1
|
Tan MC, Yeo YH, Ang QX, Kiwan C, Fatunde O, Lee JZ, Tolat A, Sorajja D. Impact of age on hospital outcomes after catheter ablation for ventricular tachycardia. J Arrhythm 2024; 40:317-324. [PMID: 38586842 PMCID: PMC10995587 DOI: 10.1002/joa3.12998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/13/2024] [Accepted: 01/20/2024] [Indexed: 04/09/2024] Open
Abstract
Background The real-world data on the safety profile of ventricular tachycardia (VT) ablation among elderly patients is not well-established. This study aimed to evaluate the procedural outcomes among those aged 18-64 years versus those aged ≥65 years who underwent catheter ablation of VT. Method Using the Nationwide Readmissions Database, our study included patients aged ≥18 years who underwent VT catheter ablation between 2017 and 2020. We divided the patients into non-elderly (18-64 years old) and elderly age groups (≥65 years old). We then analyzed the in-hospital procedural outcome and 30-day readmission between these two groups. Results Our study included 2075 (49.1%) non-elderly patients and 2153 (50.9%) elderly patients who underwent VT ablation. Post-procedurally, elderly patients had significantly higher rates of prolonged index hospitalization (≥7 days; 35.5% vs. 29.3%, p < .01), non-home discharge (13.4% vs. 6.0%, p < .01), 30-day readmission (17.0% vs. 11.4%, p < .01), and early mortality (5.5% vs. 2.4%, p < .01). There was no significant difference in the procedural complications between two groups, namely vascular complications, hemopericardium/cardiac tamponade, cerebrovascular accident (CVA), major bleeding requiring blood transfusion, and systemic embolization. Through multivariable analysis, the elderly group was associated with higher odds of early mortality (OR: 7.50; CI 1.86-30.31, p = .01), non-home discharge (OR: 2.41; CI: 1.93-3.00, p < .01) and 30-day readmission (OR: 1.58; CI 1.32-1.89, p < .01). Conclusion Elderly patients have worse in-hospital outcome, early mortality, non-home discharge, and 30-day readmission following catheter ablation for VT. There was no significant difference between elderly and non-elderly groups in the procedural complications.
Collapse
Affiliation(s)
- Min Choon Tan
- Department of Cardiovascular MedicineMayo ClinicPhoenixArizonaUSA
- Department of Internal MedicineNew York Medical College at Saint Michael's Medical CenterNewarkNew JerseyUSA
| | - Yong Hao Yeo
- Department of Internal Medicine/PediatricsWilliam Beaumont University HospitalRoyal OakMichiganUSA
| | - Qi Xuan Ang
- Department of Internal MedicineSparrow Health System and Michigan State UniversityEast LansingMichiganUSA
| | - Chrystina Kiwan
- Department of Internal MedicineNew York Medical College at Saint Michael's Medical CenterNewarkNew JerseyUSA
| | | | - Justin Z. Lee
- Department of Cardiovascular MedicineCleveland ClinicClevelandOhioUSA
| | - Aneesh Tolat
- Department of Cardiovascular MedicineHartford Healthcare/University of ConnecticutHartfordConnecticutUSA
| | - Dan Sorajja
- Department of Cardiovascular MedicineMayo ClinicPhoenixArizonaUSA
| |
Collapse
|
2
|
Complications of catheter ablation for ventricular tachycardia. JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY : AN INTERNATIONAL JOURNAL OF ARRHYTHMIAS AND PACING 2023; 66:221-233. [PMID: 36053374 DOI: 10.1007/s10840-022-01357-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/20/2022] [Indexed: 11/09/2022]
Abstract
With the increasing literature demonstrating benefits of catheter ablation for ventricular tachycardia (VT), the number of patients undergoing VT ablation has increased dramatically. As VT ablation is being performed more routinely, operators must be aware of potential complications of VT ablation. This review delves deeper into the practice of VT ablation with a focus on periprocedural complications.
Collapse
|
3
|
Cardiac stereotactic ablative radiotherapy for refractory ventricular arrhythmias: A radical alternative? A narrative review of rationale and cardiological aspects. J Med Imaging Radiat Sci 2021; 52:626-635. [PMID: 34593358 DOI: 10.1016/j.jmir.2021.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 11/21/2022]
Abstract
Ventricular arrhythmias are serious life-threatening cardiac disorders. Despite many technological improvements, a non-negligible number of patients present refractory ventricular tachycardias, resistant to a catheter ablation procedure, placing these patients in a therapeutic impasse. Recently, a cardiac stereotactic radioablative technique has been developed to treat patients with refractory ventricular arrhythmias, as a bail out strategy. This new therapeutic option historically brings together two fields of expertise unknown to each other, pointing out the necessity of an optimal partnership between cardiologists and radiation oncologists. As described in this narrative review, the understanding of cardiological aspects of the technique for radiation oncologists and treatment technical aspects comprehension for cardiologists represent a major challenge for the application and the future development of this promising treatment.
Collapse
|
4
|
Badertscher P, John L, Payne J, Bainey A, Ishida Y, Field ME, Winterfield JR, Gold MR. Impact of age on catheter ablation of premature ventricular contractions. J Cardiovasc Electrophysiol 2021; 32:1077-1084. [PMID: 33650717 DOI: 10.1111/jce.14976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/29/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Catheter ablation (CA) of frequent premature ventricular contractions (PVC) is increasingly performed in older patients as the population ages. The aim of this study was to assess the impact of age on procedural characteristics, safety and efficacy on PVC ablations. METHODS Consecutive patients with symptomatic PVCs undergoing CA between 2015 and 2020 were evaluated. Acute ablation success was defined as the elimination of PVCs at the end of the procedure. Sustained success was defined as an elimination of symptoms, and ≥80% reduction of PVC burden determined by Holter-electrocardiogram during long-term follow. Patients were sub-grouped based on age (<65 vs. ≥65 years). RESULTS A total of 114 patients were enrolled (median age 64 years, 71% males) and followed up for a median duration of 228 days. Baseline and procedural data were similar in both age groups. A left-sided origin of PVCs was more frequently observed in the elderly patient group compared to younger patients (83% vs. 67%; p = .04). The median procedure time was significantly shorter in elderly patients (160 vs. 193 min; p = .02). The rates of both acute (86% vs. 92%; p = .32) and sustained success (70% vs. 71%; p = .90) were similar between groups. Complications rates (3.7%) did not differ between the two groups. CONCLUSION In a large series of patients with a variety of underlying arrhythmia substrates, similar rates of acute procedural success, complications, and ventricular arrhythmia-free-survival were observed after CA of PVCs. Older age alone should not be a reason to withhold CA of PVCs.
Collapse
Affiliation(s)
- Patrick Badertscher
- Department of Cardiology, Medical University of South Carolina, Charleston, USA.,Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Leah John
- Department of Cardiology, Medical University of South Carolina, Charleston, USA
| | - Joshua Payne
- Department of Cardiology, Medical University of South Carolina, Charleston, USA
| | - Adam Bainey
- Department of Cardiology, Medical University of South Carolina, Charleston, USA
| | - Yuji Ishida
- Department of Cardiology, Medical University of South Carolina, Charleston, USA.,Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Michael E Field
- Department of Cardiology, Medical University of South Carolina, Charleston, USA
| | | | - Michael R Gold
- Department of Cardiology, Medical University of South Carolina, Charleston, USA
| |
Collapse
|
5
|
König S, Ueberham L, Müller-Röthing R, Wiedemann M, Ulbrich M, Sause A, Tebbenjohanns J, Schade A, Shin DI, Staudt A, Andrié R, Neuser H, Kuhlen R, Arya A, Hindricks G, Bollmann A. Catheter ablation of ventricular arrhythmias and in-hospital mortality: insights from the German-wide Helios hospital network of 5052 cases. Europace 2020; 22:100-108. [PMID: 31638643 DOI: 10.1093/europace/euz260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/27/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS Catheter ablation (CA) of ventricular arrhythmias is one of the most challenging electrophysiological interventions with an increasing use over the last years. Several benefits must be weighed against the risk of potentially life-threatening complications which necessitates a steady reevaluation of safety endpoints. Therefore, the aims of this study were (i) to investigate overall in-hospital mortality in patients undergoing such procedures and (ii) to identify variables associated with in-hospital mortality in a German-wide hospital network. METHODS AND RESULTS Between January 2010 and September 2018, administrative data provided by 85 Helios hospitals were screened for patients with main or secondary discharge diagnosis of ventricular tachycardia (VT) or premature ventricular contractions (PVCs) in combination with an arrhythmia-related CA using ICD- and OPS codes. In 5052 cases (mean age 60.9 ± 14.3 years, 30.1% female) of 30 different hospitals, in-hospital mortality was 1.27% with a higher mortality in patients ablated for VT (1.99%, n = 2, 955) compared to PVC (0.24%, n = 2, 097, P < 0.01). Mortality rates were 2.06% in patients with ischaemic heart disease (IHD, n = 2, 137), 1.47% in patients with non-ischaemic structural heart disease (NIHD, n = 1, 224), and 0.12% in patients without structural heart disease (NSHD, n = 1, 691). Considering different types of hospital admission, mortality rates were 0.35% after elective (n = 2, 825), 1.60% after emergency admission/hospital transfer <24 h (n = 1, 314) and 3.72% following delayed hospital transfer >24 h after initial admission (n = 861, P < 0.01 vs. elective admission and emergency admission/hospital transfer <24 h). In multivariable analysis, a delayed hospital transfer >24 h [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.59-3.28, P < 0.01], the occurrence of procedure-related major adverse events (OR 6.81, 95% CI 2.90-16.0, P < 0.01), Charlson Comorbidity Index (CCI, OR 2.39, 95% CI 1.56-3.66, P < 0.01) and its components congestive heart failure (OR 8.04, 95% CI 1.71-37.8, P < 0.01), and diabetes mellitus (OR 1.59, 95% CI 1.13-2.22, P < 0.01) were significantly associated with in-hospital death. CONCLUSIONS We reported in-hospital mortality rates after CA of ventricular arrhythmias in the largest multicentre, administrative dataset in Germany which can be implemented in quality management programs. Aside from comorbidities, a delayed hospital transfer to a CA performing centre is associated with an increased in-hospital mortality. This deserves further studies to determine the optimal management strategy.
Collapse
Affiliation(s)
- Sebastian König
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | - Laura Ueberham
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | | | - Michael Wiedemann
- Department of Cardiology, Helios Hospital Berlin-Buch, Berlin, Germany
| | - Michael Ulbrich
- Department of Internal Medicine I, Helios Hospital München West, München, Germany
| | - Armin Sause
- Department of Cardiology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | | | - Anja Schade
- Department of Cardiology, Helios Hospital Erfurt, Erfurt, Germany
| | - Dong-In Shin
- Department of Cardiology, Helios Hospital Krefeld, Krefeld, Germany
| | - Alexander Staudt
- Department of Cardiology and Angiology, Helios Hospital Schwerin, Schwerin, Germany
| | - René Andrié
- Department of Cardiology, Helios Hospital Siegburg, Siegburg, Germany
| | - Hans Neuser
- Department of Internal Medicine II, Helios Hospital Plauen, Plauen, Germany
| | | | - Arash Arya
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| |
Collapse
|
6
|
Catheter ablation in elderly patients: a review of current studies and pending questions. Curr Opin Cardiol 2018; 34:29-34. [PMID: 30444764 DOI: 10.1097/hco.0000000000000579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Catheter ablations are established treatment options for cardiac arrhythmias. Despite the fact that they are increasingly performed in elderly patients, publications focusing on procedural safety and success concerning this patient subgroup are sparse. The purpose of this review is to inform about current and upcoming studies regarding catheter ablations in the elderly. RECENT FINDINGS The overall pattern of available studies is indistinct because of varying age limits and scant patient populations. Most studies do not identify advanced patient age as a promoting factor for peri-procedural complications and recurrence rates. There are a few upcoming publications with regards to catheter ablations in the elderly, some of which might produce new insight. SUMMARY The results at hand might implicate, that in most cases individual patient health could be decisive instead of mere patient age to promise well-tolerated and effective catheter ablation in aged patients. Nevertheless, further studies with larger patient populations are needed to clarify the role of catheter ablation in aged patients.
Collapse
|
7
|
Markman TM, McBride DA, Liang JJ. Catheter Ablation for Ventricular Tachycardia in Patients with Structural Heart Disease. US CARDIOLOGY REVIEW 2018. [DOI: 10.15420/usc.2017:28:3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ventricular tachycardia is a potentially fatal arrhythmia that occurs most frequently in patients with structural heart disease. Acute and long- term management can be complex, requiring an integrated approach with multiple therapeutic modalities including antiarrhythmic drugs, implantable cardioverter defibrillators, and catheter ablation. Each of these options has a role in management of ventricular tachycardia and are generally used in combination. It is essential to be aware that each approach has potential deleterious consequences that must be balanced while establishing a treatment strategy. Catheter ablation for ventricular tachycardia is performed with increasing frequency with rapidly evolving techniques. In this review, we discuss the acute and long-term management of ventricular tachycardia with a focus on techniques and evidence for catheter ablation.
Collapse
|
8
|
Fulton BL, Liang JJ, Enriquez A, Garcia FC, Supple GE, Riley MP, Schaller RD, Dixit S, Callans DJ, Marchlinski FE, Han Y. Imaging characteristics of papillary muscle site of origin of ventricular arrhythmias in patients with mitral valve prolapse. J Cardiovasc Electrophysiol 2017; 29:146-153. [DOI: 10.1111/jce.13374] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 09/15/2017] [Accepted: 10/02/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Brian L. Fulton
- Department of Medicine; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Jackson J. Liang
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Andres Enriquez
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Fermin C. Garcia
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Gregory E. Supple
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Michael P. Riley
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Robert D. Schaller
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Sanjay Dixit
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - David J. Callans
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Francis E. Marchlinski
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Yuchi Han
- Department of Medicine, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| |
Collapse
|
9
|
Halbfaß P, Nentwich K, Sonne K, Ene E, Fochler F, Mügge A, Schieffer B, Deneke T. [Catheter ablation of ventricular extrasystoles and ventricular tachycardia in the elderly]. Herzschrittmacherther Elektrophysiol 2017; 28:9-15. [PMID: 28175981 DOI: 10.1007/s00399-017-0483-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/12/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The prevalence of structural heart disease increases with higher age, and thereby the basis for ventricular arrhythmias is created. Catheter ablation has been shown to be an effective therapy option that is very safe and achieves good long-term results in patients with recurrent ventricular tachycardia (VT). Data regarding ablation in patients older than 75 years is sparse, although this patient group was included as a minority in most published VT ablation studies. Data from younger patient collectives may not be transferable to older patient cohorts due to differences in patient comorbidities and baseline characteristics. METHODS Studies with patient collectives ≥75 years or even ≥80 years show comparable efficacy of catheter ablation for VT; however, the complication rate is higher, mainly due to groin complications, increases. Catheter ablation of ischemic VT appears effective and safe even in ≥75 year olds; however, extensive data for other structural heart diseases are lacking. Epicardial procedures are also possible and safe in older patients (≥80 years). Due to the significant challenges of VT ablation in older patients, including the consideration of complex comorbidities, these should be performed in specialized centers with high expertise. CONCLUSION The aim of catheter ablation in older patients is, above all, to improve quality of life and morbidity. Long-term survival is significantly lower due to the "near end of life" situation than in younger patients. Careful consideration of alternative therapy options, chances for success of the catheter ablation, and their risks, taking into account specific patient conditions and symptoms, is crucial in these patients.
Collapse
Affiliation(s)
- Philipp Halbfaß
- Klinik für Interventionelle Rhythmologie, Herz- und Gefäßklinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland.,Uniklinik Marburg, Marburg, Deutschland
| | - Karin Nentwich
- Klinik für Interventionelle Rhythmologie, Herz- und Gefäßklinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
| | - Kai Sonne
- Klinik für Interventionelle Rhythmologie, Herz- und Gefäßklinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
| | - Elena Ene
- Klinik für Interventionelle Rhythmologie, Herz- und Gefäßklinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
| | - Franziska Fochler
- Klinik für Interventionelle Rhythmologie, Herz- und Gefäßklinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
| | - Andreas Mügge
- Bergmannsheil Bochum, Ruhr-Universität Bochum, Bochum, Deutschland
| | | | - Thomas Deneke
- Klinik für Interventionelle Rhythmologie, Herz- und Gefäßklinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland. .,Bergmannsheil Bochum, Ruhr-Universität Bochum, Bochum, Deutschland.
| |
Collapse
|
10
|
Abstract
Catheter ablation is an increasingly used treatment option for patients with ventricular tachycardia (VT) in the setting of structural heart disease. Although there are extensive data from several retrospective studies as well as prospective nonrandomized observational studies, there are limited data from relatively few randomized controlled trials, especially comparing VT ablation with antiarrhythmic drugs. In this review, the authors aim to summarize the major studies examining efficacy of VT ablation in patients with structural heart disease, discuss barriers to enrollment and completion of randomized clinical trials, and propose areas of future research in the field.
Collapse
Affiliation(s)
- Jackson J Liang
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Daniele Muser
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| |
Collapse
|
11
|
Liang JJ, Santangeli P, Callans DJ. Long-term Outcomes of Ventricular Tachycardia Ablation in Different Types of Structural Heart Disease. Arrhythm Electrophysiol Rev 2015; 4:177-83. [PMID: 26835122 DOI: 10.15420/aer.2015.4.3.177] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/19/2015] [Indexed: 12/29/2022] Open
Abstract
Ventricular tachycardia (VT) often occurs in the setting of structural heart disease and can affect patients with ischaemic or nonischaemic cardiomyopathies. Implantable cardioverter-defibrillators (ICDs) provide mortality benefit and are therefore indicated for secondary prevention in patients with sustained VT, but they do not reduce arrhythmia burden. ICD shocks are associated with increased morbidity and mortality, and antiarrhythmic medications are often used to prevent recurrent episodes. Catheter ablation is an effective treatment option for patients with VT in the setting of structural heart disease and, when successful, can reduce the number of ICD shocks. However, whether VT ablation results in a mortality benefit remains unclear. We aim to review the long-term outcomes in patients with different types of structural heart disease treated with VT ablation.
Collapse
Affiliation(s)
- Jackson J Liang
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - David J Callans
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| |
Collapse
|