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Vergara P, Pignalberi C, Pisanò EC, Maglia G, Della Bella P, Zanotto G, Iacopino S, Solimene F, Calvi V, Marini M, Giammaria M, Biffi M, Rovaris G, Caravati F, Quartieri F, Curnis A, Rapacciuolo A, Senatore G, Pedretti S, Saporito D, Dello Russo A, Santobuono VE, Pepi P, Duca A, Baroni M, Falasconi G, Giacopelli D, Gargaro A, D'Onofrio A. Circadian periodicity affects the type of ventricular arrhythmias and efficacy of implantable defibrillator therapies. J Cardiovasc Electrophysiol 2021; 32:2528-2535. [PMID: 34252991 DOI: 10.1111/jce.15154] [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: 05/11/2021] [Revised: 06/14/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Factors influencing malignant arrhythmia onset are not fully understood. We explored the circadian periodicity of ventricular arrhythmias (VAs) in patients with implantable cardioverter and cardiac resynchronization defibrillators (ICD/CRT-D). METHODS Time, morphology (monomorphic/polymorphic), and mode of termination (anti-tachycardia pacing [ATP] or shock) of VAs stored in a database of remote monitoring data were adjudicated. Episodes were grouped in six 4-h timeslots from 00:00 to 24:00. Circadian distributions and adjusted marginal odds ratios (ORs), with 95% confidence interval (CI), were analyzed using mixed-effect models and logit generalized estimating equations, respectively, to account for within-subject correlation of multiple episodes. RESULTS Among 1303 VA episodes from 446 patients (63% ICD and 37% CRT-D), 120 (9%) self-extinguished, and 842 (65%) were terminated by ATP, 343 (26%) by shock. VAs clustered from 08:00 to 16:00 with 44% of episodes, as compared with 22% from 00:00 to 08:00 (p < .001) and 34% from 16:00 to 24:00 (p = .005). Episodes were more likely to be polymorphic at night with an adjusted marginal OR of 1.66 (CI, 1.15-2.40; p = .007) at 00:00-04:00 versus other timeslots. Episodes were less likely to be terminated by ATP in the 00:00-04:00 (success-to-failure ratio, 0.67; CI, 0.46-0.98; p = .039) and 08:00-12:00 (0.70; CI, 0.51-0.96; p = .02) timeslots, and most likely to be terminated by ATP between 12:00 and 16:00 (success-to-failure ratio 1.42; CI, 1.06-1.91; p = .02). CONCLUSION VAs did not distribute uniformly over the 24 h, with a majority of episodes occurring from 08:00 to 16:00. Nocturnal episodes were more likely to be polymorphic. The efficacy of ATP depended on the time of delivery.
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Affiliation(s)
- Pasquale Vergara
- Arrhythmia Unit and Electrophysiology Laboratory, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | | | | | | | - Paolo Della Bella
- Arrhythmia Unit and Electrophysiology Laboratory, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | | | | | | | - Valeria Calvi
- Policlinico G. Rodolico, Az. O.U. Policlinico-V. Emanuele, Catania, Italy
| | | | | | - Mauro Biffi
- Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | | | | | | | | | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Stefano Pedretti
- Ospedale Sant'Anna, ASST Lariana, San Fermo della Battaglia, Como, Italy
| | | | | | | | | | | | - Matteo Baroni
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giulio Falasconi
- IRCCS San Raffaele Scientific Institute and Vita Salute University, Milano, Italy
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Braunschweig F, Anker SD, Proff J, Varma N. Remote monitoring of implantable cardioverter-defibrillators and resynchronization devices to improve patient outcomes: dead end or way ahead? Europace 2020; 21:846-855. [PMID: 30903152 PMCID: PMC6545502 DOI: 10.1093/europace/euz011] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/24/2019] [Indexed: 12/11/2022] Open
Abstract
Remote monitoring (RM) has become a new standard of care in the follow-up of patients with implantable pacemakers and defibrillators. While it has been consistently shown that RM enables earlier detection of clinically actionable events compared with traditional in-patient evaluation, this advantage did not translate into improved patient outcomes in clinical trials of RM except one study using daily multiparameter telemonitoring in heart failure (HF) patients. Therefore, this review, focusing on RM studies of implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators in patients with HF, discusses possible explanations for the differences in trial outcomes. Patient selection may play an important role as more severe HF and concomitant atrial fibrillation have been associated with improved outcomes by RM. Furthermore, the technical set-up of RM may have an important impact as a higher level of connectivity with more frequent data transmission can be linked to better outcomes. Finally, there is growing evidence as to the need of effective algorithms ensuring a fast and well-structured clinical response to the events detected by RM. These factors re-emphasize the potential of remote management of device patients with HF and call for continued clinical research and technical development in the field.
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Affiliation(s)
| | - Stefan D Anker
- Department of Cardiology and Pneumology, Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany
| | | | - Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Husser D, Christoph Geller J, Taborsky M, Schomburg R, Bode F, Nielsen JC, Stellbrink C, Meincke C, Hjortshøj SP, Schrader J, Lewalter T, Hindricks G. Remote monitoring and clinical outcomes: details on information flow and workflow in the IN-TIME study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2019; 5:136-144. [PMID: 30016396 PMCID: PMC6440440 DOI: 10.1093/ehjqcco/qcy031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/02/2018] [Accepted: 07/11/2018] [Indexed: 12/02/2022]
Abstract
Aims Randomized clinical trials investigating a possible outcome effect of remote monitoring in patients with implantable defibrillators have shown conflicting results. This study analyses the information flow and workflow details from the IN-TIME study and discusses whether differences of message content, information speed and completeness, and workflow may contribute to the heterogeneous results. Methods and results IN-TIME randomized 664 patients with an implantable cardioverter/defibrillator indication to daily remote monitoring vs. control. After 12 months, a composite clinical score and all-cause mortality were improved in the remote monitoring arm. Messages were received on 83.1% of out-of-hospital days. Daily transmissions were interrupted 2.3 times per patient-year for more than 3 days. During 1 year, absolute transmission success declined by 3.3%. Information on medical events was available after 1 day (3 days) in 83.1% (94.3%) of the cases. On all working days, a central monitoring unit informed investigators of protocol defined events. Investigators contacted patients with a median delay of 1 day and arranged follow-ups, the majority of which took place within 1 week of the event being available. Conclusion Only limited data on the information flow and workflow have been published from other studies which failed to improve outcome. However, a comparison of those data to IN-TIME suggest that the ability to see a patient early after clinical events may be inferior to the set-up in IN-TIME. These differences may be responsible for the heterogeneity found in clinical effectiveness of remote monitoring concepts.
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Affiliation(s)
- Daniela Husser
- Heart Center Leipzig, Strümpelstr., 39, Leipzig, Germany
| | | | - Miloš Taborsky
- Olomouc University Hospital, I.P., Pavlova 6, Olomouc, Czech Republic
| | - Rolf Schomburg
- Segeberger Kliniken, Am Kurpark 1, Bad Segeberg, Germany
| | - Frank Bode
- Sana Kliniken Ostholstein, Mühlenkamp 5, Oldenburg, Germany
| | | | | | - Carsten Meincke
- Vivantes Klinikum Neukölln, Rudower Straße 48, Berlin, Germany
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Lazarus A, Guy-Moyat B, Mondoly P, Pons F, Quaglia C, Elkaim JP, Bayle S, Victor F. Active periodic electrograms in remote monitoring of pacemaker recipients: the PREMS study. Europace 2019; 21:130-136. [PMID: 29955890 PMCID: PMC6321961 DOI: 10.1093/europace/euy140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 05/29/2018] [Indexed: 11/12/2022] Open
Abstract
AIMS Remote monitoring (RM) is considered as a standard of care for pacemaker recipients. Remote monitoring systems provide calendar-based intracardiac electrogram recordings (IEGM) only with the current pacemaker settings (passive IEGM). PREMS (Pacemaker Remote Electrogram Monitoring Study), an observational, multicentre trial, prospectively evaluated the clinical value of an active IEGM (aIEGM), including three 10-s sections (passive IEGM, encouraged sensing, and encouraged pacing), compared to other RM data and to its passive IEGM section. Secondary objectives included the added value of the aIEGM to fully assess the sensing and pacing functions of each lead. METHODS AND RESULTS Patients were enrolled within 3 months after pacemaker implantation and followed until the first transmitted aIEGM, which was analysed together with all other RM data. In total, 567 patients were enrolled (79 ± 9 years, 62% men, 19% single-chamber, and 81% dual-chamber pacemakers). Of 547 aIEGMs transmitted in 547 patients, 161 [29.4%; 95% confidence interval (95% CI) 25.6-33.3%] indicated at least one anomaly non-detectable with certainty-or at all-on other RM data, including atrial arrhythmia, extrasystoles, undersensing, oversensing, and loss of capture. In 21.7% of cases the detected events deserved a corrective action. The sensing and pacing function of each lead could be fully assessed in 77.3% of aIEGM (95% CI 72.6-82.0%) vs. 15.5% (95% CI 11.4-19.6%) when considering only the passive IEGM section (P < 0.001). CONCLUSION An active IEGM improves the clinical value of remote pacemaker follow-up. Furthermore, compared to a passive IEGM, the aIEGM increases the capability to fully assess remotely the sensing and pacing functions.
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Affiliation(s)
- Arnaud Lazarus
- Rhythmology Unit, Clinique Ambroise Paré, 25-27 boulevard Victor Hugo, Neuilly-Sur-Seine, France
| | - Benoit Guy-Moyat
- Cardiology Unit, Centre Hospitalier Universitaire de Limoges, 2 avenue Martin Luther King, Limoges, France
| | - Pierre Mondoly
- Cardiology Unit, Centre Hospitalier Rangueil, 1 avenue du Pr Jean Poulhès, Toulouse, France
| | - Frédéric Pons
- Cardiology Unit, Hôpital d’Instruction des Armées Saint-Anne, 2 boulevard Sainte-Anne, Toulon, France
| | - Carlo Quaglia
- Cardiology Unit, Centre Hospitalier de Roanne, 28 rue de Charlieu, Roanne, France
| | - Jean-Philippe Elkaim
- Cardiology Unit, Centre Hospitalier de Douarnenez, 85 rue Laennec, Douarnenez, France
| | - Sandrine Bayle
- Cardiology Unit, Centre Hospitalier Louis Pasteur, 4 rue Claude Bernard, Le Coudray, France
| | - Frédéric Victor
- Cardiology Unit, Polyclinique Saint-Laurent, 320 avenue Général George S. Patton, Rennes, France
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Clinical Course of Dual-Chamber Implantable Cardioverter-Defibrillator Recipients followed by Cardiac Remote Monitoring: Insights from the LION Registry. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3120480. [PMID: 30519574 PMCID: PMC6241353 DOI: 10.1155/2018/3120480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 09/14/2018] [Accepted: 10/01/2018] [Indexed: 11/25/2022]
Abstract
Patients receiving dual-chamber implantable cardioverter-defibrillator (DR-ICD) therapy are at risk of developing atrial arrhythmia because of the increased rate of ventricular pacing and the progression of heart failure. Remote monitoring (RM) may identify the patients at highest risk of adverse events such as atrial arrhythmias. A total of 283 patients with 91,632 remote transmissions during a 15-month follow-up (FU) period enrolled in the LION registry were analysed. The parameters retrieved included the pacing mode, lower rate limit, percentage of atrial (%AP) and ventricular pacing (%VP), and percentage of atrial arrhythmia burden (%AB). In 92.7% of patients, the devices were initially programmed in DDD(R) or DDI(R), with changes of the pacing mode in 19.3% only. The lower rate limit remained stable in 80.4% of patients. At the first transmission, 8.7% of patients suffered from RM-detected atrial arrhythmia, which reached 36% during FU. The %AP was not associated with increased AB (p = 0.67), but the %VP was different in patients developing RM-detected atrial arrhythmia (26.9% vs. 13.7%, p < 0.00001). The %VP increased in 105 patients (significance level of α = 0.05), and 11 patients crossed the border of 50% VP. The LION substudy supports the concept of using RM in a real-world DR-ICD population. Remote monitoring of DR-ICDs allows for the quantification of the course of the pacing parameters and AB. Based on these observations, device parameters can be adjusted and optimized.
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Ono M, Varma N. Remote Monitoring for Chronic Disease Management: Atrial Fibrillation and Heart Failure. Card Electrophysiol Clin 2018; 10:43-58. [PMID: 29428141 DOI: 10.1016/j.ccep.2017.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This review aims to cover the latest evidence of remote monitoring of cardiac implantable electronic devices for the management of atrial fibrillation and heart failure. Remote monitoring is useful for early detection for device-detected atrial fibrillation, which increases the risk of thromboembolic events. Early anticoagulation based on remote monitoring potentially reduces the risk of stroke, but optimal alert setting needs to be clarified. Multiparameter monitoring with automatic transmission is useful for heart failure management. Improved adherence to remote monitoring and an optimal algorithm for transmitted alerts and their management are warranted in the management of heart failure.
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Affiliation(s)
- Maki Ono
- Department of Cardiology, Kameda General Hospital, 929 Higashi-cho, Kamogawa City, Chiba 296-8602, Japan; Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, J2-2, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Niraj Varma
- Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, J2-2, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Liu N, Kim J, Jung Y, Arisy A, Nicdao MA, Mikaheal M, Baldacchino T, Khadra M, Sud K. Remote Monitoring Systems for Chronic Patients on Home Hemodialysis: Field Test of a Copresence-Enhanced Design. JMIR Hum Factors 2017; 4:e21. [PMID: 28851680 PMCID: PMC5596297 DOI: 10.2196/humanfactors.7078] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 05/13/2017] [Accepted: 07/27/2017] [Indexed: 11/13/2022] Open
Abstract
Background Patients undertaking long-term and chronic home hemodialysis (HHD) are subject to feelings of isolation and anxiety due to the absence of physical contact with their health care professionals and lack of feedback in regards to their dialysis treatments. Therefore, it is important for these patients to feel the “presence” of the health care professionals remotely while on hemodialysis at home for better compliance with the dialysis regime and to feel connected with health care professionals. Objective This study presents an HHD system design for hemodialysis patients with features to enhance patient’s perceived “copresence” with their health care professionals. Various mechanisms to enhance this perception were designed and implemented, including digital logbooks, emotion sharing, and feedback tools. The mechanism in our HHD system aims to address the limitations associated with existing self-monitoring tools for HHD patients. Methods A field trial involving 3 nurses and 74 patients was conducted to test the pilot implementation of the copresence design in our HHD system. Mixed method research was conducted to evaluate the system, including surveys, interviews, and analysis of system data. Results Patients created 2757 entries of dialysis cases during the period of study. Altogether there were 492 entries submitted with “Very Happy” as the emotional status, 2167 entries with a “Happy” status, 56 entries with a “Neutral” status, 18 entries with an “Unhappy” status, and 24 entries with a “Very unhappy” status. Patients felt assured to share their emotions with health care professionals. Health care professionals were able to prioritize the review of the entries based on the emotional status and also felt assured to see patients’ change in mood. There were 989 entries sent with short notes. Entries with negative emotions had a higher percentage of supplementary notes entered compared to the entries with positive and neutral emotions. The qualitative data further showed that the HHD system was able to improve patients’ feelings of being connected with their health care professionals and thus enhance their self-care on HHD. The health care professionals felt better assured with patients’ status with the use of the system and reported improved productivity and satisfaction with the copresence enhancement mechanism. The survey on the system usability indicated a high level of satisfaction among patients and nurses. Conclusions The copresence enhancement design complements the conventional use of a digitized HHD logbook and will further benefit the design of future telehealth systems.
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Affiliation(s)
- Na Liu
- School of Information Technologies, Sydney, Australia
| | - Jinman Kim
- Biomedical and Multimedia Information Technology (BMIT) Group, School of Information Technologies, Sydney, Australia.,Nepean Telehealth Technology Centre, Nepean Hospital, Kingswood, Sydney, Australia
| | - Younhyun Jung
- Biomedical and Multimedia Information Technology (BMIT) Group, School of Information Technologies, Sydney, Australia.,Home Haemodialysis Unit, Regional Dialysis Centre, Blacktown Hospital, Sydney, Australia
| | - Adani Arisy
- Biomedical and Multimedia Information Technology (BMIT) Group, School of Information Technologies, Sydney, Australia
| | - Mary Ann Nicdao
- Home Haemodialysis Unit, Regional Dialysis Centre, Blacktown Hospital, Sydney, Australia
| | - Mary Mikaheal
- Home Haemodialysis Unit, Regional Dialysis Centre, Blacktown Hospital, Sydney, Australia
| | - Tanya Baldacchino
- Nepean Telehealth Technology Centre, Nepean Hospital, Kingswood, Sydney, Australia
| | - Mohamed Khadra
- Biomedical and Multimedia Information Technology (BMIT) Group, School of Information Technologies, Sydney, Australia.,Nepean Telehealth Technology Centre, Nepean Hospital, Kingswood, Sydney, Australia
| | - Kamal Sud
- Home Haemodialysis Unit, Regional Dialysis Centre, Blacktown Hospital, Sydney, Australia.,Department of Renal Medicine, Nepean Hospital, Kingswood, Sydney, Australia.,Sydney Medical School (Nepean Clinical School), The University of Sydney, Sydney, Australia
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Folino F, Buja G, Zanotto G, Marras E, Allocca G, Vaccari D, Gasparini G, Bertaglia E, Zoppo F, Calzolari V, Suh RN, Ignatiuk B, Lanera C, Benassi A, Gregori D, Iliceto S. Association between air pollution and ventricular arrhythmias in high-risk patients (ARIA study): a multicentre longitudinal study. Lancet Planet Health 2017; 1:e58-e64. [PMID: 29851582 DOI: 10.1016/s2542-5196(17)30020-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/18/2017] [Accepted: 03/15/2017] [Indexed: 05/27/2023]
Abstract
BACKGROUND Although the effects of air pollution on mortality have been clearly shown in many epidemiological and observational studies, the pro-arrhythmic effects remain unknown. We aimed to assess the short-term effects of air pollution on ventricular arrhythmias in a population of high-risk patients with implantable cardioverter-defibrillators (ICDs) or cardiac resynchronisation therapy defibrillators (ICD-CRT). METHODS In this prospective multicentre study, we assessed 281 patients (median age 71 years) across nine centres in the Veneto region of Italy. Episodes of ventricular tachycardia and ventricular fibrillation that were recorded by the diagnostic device were considered in this analysis. Concentrations of particulate matter of less than 10 μm (PM10) and less than 2·5 μm (PM2·5) in aerodynamic diameter, carbon monoxide, nitrogen dioxide, sulphur dioxide, and ozone were obtained daily from monitoring stations, and the 24 h median value was considered. Each patient was associated with exposure data from the monitoring station that was closest to their residence. Patients were followed up for 1 year and then scheduled to have a closing visit, within 1 more year. This study is registered with ClinicalTrials.gov, number NCT01723761. FINDINGS Participants were enrolled from April 1, 2011, to Sept 30, 2012, and follow-ups (completed on April 5, 2014) ranged from 637 to 1177 days (median 652 days). The incidence of episodes of ventricular tachycardia and ventricular fibrillation correlated significantly with PM2·5 (p<0·0001) but not PM10. An analysis of ventricular fibrillation episodes alone showed a significant increase in risk of higher PM2·5 (p=0·002) and PM10 values (p=0·0057). None of the gaseous pollutants were significantly linked to the occurrence of ventricular tachycardia or ventricular fibrillation. In a subgroup analysis of patients with or without a previous myocardial infarction, only the first showed a significant association between particulate matter and episodes of ventricular tachycardia or ventricular fibrillation. INTERPRETATION Particulate matter has acute pro-arrhythmic effects in a population of high-risk patients, which increase on exposure to fine particles and in patients who have experienced a previous myocardial infarction. The time sequence of the arrhythmic events suggests there is an underlying neurally mediated mechanism. From a clinical point of view, the results of our study should encourage physicians to also consider environmental risk when addressing the prevention of arrhythmic events, particularly in patients with coronary heart disease, advising them to avoid exposure to high levels of fine particulate matter. FUNDING There was no funding source for this study.
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Affiliation(s)
- Franco Folino
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy.
| | - Gianfranco Buja
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Gabriele Zanotto
- Department of Cardiology, Mater Salutis Hospital, Legnago, Italy
| | - Elena Marras
- Department of Cardiology, S Maria dei Battuti Hospital, Conegliano, Italy
| | - Giuseppe Allocca
- Department of Cardiology, S Maria dei Battuti Hospital, Conegliano, Italy
| | - Diego Vaccari
- Department of Cardiology, Civic Hospital, Montebelluna, Italy
| | | | - Emanuele Bertaglia
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Franco Zoppo
- Department of Cardiology, Civic Hospital, Mirano, Italy
| | | | - Rene Nangah Suh
- Department of Cardiology, Civic Hospital, Portogruaro, Italy
| | | | - Corrado Lanera
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Alessandro Benassi
- Regional Agency for Environmental Prevention and Protection of the Veneto Region, Padua, Italy
| | - Dario Gregori
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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