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Suriany S, Liu H, Cheng AL, Wenby R, Patel N, Badran S, Meiselman HJ, Denton C, Coates TD, Wood JC, Detterich JA. Decreased erythrocyte aggregation in Glenn and Fontan: univentricular circulation as a rheologic disease model. Pediatr Res 2024; 95:1335-1345. [PMID: 38177250 DOI: 10.1038/s41390-023-02969-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/19/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND In the Fontan palliation for single ventricle heart disease (SVHD), pulmonary blood flow is non-pulsatile/passive, low velocity, and low shear, making viscous power loss a critical determinant of cardiac output. The rheologic properties of blood in SVHD patients are essential for understanding and modulating their limited cardiac output and they have not been systematically studied. We hypothesize that viscosity is decreased in single ventricle circulation. METHODS We evaluated whole blood viscosity, red blood cell (RBC) aggregation, and RBC deformability to evaluate changes in healthy children and SVHD patients. We altered suspending media to understand cellular and plasma differences contributing to rheologic differences. RESULTS Whole blood viscosity was similar between SVHD and healthy at their native hematocrits, while viscosity was lower at equivalent hematocrits for SVHD patients. RBC deformability is increased, and RBC aggregation is decreased in SVHD patients. Suspending SVHD RBCs in healthy plasma resulted in increased RBC aggregation and suspending healthy RBCs in SVHD plasma resulted in lower RBC aggregation. CONCLUSIONS Hematocrit corrected blood viscosity is lower in SVHD vs. healthy due to decreased RBC aggregation and higher RBC deformability, a viscous adaptation of blood in patients whose cardiac output is dependent on minimizing viscous power loss. IMPACT Patients with single ventricle circulation have decreased red blood cell aggregation and increased red blood cell deformability, both of which result in a decrease in blood viscosity across a large shear rate range. Since the unique Fontan circulation has very low-shear and low velocity flow in the pulmonary arteries, blood viscosity plays an increased role in vascular resistance, therefore this work is the first to describe a novel mechanism to target pulmonary vascular resistance as a modifiable risk factor. This is a novel, modifiable risk factor in this patient population.
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Affiliation(s)
- Silvie Suriany
- Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Honglei Liu
- Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Andrew L Cheng
- Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Rosalinda Wenby
- Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Neil Patel
- Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Sarah Badran
- Division of Pediatric and Congenital Cardiology, Helen Devos Children's Hospital at Spectrum Health, Grand Rapids, MI, USA
- Division of Cardiology, Department of Medicine, Michigan State University, East Lansing, MI, USA
| | - Herbert J Meiselman
- Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Christopher Denton
- Division of Hematology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Thomas D Coates
- Division of Hematology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - John C Wood
- Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Jon A Detterich
- Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA.
- Department of Physiology and Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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2
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Turner ME, Blum KM, Watanabe T, Schwarz EL, Nabavinia M, Leland JT, Villarreal DJ, Schwartzman WE, Chou TH, Baker PB, Matsumura G, Krishnamurthy R, Yates AR, Hor KN, Humphrey JD, Marsden AL, Stacy MR, Shinoka T, Breuer CK. Tissue engineered vascular grafts are resistant to the formation of dystrophic calcification. Nat Commun 2024; 15:2187. [PMID: 38467617 PMCID: PMC10928115 DOI: 10.1038/s41467-024-46431-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024] Open
Abstract
Advancements in congenital heart surgery have heightened the importance of durable biomaterials for adult survivors. Dystrophic calcification poses a significant risk to the long-term viability of prosthetic biomaterials in these procedures. Herein, we describe the natural history of calcification in the most frequently used vascular conduits, expanded polytetrafluoroethylene grafts. Through a retrospective clinical study and an ovine model, we compare the degree of calcification between tissue-engineered vascular grafts and polytetrafluoroethylene grafts. Results indicate superior durability in tissue-engineered vascular grafts, displaying reduced late-term calcification in both clinical studies (p < 0.001) and animal models (p < 0.0001). Further assessments of graft compliance reveal that tissue-engineered vascular grafts maintain greater compliance (p < 0.0001) and distensibility (p < 0.001) than polytetrafluoroethylene grafts. These properties improve graft hemodynamic performance, as validated through computational fluid dynamics simulations. We demonstrate the promise of tissue engineered vascular grafts, remaining compliant and distensible while resisting long-term calcification, to enhance the long-term success of congenital heart surgeries.
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Affiliation(s)
- Mackenzie E Turner
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Molecular Cellular and Developmental Biology Graduate Program, The Ohio State University, Columbus, OH, USA
| | - Kevin M Blum
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Tatsuya Watanabe
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Erica L Schwarz
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Mahboubeh Nabavinia
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph T Leland
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Delaney J Villarreal
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
- Biomedical Sciences Graduate Program, The Ohio State University College of Medicine, Columbus, OH, USA
| | - William E Schwartzman
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ting-Heng Chou
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Exercise and Health Science, National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
| | - Peter B Baker
- Pathology Department at Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Goki Matsumura
- Department of Medical Safety Management, Tokyo Women's Medical University, Tokyo, Japan
| | - Rajesh Krishnamurthy
- Department of Radiology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Andrew R Yates
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kan N Hor
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
| | - Alison L Marsden
- Departments of Pediatrics and Bioengineering, Stanford University, Stanford, CA, USA
| | - Mitchel R Stacy
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
- Interdisciplinary Biophysics Graduate Program, The Ohio State University, Columbus, OH, USA
| | - Toshiharu Shinoka
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher K Breuer
- Center for Regenerative Medicine, Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
- Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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3
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Zhuravleva IY, Karpova EV, Dokuchaeva AA, Titov AT, Timchenko TP, Vasilieva MB. Calcification of Various Bioprosthetic Materials in Rats: Is It Really Different? Int J Mol Sci 2023; 24:ijms24087274. [PMID: 37108443 PMCID: PMC10139218 DOI: 10.3390/ijms24087274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
The causes of heart valve bioprosthetic calcification are still not clear. In this paper, we compared the calcification in the porcine aorta (Ao) and the bovine jugular vein (Ve) walls, as well as the bovine pericardium (Pe). Biomaterials were crosslinked with glutaraldehyde (GA) and diepoxide (DE), after which they were implanted subcutaneously in young rats for 10, 20, and 30 days. Collagen, elastin, and fibrillin were visualized in non-implanted samples. Atomic absorption spectroscopy, histological methods, scanning electron microscopy, and Fourier-transform infrared spectroscopy were used to study the dynamics of calcification. By the 30th day, calcium accumulated most intensively in the collagen fibers of the GA-Pe. In elastin-rich materials, calcium deposits were associated with elastin fibers and localized differences in the walls of Ao and Ve. The DE-Pe did not calcify at all for 30 days. Alkaline phosphatase does not affect calcification since it was not found in the implant tissue. Fibrillin surrounds elastin fibers in the Ao and Ve, but its involvement in calcification is questionable. In the subcutaneous space of young rats, which are used to model the implants' calcification, the content of phosphorus was five times higher than in aging animals. We hypothesize that the centers of calcium phosphate nucleation are the positively charged nitrogen of the pyridinium rings, which is the main one in fresh elastin and appears in collagen as a result of GA preservation. Nucleation can be significantly accelerated at high concentrations of phosphorus in biological fluids. The hypothesis needs further experimental confirmation.
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Affiliation(s)
- Irina Y Zhuravleva
- E. Meshalkin National Medical Research Center of the RF Ministry of Health, 15 Rechkunovskaya St., 630055 Novosibirsk, Russia
| | - Elena V Karpova
- N. Vorozhtsov Novosibirsk Institute of Organic Chemistry SB RAS, 9 Lavrentiev Avenue, 630090 Novosibirsk, Russia
| | - Anna A Dokuchaeva
- E. Meshalkin National Medical Research Center of the RF Ministry of Health, 15 Rechkunovskaya St., 630055 Novosibirsk, Russia
| | - Anatoly T Titov
- V. Sobolev Institute of Geology and Mineralogy SB RAS, 3 Academician Koptyug Avenue, 630090 Novosibirsk, Russia
| | - Tatiana P Timchenko
- E. Meshalkin National Medical Research Center of the RF Ministry of Health, 15 Rechkunovskaya St., 630055 Novosibirsk, Russia
| | - Maria B Vasilieva
- E. Meshalkin National Medical Research Center of the RF Ministry of Health, 15 Rechkunovskaya St., 630055 Novosibirsk, Russia
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4
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Breuer T, Jimenez M, Humphrey JD, Shinoka T, Breuer CK. Tissue Engineering of Vascular Grafts: A Case Report From Bench to Bedside and Back. Arterioscler Thromb Vasc Biol 2023; 43:399-409. [PMID: 36633008 PMCID: PMC9974789 DOI: 10.1161/atvbaha.122.318236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/29/2022] [Indexed: 01/13/2023]
Abstract
For over 25 years, our group has used regenerative medicine strategies to develop improved biomaterials for use in congenital heart surgery. Among other applications, we developed a tissue-engineered vascular graft (TEVG) by seeding tubular biodegradable polymeric scaffolds with autologous bone marrow-derived mononuclear cells. Results of our first-in-human study demonstrated feasibility as the TEVG transformed into a living vascular graft having an ability to grow, making it the first engineered graft with growth potential. Yet, outcomes of this first Food and Drug Administration-approved clinical trial evaluating safety revealed a prohibitively high incidence of early TEVG stenosis, preventing the widespread use of this promising technology. Mechanistic studies in mouse models provided important insight into the development of stenosis and enabled advanced computational models. Computational simulations suggested both a novel inflammation-driven, mechano-mediated process of in vivo TEVG development and an unexpected natural history, including spontaneous reversal of the stenosis. Based on these in vivo and in silico discoveries, we have been able to rationally design strategies for inhibiting TEVG stenosis that have been validated in preclinical large animal studies and translated to the clinic via a new Food and Drug Administration-approved clinical trial. This progress would not have been possible without the multidisciplinary approach, ranging from small to large animal models and computational simulations. This same process is expected to lead to further advances in scaffold design, and thus next generation TEVGs.
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Affiliation(s)
- Thomas Breuer
- Nationwide Children's Hospital, Columbus, OH (T.B., M.J., T.S., C.K.B.)
| | - Michael Jimenez
- Nationwide Children's Hospital, Columbus, OH (T.B., M.J., T.S., C.K.B.)
| | - Jay D Humphrey
- Yale University, School of Engineering and Applied Science, New Haven, CT (J.D.H.)
| | - Toshiharu Shinoka
- Nationwide Children's Hospital, Columbus, OH (T.B., M.J., T.S., C.K.B.)
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Salaets T, Cools B, De Meester P, Heying R, Boshoff D, Eyskens B, Brown S, Meyns B, Rega F, Van Puyvelde J, Budts W, Gewillig M. Stent expansion of restrictive Fontan conduits to nominal diameter and beyond. Catheter Cardiovasc Interv 2022; 100:1059-1066. [DOI: 10.1002/ccd.30438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 09/09/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Thomas Salaets
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Bjorn Cools
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Pieter De Meester
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Ruth Heying
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Derize Boshoff
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Benedicte Eyskens
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
| | - Stephen Brown
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
- Pediatric Cardiology University of the Free State Bloemfontein Free State South Africa
| | - Bart Meyns
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Filip Rega
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Joeri Van Puyvelde
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Werner Budts
- Department of Cardiovascular Sciences Catholic University Leuven Leuven Belgium
| | - Marc Gewillig
- Department of Cardiovascular Sciences, Pediatric & Congenital Cardiology, University Hospitals Leuven Catholic University Leuven Leuven Belgium
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6
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Van Den Helm S, Sparks CN, Ignjatovic V, Monagle P, Attard C. Increased Risk for Thromboembolism After Fontan Surgery: Considerations for Thromboprophylaxis. Front Pediatr 2022; 10:803408. [PMID: 35419321 PMCID: PMC8996130 DOI: 10.3389/fped.2022.803408] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
The Fontan circulation introduces an increased risk of thromboembolism which is associated with substantial mortality and morbidity. Adverse outcomes of thromboembolic complications post-Fontan surgery vary in both nature and severity, ranging from local tissue infarction and pulmonary embolism to Fontan failure and ischemic stroke. Furthermore, recent studies have identified that subclinical stroke is common yet underdiagnosed in Fontan patients. Fontan patients are commonly treated with antiplatelet agents and/or anticoagulants as primary thromboprophylaxis. Optimal thromboprophylaxis management in the Fontan population is still unclear, and clinical consensus remains elusive despite the growing literature on the subject. This perspective will describe the nature of thromboembolism post-Fontan surgery and provide evidence for the use of both current and emerging thromboprophylaxis options for children and adults living with Fontan circulation.
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Affiliation(s)
- Suelyn Van Den Helm
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Christopher Noel Sparks
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Anatomy and Physiology, The University of Melbourne, Melbourne, VIC, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Paul Monagle
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia.,Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Chantal Attard
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Anatomy and Physiology, The University of Melbourne, Melbourne, VIC, Australia
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Martino D, Rizzardi C, Vigezzi S, Guariento C, Sturniolo G, Tesser F, Salvo GD. Long-term management of Fontan patients: The importance of a multidisciplinary approach. Front Pediatr 2022; 10:886208. [PMID: 36090574 PMCID: PMC9452819 DOI: 10.3389/fped.2022.886208] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
The Fontan operation is a palliative procedure that leads to increased survival of patients with a functional single ventricle (SV). Starting from 1967 when the first operation was performed by Francis Fontan, more and more patients have reached adulthood. Furthermore, it is expected that in the next 20 years, the population with Fontan circulation will reach 150,000 subjects. The absence of right ventricular propulsion and the inability to improve cardiac output because of the low cardiac reserve are the main issues with the Fontan circulation; however, potential complications may also involve multiple organ systems, such as the liver, lungs, brain, bones, and the lymphatic system. As these patients were initially managed mainly by pediatric cardiologists, it was important to assure the appropriate transition to adult care with the involvement of a multidisciplinary team, including adult congenital cardiologists and multiple subspecialists, many of whom are neither yet familiar with the pathophysiology nor the end-organ consequences of the Fontan circulation. Therefore, the aim of our work was to collect all the best available evidence on Fontan's complications management to provide "simple and immediate" information sources for practitioners looking for state of the art evidence to guide their decision-making and work practices. Moreover, we suggest a model of follow-up of patients with Fontan based on a patient-centered multidisciplinary approach.
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Affiliation(s)
- Diletta Martino
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Caterina Rizzardi
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Serena Vigezzi
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Chiara Guariento
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Giulia Sturniolo
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Francesca Tesser
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Giovanni di Salvo
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
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