SE1 7EH
- St. Thomas Guy's and St Thomas' NHS Foundation Trust
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London, England, Zjednoczone Królestwo, SW3 6NP
- Royal Brompton and Harefield Guy's and St Thomas' NHS Foundation Trust
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Manchester, England, Zjednoczone Królestwo, M23 9LT
- Manchester University NHS Foundation Trust
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West Sussex
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Worthing, West Sussex, Zjednoczone Królestwo, BN2 5BE
- University Hospitals Sussex NHS Foundation Trust
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Kryteria uczestnictwa
Kryteria kwalifikacji
Kryteria kwalifikacji
Wiek uprawniający do nauki
Akceptuje zdrowych ochotników
Płeć kwalifikująca się do nauki
Opis
The patient population for this trial consists of adults with severe, primary degenerative MR for whom the local heart team has verified that an indication for MV intervention is present and for whom both transcatheter edge-to-edge and surgical repair strategies are anatomically feasible. Specific inclusion and exclusion criteria are listed below. All patients who meet eligibility criteria will be included in the study regardless of gender, race, or ethnicity.
Inclusion Criteria:
- Adult patients ≥60 years with moderately-severe or severe (3+ or 4+/4+) primary degenerative (Carpentier type II) MR defined by transthoracic echocardiography
- Clinical indication for MV intervention and anatomic candidate for both surgical MV repair and transcatheter edge-to-edge repair (TEER) per local heart team assessment with central eligibility committee verification
- Patients across the surgical risk spectrum (low, intermediate, and high risk) depending on local heart team assessment and central eligibility committee verification (see ACC/AHA 2020 guidelines for the management of patients with valvular heart disease)
- Patients with AF who meet an indication for a concomitant ablation procedure be included provided the local heart team and central eligibility committee decide they are eligible for both catheter-based and surgical ablation.
- Ability to perform 6-minute walk test (6MWT) and complete Kansas City Cardiomyopathy Questionnaire (KCCQ) instrument
Exclusion Criteria:
- Non-degenerative types of primary MR (e.g., cleft leaflet)
- Secondary or functional MR
- Hypertrophic obstructive cardiomyopathy
- Presence of an IVC filter or permanent pacing/ICD leads that would interfere with TEER per local heart team assessment
- Known allergic reactions to intravenous contrast
- Febrile illness within 30-days prior to randomization
- Any absolute contraindication to transesophageal echocardiography
- Any contraindication to systemic heparinization including active bleeding diatheses, and heparin induced thrombocytopenia
- Patients with CAD requiring revascularization
- Any prior mitral valve intervention or any prior repair of atrial septal defect
- Any prior MV intervention or any prior repair of atrial septal defect
- Need for any of the following concomitant procedures: aortic valve or aortic surgery, tricuspid valve surgery
- Need for any emergency intervention or surgery
- Active endocarditis
- Hemodynamic instability defined as cardiac index <2.0 l/min/m2 or systolic blood pressure <90mmHg or need for inotropic support or any mechanical circulatory support
- Left ventricular ejection fraction <25%
- Intracardiac mass or thrombus
- Co-morbid medical or oncologic condition for which local heart team believes that survival beyond 2 years is unlikely
- Active substance abuse
- Suspected inability to adhere to follow-up
- Treatment with another investigational drug or other intervention, assessment of which has not completed the primary endpoint or that clinically interferes with the present study endpoints.
Plan studiów
Jak projektuje się badanie?
Szczegóły projektu
- Główny cel: Leczenie
- Przydział: Randomizowane
- Model interwencyjny: Przydział równoległy
- Maskowanie: Brak (otwarta etykieta)
Liczba ramion
Broń i interwencje
Grupa uczestników / ArmGrupa uczestników / Arm |
Interwencja / LeczenieInterwencja / Leczenie |
|---|---|
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Aktywny komparator: Surgical mitral valve repair
Patients who are randomized to the surgical arm will undergo mitral surgery. |
Patients who are randomized to the surgical arm will undergo mitral surgery. Mitral surgery will be conducted using general anesthesia and cardiopulmonary bypass. Mitral surgery may be performed via a sternotomy or a right thoracotomy approach with or without robotic assistance. Standard techniques commonly include a ring or band annuloplasty to correct and prevent annular dilatation; leaflet prolapse and redundancy may be corrected by leaflet resection techniques and / or chordal reconstruction.
Inne nazwy:
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Aktywny komparator: Transcatheter edge-to-edge repair
In the transcatheter edge-to-edge repair arm, patients will be treated with a commercially-approved edge-to-edge mitral repair device. |
Patients will be treated with a commercially-approved edge-to-edge mitral repair device. The steerable guide catheter (guide) is inserted into the femoral vein and advanced across the inter-atrial septum using image guided puncture. Fluoroscopic and echocardiographic guidance will be used to visualize the devices and assess the repair. The guide is positioned over the MV and the clip/clasp delivery system is inserted into the guide and positioned over the MV in accordance with the manufacturer's instructions. The delivery catheter is advanced until the clip/clasp emerges from the tip of the guide into the left atrium. The catheter is manipulated using the control handle until the clip/clasp is correctly oriented with respect to the line of coaptation of the mitral valve. The clip/clasp is opened, and advanced across the mitral valve into the left ventricle then pulled back to grasp the leaflets.
Inne nazwy:
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Co mierzy badanie?
Podstawowe miary wyniku
Podstawowe miary wyniku
Miara wyniku |
Opis środka |
Ramy czasowe |
|---|---|---|
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All-cause mortality, valve re-intervention, hospitalizations and urgent visits for heart failure, or onset of ≥ 2+ MR (by transthoracic echocardiogram (TTE)) composite score.
Ramy czasowe: 3 years post intervention
|
All-cause mortality, valve re-intervention, hospitalizations/urgent visits for heart failure (without a blanking period), or onset of ≥ 2+ MR (by transthoracic echocardiogram (TTE)) from randomization to a minimum of 3 years post intervention. Composite score will be expressed as a Z-score - The Z-Score is a statistical measurement of a score's relationship to the mean in a group of scores. A Z-score of 0 is equal to the mean, with negative numbers indicating values lower than the mean and positive values higher than the mean. |
3 years post intervention
|
Miary wyników drugorzędnych
Miary wyników drugorzędnych
Miara wyniku |
Opis środka |
Ramy czasowe |
|---|---|---|
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Adequacy of MR correction
Ramy czasowe: one year post intervention
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Adequacy of MR correction at one year post intervention, defined as < 2+ MR as assessed by TTE |
one year post intervention
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Kansas City Cardiomyopathy Questionnaire (KCCQ)
Ramy czasowe: up to 10 years post intervention
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Disease-specific quality of life as measured by the KCCQ at 6-month time intervals up to 5 years. KCCQ has 23 items that map to 7 domains: symptom frequency; symptom burden; symptom stability; physical limitations; social limitations; quality of life; and self-efficacy. The symptom frequency and symptom burden domains are merged into a total symptom score, which can be combined with the physical limitation domain to create a clinical summary score. All scores are scaled 0 to 100, with higher scores indicating better health outcome. |
up to 10 years post intervention
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Procedure failure
Ramy czasowe: End of procedure
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Procedure failure defined as residual moderately severe or severe (3+ or 4+/4+) MR at the end of the procedure, or conversion of a TEER to an open surgical repair or replacement, or conversion of a surgical mitral valve repair to a mitral valve replacement procedure. |
End of procedure
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Procedure failure
Ramy czasowe: 10 years post randomization
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Procedure failure defined as residual moderately severe or severe (3+ or 4+/4+) MR at the end of the procedure, or conversion of a TEER to an open surgical repair or replacement, or conversion of a surgical mitral valve repair to a mitral valve replacement procedure. |
10 years post randomization
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All-cause mortality
Ramy czasowe: 5 years post randomization
|
All-cause mortality through 5 years post randomization |
5 years post randomization
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All-cause mortality
Ramy czasowe: 10 years post intervention
|
All-cause mortality from randomization through 10 years post intervention |
10 years post intervention
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Cardiovascular and non-cardiovascular mortality
Ramy czasowe: 5 years post intervention
|
Cardiovascular and non-cardiovascular mortality from randomization through 5 years post intervention |
5 years post intervention
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Cardiovascular and non-cardiovascular mortality
Ramy czasowe: 10 years post intervention
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Cardiovascular and non-cardiovascular mortality from randomization through 10 years post intervention |
10 years post intervention
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Valve re-interventions
Ramy czasowe: 5 years post intervention
|
Valve re-interventions through 5 years post intervention |
5 years post intervention
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Valve re-interventions
Ramy czasowe: 10 years post intervention
|
Valve re-interventions through 10 years post intervention |
10 years post intervention
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Serious or protocol-defined adverse events
Ramy czasowe: 5 years post intervention
|
Serious or protocol-defined adverse events, including stroke, acute kidney injury (AKI), and renal failure, through 5 years |
5 years post intervention
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MR grade
Ramy czasowe: up to 6 years post intervention
|
Mitral Regurgitation (MR) grade as mild, moderate, or severe. (grade I-IV, with higher grade indicating poorer health outcomes.) |
up to 6 years post intervention
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Left Ventricular Ejection Fraction (LVEF)
Ramy czasowe: up to 6 years post intervention
|
Left ventricular ejection fraction (LVEF) is the measurement of how much blood is being pumped out of the left ventricle of the heart (the main pumping chamber) with each contraction. |
up to 6 years post intervention
|
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Left Ventricular End Diastolic Dimension (LVEDD)
Ramy czasowe: up to 6 years post intervention
|
Left ventricular end diastolic dimension (LVEDD) is the diameter across the left ventricle of the heart at the end of diastole, that is, when the heart muscle is maximally relaxed, and usually corresponds to its largest diameter. |
up to 6 years post intervention
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Left Ventricular End Systolic Dimension (LVESD)
Ramy czasowe: up to 6 years post intervention
|
Left ventricular end systolic dimension (LVESD) is the diameter across the left ventricle of the heart at the end of systole, that is, when the heart muscle is maximally contracted, and usually corresponds to its smallest diameter. |
up to 6 years post intervention
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Left Ventricular End Diastolic Volume (LVEDV)
Ramy czasowe: up to 6 years post intervention
|
Left Ventricular end diastolic volume (LVEDV) is the volume of blood in the left ventricle at the end of the diastole or ventricular filling. |
up to 6 years post intervention
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Left Ventricular End Systolic Volume (LVESV)
Ramy czasowe: up to 6 years post intervention
|
Left Ventricular end systolic volume (LVESV) is the volume of blood in the left ventricle at the end of the systolic ejection phase immediately before the beginning of diastole or ventricular filling. |
up to 6 years post intervention
|
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Mitral valve gradient
Ramy czasowe: up to 6 years post intervention
|
The valve gradient is the difference in pressure on each side of the valve. When a valve is narrowed (a condition called stenosis), the pressure on the front of the valve builds up as blood is forced through the narrow opening. This causes a larger pressure difference between the front and back of the valve. The valve gradient can be used to determine the severity of the valve disorder. |
up to 6 years post intervention
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Forward stroke volume
Ramy czasowe: up to 6 years post intervention
|
The forward stroke volume is the volume entering the aorta. |
up to 6 years post intervention
|
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6 Minute Walk Test (6MWT)
Ramy czasowe: up to 5 years post intervention
|
Functional status as measured by the 6MWT at yearly time intervals over 5 years. 6MT - The distance covered over a time of 6 minutes |
up to 5 years post intervention
|
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EuroQol- 5 Dimension (EQ-5D)
Ramy czasowe: through 10 years post intervention
|
Generic QoL as measured by the EuroQol-5D (EQ-5D). The EQ-5D descriptive system is a preference-based HRQL measure with one question for each of the five dimensions that include mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. The answers given to ED-5D permit to find 243 unique health states or can be converted into EQ- 5D index an utility scores anchored at 0 for death and 1 for perfect health. The EQ-5D questionnaire also includes a Visual Analog Scale (VAS), by which respondents can report their perceived health status with a grade ranging from 0 (the worst possible health status) to 100 (the best possible health status). |
through 10 years post intervention
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Length of stay (LOS)
Ramy czasowe: through 10 years post intervention
|
Length of stay as measured by number of days hospitalized. |
through 10 years post intervention
|
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ICU days of index hospitalization
Ramy czasowe: through 10 years post intervention
|
Number of ICU days of index hospitalization |
through 10 years post intervention
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Number and reasons for readmissions
Ramy czasowe: through 10 years post intervention
|
Number and reasons for readmissions, including for valve re-intervention and readmissions/urgent visits for heart failure |
through 10 years post intervention
|
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Cost
Ramy czasowe: through 10 years post intervention
|
Costs associated with the index hospitalization as well as follow-up readmissions will be measured. |
through 10 years post intervention
|
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Cost-effectiveness
Ramy czasowe: through 10 years post intervention
|
A cost-effectiveness analysis (CEA) comparing cumulative costs and quality-adjusted life years (QALYs) of transcatheter edge-to-edge repair vs surgical repair will be performed from U.S., Canadian, German and United Kingdom health care sector perspectives according to national guidelines. |
through 10 years post intervention
|
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Number of participants with stroke with disability
Ramy czasowe: 30 days post-intervention
|
Stroke with disability is defined as a modified Rankin score of ≥ 2 and/or major bleeding (BARC Type 3b, 3c and 5) by 30 days post-intervention |
30 days post-intervention
|
Współpracownicy i badacze
Sponsor
Sponsor
Współpracownicy
Współpracownicy
Śledczy
Śledczy
- Dyrektor Studium: Martin Leon, MD, Columbia University
- Dyrektor Studium: Patrick O'Gara, MD, Brigham and Women's Hospital
- Dyrektor Studium: Joanna Chikwe, MD, Cedars Sinai
Publikacje i pomocne linki
Przydatne linki
Daty zapisu na studia
Główne daty studiów
Rozpoczęcie studiów (Rzeczywisty)
Rozpoczęcie studiów
Zakończenie podstawowe (Szacowany)
Zakończenie podstawowe
Ukończenie studiów (Szacowany)
Ukończenie studiów
Daty rejestracji na studia
Pierwszy przesłany
Pierwszy przesłany
Pierwszy przesłany, który spełnia kryteria kontroli jakości
Pierwszy przesłany, który spełnia kryteria kontroli jakości
Pierwszy wysłany (Rzeczywisty)
Pierwszy wysłany
Aktualizacje rekordów badań
Ostatnia wysłana aktualizacja (Rzeczywisty)
Ostatnia wysłana aktualizacja
Ostatnia przesłana aktualizacja, która spełniała kryteria kontroli jakości
Ostatnia przesłana aktualizacja, która spełniała kryteria kontroli jakości
Ostatnia weryfikacja
Ostatnia weryfikacja
Więcej informacji
Terminy związane z tym badaniem
Słowa kluczowe
Dodatkowe istotne warunki MeSH
- Choroby układu krążenia
- Choroby serca
- Choroby zastawek serca
- Niedoczynność zastawki mitralnej
- Procedury chirurgiczne, operacyjny
- Procedury chirurgiczne sercowo -naczyniowe
- Procedury chirurgiczne serca
- Procedury chirurgiczne klatki piersiowej
- Annuloplastyka zaworu serca
- Annuloplastyka zastawki mitralnej
Inne numery identyfikacyjne badania
Inne numery identyfikacyjne badania
- STUDY-21-01246
- 5U01HL088942 (Grant/umowa NIH USA)
Plan dla danych uczestnika indywidualnego (IPD)
Planujesz udostępniać dane poszczególnych uczestników (IPD)?
Opis planu IPD
Individual participant data that underlie the results reported in this article, after deidentification (text, tables, figures, and appendices).
Ramy czasowe udostępniania IPD
De-identified study data sets must be submitted to the designated NHLBI Program Official no later than 3 years after the end of the clinical activity (final patient follow-up, etc.) or 2 years after the main paper of the trial has been published, whichever comes first. Data are prepared by the study coordinating center and sent to the designated PO for review prior to release.
Kryteria dostępu do udostępniania IPD
Anyone who wishes to access the data. Any purpose. Data are available indefinitely at link included in the URL field below.
Typ informacji pomocniczych dotyczących udostępniania IPD
- PROTOKÓŁ BADANIA
- SOK ROŚLINNY
- ICF
Informacje o lekach i urządzeniach, dokumenty badawcze
Bada produkt leczniczy regulowany przez amerykańską FDA
Bada produkt urządzenia regulowany przez amerykańską FDA
produkt wyprodukowany i wyeksportowany z USA
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