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Deneke T, Kutyifa V, Hindricks G, Sommer P, Zeppenfeld K, Carbucicchio C, Pürerfellner H, Heinzel FR, Traykov VB, De Riva M, Pontone G, Lehmkuhl L, Haugaa K. Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology. Europace 2024; 26:euae108. [PMID: 38743765 PMCID: PMC11104536 DOI: 10.1093/europace/euae108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/16/2024] Open
Abstract
Imaging using cardiac computed tomography (CT) or magnetic resonance (MR) imaging has become an important option for anatomic and substrate delineation in complex atrial fibrillation (AF) and ventricular tachycardia (VT) ablation procedures. Computed tomography more common than MR has been used to detect procedure-associated complications such as oesophageal, cerebral, and vascular injury. This clinical consensus statement summarizes the current knowledge of CT and MR to facilitate electrophysiological procedures, the current value of real-time integration of imaging-derived anatomy, and substrate information during the procedure and the current role of CT and MR in diagnosing relevant procedure-related complications. Practical advice on potential advantages of one imaging modality over the other is discussed for patients with implanted cardiac rhythm devices as well as for planning, intraprocedural integration, and post-interventional management in AF and VT ablation patients. Establishing a team of electrophysiologists and cardiac imaging specialists working on specific details of imaging for complex ablation procedures is key. Cardiac magnetic resonance (CMR) can safely be performed in most patients with implanted active cardiac devices. Standard procedures for pre- and post-scanning management of the device and potential CMR-associated device malfunctions need to be in place. In VT patients, imaging-specifically MR-may help to determine scar location and mural distribution in patients with ischaemic and non-ischaemic cardiomyopathy beyond evaluating the underlying structural heart disease. Future directions in imaging may include the ability to register multiple imaging modalities and novel high-resolution modalities, but also refinements of imaging-guided ablation strategies are expected.
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Affiliation(s)
- Thomas Deneke
- Clinic for Rhythmology at Klinikum Nürnberg Campus Süd, University Hospital of the Paracelsus Medical University, Nuremberg, Germany
| | | | | | | | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | | | - Helmut Pürerfellner
- Department of Clinical Electrophysiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Frank R Heinzel
- Städtisches Klinikum Dresden, Department of Cardiology, Angiology and Intensive Care Medicine, Dresden, Germany
| | - Vassil B Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Marta De Riva
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Lukas Lehmkuhl
- Department of Radiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Germany
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Falasconi G, Penela D, Soto-Iglesias D, Francia P, Saglietto A, Turturiello D, Viveros D, Bellido A, Alderete J, Zaraket F, Franco-Ocaña P, Huguet M, Cámara Ó, Vătășescu R, Ortiz-Pérez JT, Martí-Almor J, Berruezo A. Personalized pulmonary vein isolation with very high-power short-duration lesions guided by left atrial wall thickness: the QDOT-by-LAWT randomized trial. Europace 2024; 26:euae087. [PMID: 38652090 PMCID: PMC11036893 DOI: 10.1093/europace/euae087] [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: 02/18/2024] [Accepted: 04/03/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS Pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) using very high-power short-duration (vHPSD) radiofrequency (RF) ablation proved to be safe and effective. However, vHPSD applications result in shallower lesions that might not be always transmural. Multidetector computed tomography-derived left atrial wall thickness (LAWT) maps could enable a thickness-guided switching from vHPSD to the standard-power ablation mode. The aim of this randomized trial was to compare the safety, the efficacy, and the efficiency of a LAWT-guided vHPSD PVI approach with those of the CLOSE protocol for PAF ablation (NCT04298177). METHODS AND RESULTS Consecutive patients referred for first-time PAF ablation were randomized on a 1:1 basis. In the QDOT-by-LAWT arm, for LAWT ≤2.5 mm, vHPSD ablation was performed; for points with LAWT > 2.5 mm, standard-power RF ablation titrating ablation index (AI) according to the local LAWT was performed. In the CLOSE arm, LAWT information was not available to the operator; ablation was performed according to the CLOSE study settings: AI ≥400 at the posterior wall and ≥550 at the anterior wall. A total of 162 patients were included. In the QDOT-by-LAWT group, a significant reduction in procedure time (40 vs. 70 min; P < 0.001) and RF time (6.6 vs. 25.7 min; P < 0.001) was observed. No difference was observed between the groups regarding complication rate (P = 0.99) and first-pass isolation (P = 0.99). At 12-month follow-up, no significant differences occurred in atrial arrhythmia-free survival between groups (P = 0.88). CONCLUSION LAWT-guided PVI combining vHPSD and standard-power ablation is not inferior to the CLOSE protocol in terms of 1-year atrial arrhythmia-free survival and demonstrated a reduction in procedural and RF times.
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Affiliation(s)
- Giulio Falasconi
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, Barcelona, Spain
- Arrhythmology Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Diego Penela
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Arrhythmology Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - David Soto-Iglesias
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Pietro Francia
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Division of Cardiology, Department of Clinical and Molecular Medicine, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Andrea Saglietto
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Dario Turturiello
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Open Heart Foundation, Barcelona, Spain
| | - Daniel Viveros
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, Barcelona, Spain
| | - Aldo Bellido
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Jose Alderete
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
- Campus Clínic, University of Barcelona, Barcelona, Spain
- Open Heart Foundation, Barcelona, Spain
| | - Fatima Zaraket
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Paula Franco-Ocaña
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Marina Huguet
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | | | - Radu Vătășescu
- Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | | | - Julio Martí-Almor
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
| | - Antonio Berruezo
- Heart Institute, Teknon Medical Centre, Calle Villana 12, 08022 Barcelona, Spain
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Rademaker R, Kimura Y, de Riva Silva M, Beukers HC, Piers SRD, Wijnmaalen AP, Dekkers OM, Zeppenfeld K. Area-weighted unipolar voltage to predict heart failure outcomes in patients with ischaemic cardiomyopathy and ventricular tachycardia. Europace 2024; 26:euad346. [PMID: 38308809 PMCID: PMC10838146 DOI: 10.1093/europace/euad346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/15/2023] [Indexed: 02/05/2024] Open
Abstract
AIMS Patients with ischaemic cardiomyopathy (ICM) referred for catheter ablation of ventricular tachycardia (VT) are at risk for end-stage heart failure (HF) due to adverse remodelling. Local unipolar voltages (UV) decrease with loss of viable myocardium. A UV parameter reflecting global viable myocardium may predict prognosis. We evaluate if a newly proposed parameter, area-weighted unipolar voltage (awUV), can predict HF-related outcomes [HFO; HF death/left ventricular (LV) assist device/heart transplant] in ICM. METHODS AND RESULTS From endocardial voltage maps of consecutive patients with ICM referred for VT ablation, awUV was calculated by weighted interpolation of local UV. Associations between clinical and mapping parameters and HFO were evaluated and validated in a second cohort. The derivation cohort consisted of 90 patients [age 68 ±8 years; LV ejection fraction (LVEF) 35% interquartile range (IQR) (24-40)] and validation cohort of 60 patients [age 67 ± 9, LVEF 39% IQR (29-45)]. In the derivation cohort, during a median follow-up of 45 months [IQR (34-83)], 36 (43%) patients died and 23 (26%) had HFO. Patients with HFO had lower awUV [4.51 IQR (3.69-5.31) vs. 7.03 IQR (6.08-9.2), P < 0.001]. A reduction in awUV [optimal awUV (5.58) cut-off determined by receiver operating characteristics analysis] was a strong predictor of HFO (3-year HFO survival 97% vs. 57%). The cut-off value was confirmed in the validation cohort (2-year HFO-free survival 96% vs. 60%). CONCLUSION The newly proposed parameter awUV, easily available from routine voltage mapping, may be useful at identifying ICM patients at high risk for HFO.
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Affiliation(s)
- Robert Rademaker
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Yoshi Kimura
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Marta de Riva Silva
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Hans C Beukers
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Sebastiaan R D Piers
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Adrianus P Wijnmaalen
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology (C-05-P), Leiden University Medical Center, P.O. Box 9600, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Willem Einthoven Center of Arrhythmia Research and Management, Leiden, The Netherlands
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Chevance V, Azarine A, Hamon DA, Dhanjal TS, Teiger E, Deux JF, Lellouche N. Wall shear stress in outflow tract premature ventricular contraction location assessed through 4D-flow MRI. Europace 2024; 26:euae034. [PMID: 38290435 PMCID: PMC10849830 DOI: 10.1093/europace/euae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/22/2024] [Indexed: 02/01/2024] Open
Affiliation(s)
- Virgile Chevance
- Radiology Department, Hopital Henri Mondor, APHP, Creteil, France
- Radiology Department, Centre Chirurgical Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Arshid Azarine
- Radiology Department, Centre Chirurgical Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - David A Hamon
- Cardiology and Electrophysiology Unit, Hopital Henri Mondor, APHP, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
- University of Iowa Hospitals and Clinics (UIHC), Department of Cardiology, Carver College of Medicine, Iowa City, IA
| | - Tarvinder S Dhanjal
- Department of Cardiac Electrophysiology, University of Warwick, Gibbet Hill, Coventry, UK
| | - Emmanuel Teiger
- Cardiology and Electrophysiology Unit, Hopital Henri Mondor, APHP, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
| | - Jean-François Deux
- Radiology Department, Hopital Henri Mondor, APHP, Creteil, France
- Radiology Department, University Hospitals of Geneva, Geneva, Switzerland
| | - Nicolas Lellouche
- Cardiology and Electrophysiology Unit, Hopital Henri Mondor, APHP, 51 Avenue du Marechal de Lattre de Tassigny, 94000 Creteil, France
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Auricchio A. Editorial. Europace 2023; 26:euae008. [PMID: 38207128 PMCID: PMC10803038 DOI: 10.1093/europace/euae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Indexed: 01/13/2024] Open
Affiliation(s)
- Angelo Auricchio
- Istituto Cardiocentro Ticino - Ente Ospedaliero Cantonale, Via Tesserete 48, 6900 Lugano, Switzerland
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Garcia Garcia J, Arya A, Dinov B, Bollmann A, ter Bekke RMA, Vernooy K, Dagres N, Hindricks G, Darma A. Impact of repeat ablation of ventricular tachycardia in patients with structural heart disease. Europace 2023; 26:euad367. [PMID: 38127308 PMCID: PMC10755192 DOI: 10.1093/europace/euad367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
AIMS Recurrences of ventricular tachycardia (VT) after initial catheter ablation is a significant clinical problem. In this study, we report the efficacy and risks of repeat VT ablation in patients with structural heart disease (SHD) in a tertiary single centre over a 7-year period. METHODS AND RESULTS Two hundred ten consecutive patients referred for repeat VT ablation after previous ablation in our institution were included in the analysis (53% ischaemic cardiomyopathy, 91% males, median age 65 years, mean left ventricular ejection fraction 35%). After performing repeat ablation, the clinical VTs were acutely eliminated in 82% of the patients, but 46% of the cohort presented with VT recurrence during the 25-month follow-up. Repeat ablation led to a 73% reduction of shock burden in the first year and 61% reduction until the end of follow-up. Similarly, VT burden was reduced 55% in the first year and 36% until the end of the study. Fifty-two patients (25%) reached the combined endpoint of ventricular assist device implantation, heart transplantation, or death. Advanced New York Heart Association functional class, anteroseptal substrate, and periprocedural complication after repeat ablation were associated with worse prognosis independently of the type of cardiomyopathy. CONCLUSION While complete freedom from VT after repeat ablation in SHD was difficult to achieve, ablation led to a significant reduction in VT and shock burden. Besides advanced heart failure characteristics, anteroseptal substrate and periprocedural complications predicted a worse outcome.
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Affiliation(s)
- Joaquin Garcia Garcia
- Department of Cardiac Electrophysiology, Heart Center of Leipzig, Struempellstrasse 39, Leipzig 04289, Germany
| | - Arash Arya
- Department of Cardiac Electrophysiology, Halle University, Halle (Saale), Germany
| | - Borislav Dinov
- Department of Cardiac Electrophysiology, Heart Center of Leipzig, Struempellstrasse 39, Leipzig 04289, Germany
| | - Andreas Bollmann
- Department of Cardiac Electrophysiology, Heart Center of Leipzig, Struempellstrasse 39, Leipzig 04289, Germany
| | - Rachel M A ter Bekke
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Angeliki Darma
- Department of Cardiac Electrophysiology, Heart Center of Leipzig, Struempellstrasse 39, Leipzig 04289, Germany
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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Saglietto A, Falasconi G, Soto-Iglesias D, Francia P, Penela D, Alderete J, Viveros D, Bellido AF, Franco-Ocaña P, Zaraket F, Turturiello D, Marti-Almor J, Berruezo A. Assessing left atrial intramyocardial fat infiltration from computerized tomography angiography in patients with atrial fibrillation. Europace 2023; 25:euad351. [PMID: 38011712 PMCID: PMC10751854 DOI: 10.1093/europace/euad351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/27/2023] [Accepted: 11/22/2023] [Indexed: 11/29/2023] Open
Abstract
AIMS Epicardial adipose tissue might promote atrial fibrillation (AF) in several ways, including infiltrating the underlying atrial myocardium. However, the role of this potential mechanism has been poorly investigated. The aim of this study is to evaluate the presence of left atrial (LA) infiltrated adipose tissue (inFAT) by analysing multi-detector computer tomography (MDCT)-derived three-dimensional (3D) fat infiltration maps and to compare the extent of LA inFAT between patients without AF history, with paroxysmal, and with persistent AF. METHODS AND RESULTS Sixty consecutive patients with AF diagnosis (30 persistent and 30 paroxysmal) were enrolled and compared with 20 age-matched control; MDCT-derived images were post-processed to obtain 3D LA inFAT maps for all patients. Volume (mL) and mean signal intensities [(Hounsfield Units (HU)] of inFAT (HU -194; -5), dense inFAT (HU -194; -50), and fat-myocardial admixture (HU -50; -5) were automatically computed by the software. inFAT volume was significantly different across the three groups (P = 0.009), with post-hoc pairwise comparisons showing a significant increase in inFAT volume in persistent AF compared to controls (P = 0.006). Dense inFAT retained a significant difference also after correcting for body mass index (P = 0.028). In addition, more negative inFAT radiodensity values were found in AF patients. Regional distribution analysis showed a significantly higher regional distribution of LA inFAT at left and right superior pulmonary vein antra in AF patients. CONCLUSION Persistent forms of AF are associated with greater degree of LA intramyocardial adipose infiltration, independently of body mass index. Compared to controls, AF patients present higher LA inFAT volume at left and right superior pulmonary vein antra.
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Affiliation(s)
- Andrea Saglietto
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Citta della Salute e della Scienza’ Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giulio Falasconi
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- IRCCS Humanitas Research Hospital, Electrophysiology Department, Rozzano, Milan, Italy
- Campus Clínic, University of Barcelona, C/Villarroel 170, Barcelona, 08024, Spain
| | - David Soto-Iglesias
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Pietro Francia
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- Department of Clinical and Molecular Medicine, Cardiology Unit, Sant’Andrea Hospital, University Sapienza, Rome, Italy
| | - Diego Penela
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- IRCCS Humanitas Research Hospital, Electrophysiology Department, Rozzano, Milan, Italy
| | - José Alderete
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- OpenHeart Foundation, Barcelona, Spain
| | - Daniel Viveros
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Aldo Francisco Bellido
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- OpenHeart Foundation, Barcelona, Spain
| | - Paula Franco-Ocaña
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Fatima Zaraket
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Darío Turturiello
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- OpenHeart Foundation, Barcelona, Spain
| | - Julio Marti-Almor
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Antonio Berruezo
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
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