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Bush AL, Allencherril J, Alam M. Managing Thrombosis and Hemorrhage in a Man with Myocardial Infarction and Traumatic Hemopericardium with Cardiac Tamponade. Tex Heart Inst J 2021; 48:469062. [PMID: 34379771 DOI: 10.14503/thij-20-7308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 79-year-old man had an out-of-hospital acute ST-segment-elevation myocardial infarction with cardiac arrest. Cardiopulmonary resuscitation performed by a bystander resulted in traumatic hemopericardium. We discuss the patient's case, highlight the challenges of managing simultaneously life-threatening thrombosis and hemorrhage, and present our conclusions regarding the patient's eventual death.
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Affiliation(s)
- Aaron L Bush
- Department of Cardiology, Texas Heart Institute, Houston, Texas.,Department of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Joseph Allencherril
- Department of Cardiology, Texas Heart Institute, Houston, Texas.,Department of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mahboob Alam
- Department of Cardiology, Texas Heart Institute, Houston, Texas.,Department of Cardiology, Baylor College of Medicine, Houston, Texas
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Marto JP, Kauppila LA, Jorge C, Calado S, Viana-Baptista M, Pinho-E-Melo T, Fonseca AC. Intravenous Thrombolysis for Acute Ischemic Stroke After Recent Myocardial Infarction: Case Series and Systematic Review. Stroke 2019; 50:2813-2818. [PMID: 31436141 DOI: 10.1161/strokeaha.119.025630] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background and Purpose- The safety of IV r-tPA (intravenous tissue-type plasminogen activator) for acute ischemic stroke (AIS) treatment after recent myocardial infarction (MI) is still a matter of debate. We studied the safety of delivering IV r-tPA to AIS patients with a MI within the preceding 3 months. Methods- Retrospective review of consecutive AIS admitted to 2 tertiary university hospitals' and systematic literature review for AIS patients with history of MI in the previous 3 months. Patients were divided into 2 groups: treated or not treated with standard IV r-tPA dose for AIS. Cardiac complications (cardiac rupture/tamponade, intracardiac thrombus embolization, or life-threatening arrhythmias) were compared between groups and assessed by type of MI (non-ST-segment-elevation myocardial infarction [STEMI], or STEMI) and time elapsed between vascular events. Results- One hundred and two patients were included; 46 (45.1%) were derived from literature review. Median age (interquartile range) was 64 (53-75) years old, and 69 (67.6%) were men. Forty-seven (46.1%) received IV r-tPA. In the treated group, 25 (53.2%) and 23 (48.9%) patients had, respectively, concurrent AIS and MI and STEMI, in comparison with 12 (21.8%; P=0.002) and 36 (65.5%; P=0.110) patients in the nontreated. Four (8.5%) IV r-tPA-treated patients died from confirmed or presumed cardiac rupture/ tamponade, all with a STEMI in the week preceding stroke. This complication occurred in 1 (1.8%) patients in the nontreated group (P=0.178). There were no differences in thrombus embolization (1 [2.1%) versus 2 [3.6]; P=1.000) and life-threatening arrhythmias (3 [6.4%) versus 7 [12.7]; P=0.335). No non-STEMI patients receiving IV r-tPA had cardiac complications. Conclusions- In patients with AIS and recent or concurrent MI, MI type and the time elapsed between the 2 events should be taken into consideration when deciding to deliver IV r-tPA. Although recent non-STEMI or concurrent events seem safe, STEMI in the week preceding stroke should prompt caution. The low number of events and publication bias may have influenced our conclusions.
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Affiliation(s)
- João Pedro Marto
- From the Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal (J.P.M., S.C., M.V.-B.)
- CEDOC - Nova Medical School, Universidade Nova de Lisboa, Portugal (J.P.M., S.C., M.V.-B.)
| | - Linda Azevedo Kauppila
- Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal (L.A.K., T.P.-e.-M., C.F.)
| | - Cláudia Jorge
- Department of Cardiology, Hospital de Santa Maria, University of Lisboa, Portugal (C.J.)
| | - Sofia Calado
- From the Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal (J.P.M., S.C., M.V.-B.)
- CEDOC - Nova Medical School, Universidade Nova de Lisboa, Portugal (J.P.M., S.C., M.V.-B.)
| | - Miguel Viana-Baptista
- From the Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal (J.P.M., S.C., M.V.-B.)
- CEDOC - Nova Medical School, Universidade Nova de Lisboa, Portugal (J.P.M., S.C., M.V.-B.)
| | - Teresa Pinho-E-Melo
- Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal (L.A.K., T.P.-e.-M., C.F.)
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal (T.P.-e.-M., C.F.)
| | - Ana Catarina Fonseca
- Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal (L.A.K., T.P.-e.-M., C.F.)
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal (T.P.-e.-M., C.F.)
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Miller AC, Rosati SF, Suffredini AF, Schrump DS. A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries. Resuscitation 2014; 85:724-31. [PMID: 24525116 DOI: 10.1016/j.resuscitation.2014.01.028] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/18/2014] [Accepted: 01/26/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The incidence of thoracic injuries resulting from cardiopulmonary resuscitation (CPR) is not well characterized. We describe a case in which a CPR-associated atrial rupture was identified with ultrasound and successfully managed in the intensive care unit with a bedside thoracotomy and atrial repair. We then describe a systematic review with pooled data analysis of CPR-associated cardiovascular, pulmonary, pleural, and thoracic wall injuries. DATA SOURCES PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. Unpublished studies were identified by searching the Australian and New Zealand Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform, Cochrane Library, ClinicalTrials.gov, Current Controlled Trials, and Google. STUDY SELECTION Inclusion criteria for the pooled analysis were any clinical or autopsy study in which (a) patients underwent cardiopulmonary resuscitation, (b) chest compressions were administered either manually or with the assistance of active compression-decompression devices, and (c) autopsy or dedicated imaging assessments were conducted to identify complications. Exclusion criteria for the pooled analysis were pre-clinical studies, case reports and abstracts. DATA EXTRACTION Nine-hundred twenty-eight potentially relevant references were identified. Twenty-seven references met inclusion criteria. DATA SYNTHESIS A systematic review of the literature is provided with pooled data analysis. CONCLUSIONS The incidence of reported CPR-associated cardiovascular and thoracic wall injuries varies widely. CPR with active compression-decompression devices has a higher reported incidence of cardiopulmonary injuries. Bedside ultrasound may be a useful adjunct to assess and risk-stratify patients to identify serious or life-threatening CPR-associated injuries.
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Affiliation(s)
- Andrew C Miller
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States.
| | - Shannon F Rosati
- Surgery Branch, Thoracic Oncology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Anthony F Suffredini
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - David S Schrump
- Surgery Branch, Thoracic Oncology Section, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
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Barton CA, McMillian WD, Raza SS, Keller RE. Hemopericardium in a patient treated with dabigatran etexilate. Pharmacotherapy 2012; 32:e103-7. [PMID: 22488474 DOI: 10.1002/j.1875-9114.2012.01036.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Dabigatran etexilate is a new oral anticoagulant used for the prevention of systemic thromboembolism in patients with atrial fibrillation. Acute bleeding episodes are known to occur with dabigatran etexilate therapy; however, only a few case reports in the literature describe such events. We describe a 70-year-old man treated with dabigatran etexilate for newly diagnosed, nonvalvular atrial fibrillation who developed a large hemopericardium that appeared to be temporally related to dabigatran etexilate administration. One month after starting the drug, an incidental finding of a small pericardial effusion was found on echocardiography. One month later, the patient came to his pulmonologist's office complaining of shortness of breath; a large pericardial effusion was found on a noncontrast computed tomographic scan, and the patient was admitted to the hospital. Laboratory monitoring of his coagulation status was limited due to the lack of assays available to directly monitor the therapeutic effects of dabigatran. The internal laboratory was able to perform a dilute thrombin time (DTT) test as part of a quality improvement project aiming to validate an assay for monitoring patients receiving dabigatran therapy. A DTT was therefore performed in conjunction with routine coagulation assays to evaluate the patient's coagulation status. After pericardiocentesis, the patient recovered without incident and was discharged without anticoagulant therapy. Although the Naranjo adverse reaction probability scale only indicated a possible relationship (score of 1) between the patient's development of hemopericardium and dabigatran etexilate therapy, investigation into the patient's clinical course, comorbidities, and laboratory results led us to conclude that dabigatran etexilate was responsible for the hemopericardium. To our knowledge, this report is the first to describe a case of potentially life-threatening pericardial bleeding that was temporally related to starting dabigatran etexilate therapy. Although we found that the DTT was a viable method of monitoring coagulation status in a patient receiving dabigatran etexilate therapy, the assay lacks approval by the United States Food and Drug Administration, which limits its clinical utility and widespread use at this time. Clinicians should be aware of the potential for life-threatening bleeding with use of this agent and the difficulty associated with monitoring and reversing this therapy in the setting of acute bleeding.
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Affiliation(s)
- Cassie A Barton
- Department of Pharmacy, Fletcher Allen Health Care, Burlington, VT 05401, USA.
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Restrepo CS, Lemos DF, Lemos JA, Velasquez E, Diethelm L, Ovella TA, Martinez S, Carrillo J, Moncada R, Klein JS. Imaging Findings in Cardiac Tamponade with Emphasis on CT. Radiographics 2007; 27:1595-610. [PMID: 18025505 DOI: 10.1148/rg.276065002] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- C Santiago Restrepo
- Department of Radiology, University of Texas Health Sciences Center, San Antonio, USA
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De Keyser J, Gdovinová Z, Uyttenboogaart M, Vroomen PC, Luijckx GJ. Intravenous alteplase for stroke: beyond the guidelines and in particular clinical situations. Stroke 2007; 38:2612-8. [PMID: 17656661 DOI: 10.1161/strokeaha.106.480566] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Because of the risk of hemorrhage, especially in the brain, thrombolytic therapy with intravenous alteplase is restricted by guidelines, and only a small number of selected patients are being treated. Findings from metaanalyses, post hoc analyses of the randomized trials, and postlicensing experience suggest that more subjects, who otherwise have a poor predicted outcome without treatment, might benefit from intravenous alteplase. Summary of Review- There is a strong indication that treatment may still be beneficial beyond 3 hours up until 4.5 hours. The risk of symptomatic intracerebral hemorrhage is not increased in patients aged 80 years or older. Excluding patients with severe stroke or with early ischemic changes in more than one third of the middle cerebral artery territory on baseline CT scan is probably not necessary when treatment is started <3 hours of symptom onset. Patients with minor or improving symptoms can also benefit. Intravenous thrombolysis appears appropriate as first line therapy for posterior circulation stroke. Alteplase can be given to patients with cervical artery dissection, seizure at onset and evidence of acute ischemia on brain imaging, and after carefully weighing risk and benefit in pregnancy and during menstruation. There are anecdotal reports on its use in children, patients with recent myocardial infarction, cardiac embolus, intracranial aneurysm or arteriovenous malformation, prior stroke and recent surgery. There appears to be a substantially increased risk of symptomatic cerebral hemorrhage in hyperglycemic stroke patients. The combined intravenous and intraarterial approach to recanalization appears safe and is currently under investigation in a randomized trial. CONCLUSIONS This document does not intend to change the guidelines but reviews the literature on the use of intravenous alteplase for stroke beyond guidelines and in particular conditions.
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Affiliation(s)
- Jacques De Keyser
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Patel MR, Meine TJ, Lindblad L, Griffin J, Granger CB, Becker RC, Van de Werf F, White H, Califf RM, Harrington RA. Cardiac tamponade in the fibrinolytic era: analysis of >100,000 patients with ST-segment elevation myocardial infarction. Am Heart J 2006; 151:316-22. [PMID: 16442893 DOI: 10.1016/j.ahj.2005.04.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2005] [Accepted: 04/25/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cardiac tamponade is a life-threatening complication of acute myocardial infarction (MI). Data on the incidence, risk factors, and outcome of tamponade in patients with acute MI in the fibrinolytic era are limited. METHODS Data from a combined clinical trials database of ST-segment elevation MI were used to evaluate the incidence of cardiac tamponade, baseline characteristics, and outcomes in patients with and without tamponade. Univariable and multivariable analyses assessed the relationship between patient characteristics and tamponade development, and the influence of tamponade on mortality. RESULTS Of 102,060 patients, 865 (0.85%) developed isolated cardiac tamponade during initial hospitalization. Patients with tamponade were older (median 71.9 vs 61.6 years, P < .001), were more likely to be female (54.0% vs 25.1%, P < .001), were more likely to have an anterior MI (61.9% vs 41.5%, P < .001), and had a longer time from symptom onset to reperfusion (median 3.5 vs 2.8 hours, P < .001) than those without tamponade. Multivariable analyses identified increasing age, anterior MI location, female sex, and increased time from symptom onset to treatment as significant independent predictors of tamponade. Patients with tamponade had an increased death rate at 30 days (hazard ratio 7.9, 95% CI 4.7-13.5). CONCLUSION Cardiac tamponade occurs in < 1% of patients with fibrinolytic-treated acute MI and is associated with increased 30-day mortality. Time from symptom onset to treatment strongly predicted the development of tamponade, underscoring the need for continued efforts to increase speed to treatment in acute MI.
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Su HM, Voon WC, Chu CS, Lin TH, Lai WT, Sheu SH. Heparin-induced cardiac tamponade and life-threatening hyperkalema in a patient with chronic hemodialysis. Kaohsiung J Med Sci 2005; 21:128-33. [PMID: 15875438 DOI: 10.1016/s1607-551x(09)70289-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Heparin, a commonly used anticoagulant agent, is frequently used in patients undergoing hemodialysis. As with most medications, heparin has a significant side effect profile. Two of its most important side effects, major bleeding and hyperkalemia, may be devastating without immediate diagnosis and treatment. Major bleeding such as gastrointestinal, genitourinary or intracranial bleeding is occasionally encountered and rarely neglected. However, heparin-induced cardiac tamponade is rarely encountered and may be easily overlooked. Another side effect, heparin-induced hyperkalemia, an unusual but well-described side effect, is frequently forgotten until life-threatening arrhythmia has occurred. We report a case involving a 40-year-old male patient with uremia, who had received heparin for 10 days for deep vein thrombosis in the left lower extremity. Hemopericardium with cardiac tamponade and life-threatening hyperkalemia were both noted in this patient.
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Affiliation(s)
- Ho-Ming Su
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Birnbaum Y, Chamoun AJ, Anzuini A, Lick SD, Ahmad M, Uretsky BF. Ventricular free wall rupture following acute myocardial infarction. Coron Artery Dis 2003; 14:463-70. [PMID: 12966268 DOI: 10.1097/00019501-200309000-00008] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY Ventricular free wall rupture remains a dreaded complication of acute myocardial infarction. A dramatic fatal presentation is not universal and if recognized early, especially in its sub-acute form, a therapeutic intervention may be lifesaving. Changing trends in its natural history and the previously described pathological subtypes have emerged since the advent of thrombolysis. Although frequently unpredictable, certain clinical, echocardiographic and electrocardiographic signs should suggest the diagnosis. Moreover, knowledge of predisposing risk factors and a high index of suspicion are helpful in early recognition of this complication. In recent years, several different therapeutic approaches have been described including percutaneous seals and surgical mechanical closure of ventricular free wall rupture. In this review, we sought to highlight established and debatable aspects of this pathology to hopefully enhance prompt diagnosis and treatment by all clinicians caring for patients suffering acute myocardial infarction.
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Affiliation(s)
- Yochai Birnbaum
- Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, 5106 John Sealy Annex, 301 University Boulevard, Galveston, TX 77555-0553, USA.
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Srichai MB, Casserly IP, Lever HM. Cardiac tamponade masking clinical presentation and hemodynamic effects of papillary muscle rupture after acute myocardial infarction. J Am Soc Echocardiogr 2002; 15:1000-3. [PMID: 12221421 DOI: 10.1067/mje.2002.121610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A 67-year-old woman sustained an acute lateral-wall myocardial infarction and was treated with thrombolytic therapy. Postinfarction hypotension developed 3 days later. Clinical findings at that time were consistent with cardiac tamponade, and an echocardiographic study revealed a moderate-sized pericardial effusion. She underwent urgent pericardiocentesis with transient improvement in hemodynamics, followed by deterioration associated with the development of acute pulmonary edema. Follow-up transesophageal echocardiographic imaging revealed papillary muscle rupture with severe mitral regurgitation. The patient underwent urgent surgical intervention consisting of coronary artery bypass grafting and mitral valve replacement. The presence of cardiac tamponade in this patient masked the clinical manifestations of papillary muscle rupture through the hemodynamic effect of tamponade physiology on mitral regurgitation.
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Affiliation(s)
- Monvadi B Srichai
- Department of Cardiology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Taponamiento cardíaco secundario a pericarditis hemorrágica tras la trombólisis de un infarto agudo de miocardio. Med Clin (Barc) 2002. [DOI: 10.1016/s0025-7753(02)73539-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Gregor P, Widimský P. Pericardial Effusion as a Consequence of Acute Myocardial Infarction. Echocardiography 1999; 16:317-320. [PMID: 11175156 DOI: 10.1111/j.1540-8175.1999.tb00820.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Pericarditis is a common complication of acute myocardial infarction (MI). Its incidence during the first few days after acute MI is 24%-43% when echocardiographic criteria are used, whereas the frequency of clinical pericarditis is much less (from 5% for all acute MIs to 21% for anterior Q wave MIs). Clinical, electrocardiographic findings are discussed. Effusions are mostly small, and the resolution is frequently slow, lasting 1-18 months. Tamponade is extremely rare in the absence of cardiac rupture. Q wave MIs (especially anterior) are more frequently accompanied by pericardial effusion. The prognostic significance of echocardiographically proved pericarditis is questionable.
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Affiliation(s)
- Pavel Gregor
- Cardiocenter, Department of Medicine II, University Hospital Kralovske Vinohrady, Srobárova 50, 100 34 Praha 10, Czech Republic
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