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Khanna S, Lo P, Cho K, Subbiah R. Ventricular Arrhythmias in Cardiac Amyloidosis: A Review of Current Literature. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820963055. [PMID: 33088185 PMCID: PMC7545745 DOI: 10.1177/1179546820963055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/06/2020] [Indexed: 01/29/2023]
Abstract
Cardiac Amyloidosis is an infiltrative cardiomyopathy which occurs secondary to deposition of mis-folded protein in the myocardium, with the two most common subtypes being AL amyloidosis and TTR amyloidosis. The pathogenesis of the disease is multifaceted and involves a variety of mechanisms including an inflammatory response cascade, oxidative stress and subsequent separation of myocyte fibrils. Cardiac Amyloidosis frequently results in congestive cardiac failure and arrhythmias, from a disruption in cardiac substrate with subsequent electro-mechanical remodelling. Disease progression is usually demonstrated by development of progressive pump failure, which may be seen with a high arrhythmic burden, usually portending a poor prognosis. There is a paucity of literature on the clinical implications of ventricular arrhythmias in the context of cardiac amyloidosis. The important diagnostic investigations for these patients include transthoracic echocardiography, cardiac magnetic resonance imaging and an electrophysiology study. Whilst there are no robust management guidelines, studies have indicated benefits from contemporary pharmacological therapy and case-by-case catheter ablation. There are novel directed therapies available for TTR amyloidosis that have shown to improve overall survival. The role of ICD therapy in cardiac amyloidosis is controversial, with benefits seen predominantly in early phases of the disease process. The only definitive surgical therapy includes heart transplantation, but is largely indicated for progressive decompensated heart failure (Figure 1). Further large-scale studies are required to better outline management paradigms for treating ventricular arrhythmias in cardiac amyloidosis.
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Affiliation(s)
- Shaun Khanna
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Phillip Lo
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Kenneth Cho
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Rajesh Subbiah
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Kensington, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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Liu C, Su Z, Wang L, Li B, Wang J, Yu Y, Gu C. Surgical Endoepicardial Linear Ablation for Ventricular Tachycardia With Postinfarction Left Ventricular Aneurysm. Tex Heart Inst J 2020; 47:194-201. [PMID: 32997773 DOI: 10.14503/thij-18-6615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This retrospective study evaluated the feasibility of surgical endoepicardial linear ablation for ventricular tachycardia in patients with postinfarction left ventricular aneurysm. Sixty-four patients with multivessel coronary artery disease and left ventricular aneurysm but no mural thrombosis of the aneurysm or valve disease were treated at our institution from March 2012 through July 2015. All underwent off-pump coronary artery bypass grafting and left ventricular aneurysm repair by linear plication. Twenty-three patients (35.9%) had ventricular tachycardia and underwent surgical endoepicardial linear ablation on the beating heart guided by epicardial substrate mapping with the Carto 3 system. The remaining 41 patients (64.1%) composed the no-ablation group. The effectiveness of surgical linear ablation in the ablation group was evaluated. Safety and clinical outcomes were evaluated and compared between the groups. The ventricular tachycardia recurrence rate in the ablation group was 17.4% in the immediate postoperative period and 23.8% at last follow-up (39 ± 21 mo). Early (<30-d) mortality rates were 8.7% in the ablation group and 4.9% in the no-ablation group (P=0.41); the respective late mortality rates were 19.1% and 18% (P=0.70). Multivariate Cox regression analysis indicated that preoperatively poor left ventricular function was an independent risk factor for early and late death in both groups. The groups were similar in terms of the need for postoperative mechanical circulatory support, intensive care unit stay, and cumulative survival rate. We conclude that, for carefully selected candidates, surgical endoepicardial linear ablation combined with off-pump coronary artery bypass grafting and left ventricular aneurysm linear plication is a feasible treatment for ventricular tachycardia with postinfarction left ventricular aneurysm.
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Affiliation(s)
- Changcheng Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing 100029, People's Republic of China
| | - Zhaoping Su
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing 100029, People's Republic of China
| | - Liangshan Wang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing 100029, People's Republic of China
| | - Bo Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing 100029, People's Republic of China
| | - Jin Wang
- Department of Cardiology, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing 100029, People's Republic of China
| | - Yang Yu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing 100029, People's Republic of China
| | - Chengxiong Gu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Diseases, Capital Medical University, Beijing 100029, People's Republic of China
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Li B, Liu C, Wang L, Wang J, Hu Y, Gu C. Open chest epicardial and transapical endocardial substrate ablation for ventricular tachycardia with left ventricular aneurysm in a porcine model. Perfusion 2018; 34:154-163. [PMID: 30445894 DOI: 10.1177/0267659118814689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endo-epicardial radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) as a first-line strategy has been shown to improve outcomes. This study sought to evaluate the feasibility and validity of open-chest epicardial and transapical endocardial substrate ablation for VT with left ventricular aneurysm (LVA) applying to routine cardiac surgery. METHODS Porcine models of LVA with VT were developed and were divided into a study group (RFCA from the epicardium via direct-view and endocardium via transapical access) and a control group (endocardial RFCA via retrograde transaortic access). Substrate-based mapping and ablation targeting abnormal potentials were performed under thoracotomy. Outcomes, including procedural success and acute freedom from VT, were analysed. RESULTS Twenty-four of 35 (68.57%) acute myocardial infarction (AMI) pigs developed LVA with VT in a 6-week survival period and were randomly divided into a study group (n=12) and a control group (n=12). All animals in the study group successfully underwent endocardial mapping and ablation by transapical access. The scar size of the endocardium and the left ventricular chamber volume were similar in the two groups. Acute freedom from VT in the study group was remarkably superior to that in the control group (88.33% vs. 58.33%, p=0.04). CONCLUSIONS Combined, direct epicardial and transapical endocardial substrate mapping and ablation appeared to be feasible and effective for treating VT with LVA under thoracotomy.
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Affiliation(s)
- Bo Li
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Changcheng Liu
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Liangshan Wang
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jin Wang
- 2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.,3 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yucai Hu
- 4 Department of Cardiology, the First-affiliated Hospital of Henan University of Traditional Chinese Medicine, Henan, China
| | - Chengxiong Gu
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
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Liu C, Wang L, Li B, Wang J, Hu Y, Li S, Yu Y, Gu C. Surgical linear ablation for ventricular tachycardia with postinfarction ventricular aneurysm. J Surg Res 2018; 228:211-220. [PMID: 29907214 DOI: 10.1016/j.jss.2018.02.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 12/28/2017] [Accepted: 02/14/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Left ventricular aneurysm (LVA) might be an arrhythmogenic substrate. Endocardiectomy and cryoablation for ventricular tachycardia (VT) with LVA can cause extensive myocardial damage. We aimed to evaluate the feasibility of surgical radial linear ablation for VT with LVA guided by electrophysiological mapping. MATERIALS AND METHODS Porcine models of VT with LVA were developed. Endocardial and epicardial substrate mapping during sinus rhythm were performed under thoracotomy. Surgical radial linear ablation was achieved by a bipolar radiofrequency ablation device. Outcomes, including procedural success and acute freedom of VT, were analyzed. RESULTS Fifteen of 20 pigs developed LVA in a 6-wk survival period. A total of 28 sustained monomorphic VTs were initiated in 13 of 15 pigs (86.67%). The number of potential points captured from the endocardium and epicardium were 319 ± 45 and 358 ± 52 per animal, respectively. The ablative targets containing abnormal potentials were located largely on the border zone of LVA. Eight linear lesions from core to border zone of LVA were achieved per animal in a radial and even manner continuously, and ablation was repeated three times to transect border zone. The acute freedom of VT was 84.62%, P < 0.05. CONCLUSIONS Surgical linear endo-epicardial ablation seemed to be feasible in a porcine model with VT and LVA.
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Affiliation(s)
- Changcheng Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Liangshan Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Bo Li
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jin Wang
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yucai Hu
- Department of Cardiology, the First-affiliated Hospital of Henan University of Traditional Chinese Medicine, Henan, China
| | - Songnan Li
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China; Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Yu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.
| | - Chengxiong Gu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.
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Mechanisms and Clinical Management of Ventricular Arrhythmias following Blunt Chest Trauma. Cardiol Res Pract 2016; 2016:7270247. [PMID: 26981308 PMCID: PMC4766339 DOI: 10.1155/2016/7270247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/13/2016] [Indexed: 11/21/2022] Open
Abstract
Nonpenetrating, blunt chest trauma is a serious medical condition with varied clinical presentations and implications. This can be the result of a dense projectile during competitive and recreational sports but may also include other etiologies such as motor vehicle accidents or traumatic falls. In this setting, the manifestation of ventricular arrhythmias has been observed both acutely and chronically. This is based on two entirely separate mechanisms and etiologies requiring different treatments. Ventricular fibrillation can occur immediately after chest wall injury (commotio cordis) and requires rapid defibrillation. Monomorphic ventricular tachycardia can develop in the chronic stage due to underlying structural heart disease long after blunt chest injury. The associated arrhythmogenic tissue may be complex and provides the necessary substrate to form a reentrant VT circuit. Ventricular tachycardia in the absence of overt structural heart disease appears to be focal in nature with rapid termination during ablation. Regardless of the VT mechanism, patients with recurrent episodes, despite antiarrhythmic medication in the chronic stage following blunt chest injury, are likely to require ablation to achieve VT control. This review article will describe the mechanisms, pathophysiology, and treatment of ventricular arrhythmias that occur in both the acute and chronic stages following blunt chest trauma.
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Shakil O, Josephson ME, Matyal R, Khabbaz KR, Mahmood F. Traumatic right ventricular aneurysm and ventricular tachycardia. Heart Rhythm 2012; 9:1501-3. [PMID: 22484649 DOI: 10.1016/j.hrthm.2012.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Indexed: 11/17/2022]
Affiliation(s)
- Omair Shakil
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, Massachusetts 02215, USA.
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Furushima H, Chinushi M, Iijima K, Hasegawa K, Sato A, Izumi D, Watanabe H, Aizawa Y. Is the coexistence of sustained ST-segment elevation and abnormal Q waves a risk factor for electrical storm in implanted cardioverter defibrillator patients with structural heart diseases? Europace 2011; 14:675-81. [PMID: 22158850 DOI: 10.1093/europace/eur386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIM The aim of this study was to determine whether or not the coexistence of sustained ST-segment elevation and abnormal Q waves (STe-Q) could be a risk factor for electrical storm (ES) in implanted cardioverter defibrillator (ICD) patients with structural heart diseases. METHODS AND RESULTS In all, 156 consecutive patients received ICD therapy for secondary prevention of sudden cardiac death and/or sustained ventricular tachyarrhythmias were included. Electrical storm was defined as ≥3 separate episodes of ventricular tachycardia (VT) and/or ventricular fibrillation (VF) terminated by ICD therapies within 24 h. During a mean follow-up of 1825 ± 1188 days, 42 (26.9%) patients experienced ES, of whom 12 had coronary artery disease, 15 had idiopathic dilated cardiomyopathy, 6 had hypertrophic cardiomyopathy, 4 had arrhythmogenic right ventricular cardiomyopathy, 4 had cardiac sarcoidosis, and 1 had valvular heart disease. Sustained ST-segment elevation and abnormal Q waves in ≥2 leads on the 12-lead electrocardiography was observed in 33 (21%) patients. On the Kaplan-Meier analysis, patients with STe-Q had a markedly higher risk of ES than those without STe-Q (P< 0.0001). The multivariate Cox proportional hazards regression model indicated that STe-Q and left ventricular ejection fraction (LVEF) (<30%) were independent risk factors associated with the recurrence of VT/VF (STe-Q: HR 1.962, 95% CI 1.24-3.12, P= 0.004; LVEF: HR 1.860, 95% CI 1.20-2.89, P= 0.006), and STe-Q was an independent risk factor associated with ES (HR 4.955, 95% CI 2.69-9.13, P< 0.0001). CONCLUSION Sustained ST-segment elevation and abnormal Q waves could be a risk factor of not only recurrent VT/VF but also ES in patients with structural heart diseases.
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Affiliation(s)
- Hiroshi Furushima
- The First Department of Internal Medicine, Niigata University School of Medicine, 1-754 Asahi-machi-dori, Niigata 951-8510, Japan
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Feld GK, Yao B, Reu G, Kudaravalli R. Acute and chronic effects of cryoablation of the pulmonary veins in the dog as a potential treatment for focal atrial fibrillation. J Interv Card Electrophysiol 2003; 8:135-40. [PMID: 12766505 DOI: 10.1023/a:1023660901347] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) may be triggered by premature atrial depolarizations originating in the pulmonary veins (PV). Radiofrequency catheter ablation of PV foci may prevent recurrence of AF, but may cause PV stenosis. Therefore, a safer method for ablation of PV foci is needed. This study evaluated the acute and chronic effects of PV ablation using a cryocatheter ablation (CCA) system, which may be less likely to cause PV stenosis. METHODS CCA was performed by freezing for 5 minutes or more in one or more PVs in 10 anesthetized dogs. Pacing threshold and vessel diameter were measured before and after PV cryoablation. All dogs were restudied at 4.0 +/- 1.64 months (range 2-7) in a manner identical to baseline. RESULTS CCA was performed in 27 PVs (range 1-4/dog), with a mean freeze time of 8.62 +/- 5.42 minutes per vein (range 5.23-22.06). Mean temperature for all freezes was -65 +/- 5.3 degrees C. Mean PV diameter was 6.49 +/- 1.73 vs 6.24 +/- 1.83 mm (p = NS) and mean pacing threshold 1.32 +/- 0.75 vs 9.36 +/- 5.93 mA (p <.01), before vs. acutely after ablation. At followup, at the ablation sites PV diameter (7.02 +/- 1.88 mm) was unchanged from baseline, whereas pacing threshold remained elevated (2.54 +/- 1.44 mA, p <.05 vs baseline). There were no acute or long-term complications. CONCLUSIONS; (1) CCA of PVs produced a significant rise in acute and chronic pacing threshold indicating loss of atrial conductivity. (2) CCA of PVs did not cause PV stenosis or other complications. (3) The data suggest that CCA of PVs may be a safe and effective method for treating focal AF.
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Affiliation(s)
- Gregory K Feld
- Department of Medicine, Cardiac Electrophysiology Program, Division of Cardiology, University of California-San Diego, UCSD Medical Center, 200 W. Arbor Drive, San Diego, CA 92103, USA
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Affiliation(s)
- R P Scott
- Department of Surgery, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA.
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Miller JM, Coppess MA, Altemose GT, Gervacio-Domingo G, Scott LR. Management of postinfarct ventricular tachycardias. Cardiol Clin 2000; 18:293-307. [PMID: 10849874 DOI: 10.1016/s0733-8651(05)70142-9] [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: 10/25/2022]
Abstract
The clinical profile of patients with postinfarct VT has changed in the past two decades. Along with these changes, existing treatments have improved, and entirely new therapeutic approaches have been developed. The expanded range of treatment options has made postinfarct VT a less imposing clinical problem than it once was. Emerging therapies promise to make an even greater beneficial impact. The challenge in treating patients with postinfarct VT has changed from merely keeping patients alive to keeping up with innovations in therapy that can provide them with a better quantity and quality of life.
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Affiliation(s)
- J M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, USA.
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Lustgarten DL, Keane D, Ruskin J. Cryothermal ablation: mechanism of tissue injury and current experience in the treatment of tachyarrhythmias. Prog Cardiovasc Dis 1999; 41:481-98. [PMID: 10445872 DOI: 10.1016/s0033-0620(99)70024-1] [Citation(s) in RCA: 157] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cryosurgery has been an integral part of the surgical management of cardiac arrhythmias since the late 1970s. With the recent development of intravenous cryocatheters, the use of cryothermy in the treatment of cardiac arrhythmias will increase in the near future. The following discussion includes a detailed consideration of the mode of tissue injury associated with cryothermy and a comprehensive review of cryosurgery in the management of a variety of cardiac arrhythmias. Cryosurgical management of supraventricular and ventricular tachycardias has proven to be both safe and effective. Cryothermal tissue injury is distinguished from hyperthermic injury by the preservation of basic underlying tissue architecture and minimal thrombus formation. Such differences will be particularly important in settings requiring extensive lesion formation, such as catheter-based maze procedures for the treatment of atrial fibrillation.
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Affiliation(s)
- D L Lustgarten
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston 02114, USA
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