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Nair GM, Birnie DH, Sumner GL, Krahn AD, Healey JS, Nery PB, Kalfon E, Verma A, Ayala-Paredes F, Coutu B, Becker G, Philippon F, Eikelboom J, Sandhu RK, Sapp J, Leather R, Yung D, Thibault B, Simpson CS, Ahmad K, Sturmer M, Kavanagh K, Crystal E, Wells GA, Essebag V. Post-operative pain following cardiac implantable electronic device implantation: insights from the BRUISE CONTROL trials. Europace 2021; 23:748-756. [PMID: 33367623 DOI: 10.1093/europace/euaa349] [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: 07/30/2020] [Accepted: 11/12/2020] [Indexed: 01/15/2023] Open
Abstract
AIMS Post-operative pain following cardiac implantable electronic device (CIED) insertion is associated with patient dissatisfaction, emotional distress, and emergency department visits. We sought to identify factors associated with post-operative pain and develop a prediction score for post-operative pain. METHODS AND RESULTS All patients from the BRUISE CONTROL-1 and 2 trials were included in this analysis. A validated Visual Analogue Scale (VAS) was used to assess the severity of pain related to CIED implant procedures. Patients were asked to grade the most severe post-operative pain, average post-operative pain, and pain on the day of the first post-operative clinic. Multivariable regression analyses were performed to identify predictors of significant post-operative pain and to develop a pain-prediction score. A total of 1308 patients were included. Multivariable regression analysis found that the presence of post-operative clinically significant haematoma {CSH; P value < 0.001; odds ratio (OR) 3.82 [95% confidence interval (CI): 2.37-6.16]}, de novo CIED implantation [P value < 0.001; OR 1.90 (95% CI: 1.47-2.46)], female sex [P value < 0.001; OR 1.61 (95% CI: 1.22-2.12)], younger age [<65 years; P value < 0.001; OR 1.54 (95% CI: 1.14-2.10)], and lower body mass index [<20 kg/m2; P value < 0.05; OR 2.05 (95% CI: 0.98-4.28)] demonstrated strong and independent associations with increased post-operative pain. An 11-point post-operative pain prediction score was developed using the data. CONCLUSION Our study has identified multiple predictors of post-operative pain after CIED insertion. We have developed a prediction score for post-operative pain that can be used to identify individuals at risk of experiencing significant post-operative pain.
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Affiliation(s)
- Girish M Nair
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - David H Birnie
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Glen L Sumner
- Department of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Andrew D Krahn
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jeffrey S Healey
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton Health Sciences, Population Health Research Institute, Hamilton, ON, Canada
| | - Pablo B Nery
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Eli Kalfon
- Department of Medicine, Galilee Medical Center, Nahariya, Israel
| | - Atul Verma
- Department of Medicine, Southlake Regional Health Center, University of Toronto, Toronto, ON, Canada
| | | | - Benoit Coutu
- Department of Medicine, Centre Hospitalier de l'Universite de Montreal, Hopital Hotel-Dieu, Montreal, QC, Canada
| | - Giuliano Becker
- Department of Medicine, McGill University Health Center, Montreal, QC, Canada
| | | | - John Eikelboom
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton Health Sciences, Population Health Research Institute, Hamilton, ON, Canada
| | - Roopinder K Sandhu
- Department of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - John Sapp
- Department of Medicine, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Richard Leather
- Scarborough Health Network, University of Toronto, Toronto, ON, Canada
| | - Derek Yung
- Scarborough Health Network, University of Toronto, Toronto, ON, Canada
| | - Bernard Thibault
- Division of Cardiology, Department of Medicine, Montreal Heart Institute Montreal, QC, Canada
| | | | - Kamran Ahmad
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marcio Sturmer
- Division of Cardiology, Department of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Katherine Kavanagh
- Department of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Eugene Crystal
- Department of Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - George A Wells
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
| | - Vidal Essebag
- Division of Cardiology, Department of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, AB, Canada
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Blomstrom-Lundqvist C, Ostrowska B. Prevention of cardiac implantable electronic device infections: guidelines and conventional prophylaxis. Europace 2021; 23:euab071. [PMID: 34037227 PMCID: PMC8221047 DOI: 10.1093/europace/euab071] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/09/2021] [Indexed: 01/19/2023] Open
Abstract
Cardiac implantable electronic devices (CIED) are potentially life-saving treatments for several cardiac conditions, but are not without risk. Despite dissemination of recommended strategies for prevention of device infections, such as administration of antibiotics before implantation, infection rates continue to rise resulting in escalating health care costs. New trials conveying important steps for better prevention of device infection and an EHRA consensus paper were recently published. This document will review the role of various preventive measures for CIED infection, emphasizing the importance of adhering to published recommendations. The document aims to provide guidance on how to prevent CIED infections in clinical practice by considering modifiable and non-modifiable risk factors that may be present pre-, peri-, and/or post-procedure.
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Affiliation(s)
| | - Bozena Ostrowska
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Philippon F, O'Hara GE, Champagne J, Hohnloser SH, Glikson M, Neuzner J, Mabo P, Vinolas X, Kautzner J, Gadler F, Lashevsky N, Connolly SJ, Liu YY, Healey JS. Rate, Time Course, and Predictors of Implantable Cardioverter Defibrillator Infections: An Analysis From the SIMPLE Trial. CJC Open 2020; 2:354-359. [PMID: 32995720 PMCID: PMC7499364 DOI: 10.1016/j.cjco.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background The number of implantable cardioverter defibrillator (ICD) infections is increasing due to an increased number of ICD implants, higher-risk patients, and more frequent replacement procedures, which carry a higher risk of infection. Reducing the morbidity, mortality, and cost of ICD-related infections requires an understanding of the current rate of this complication and its predictors. Methods The Shock Implant Evaluation Trial (SIMPLE) trial randomized 2500 ICD recipients to defibrillation testing or not. Over an average of 3.1 years, patients were seen every 6 months and examined for evidence of ICD infection, which was defined as requiring device removal and/or intravenous antibiotics. Results Within 24 months, 21 patients (0.8%) developed infection. Fourteen patients (67%) with infection presented within 30 days, 20 patients by 12 months, and only 1 patient beyond 12 months. Univariate analysis demonstrated that patients with primary electrical disorders (3 patients, P = 0.009) and those with a secondary prevention indication (13 patients, P = 0.0009) were more likely to develop infection. Among the 2.2% of patients who developed an ICD wound hematoma, 10.4% developed an infection. Among the 8.3% of patients requiring an ICD reintervention, 1.9% developed an infection. Conclusions This cohort of ICD recipients at high-volume centres have a low risk of device-related infection. However; strategies to reduce wound hematoma and the need for ICD reintervention could further reduce the rate of infection.
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Affiliation(s)
- François Philippon
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Gilles E O'Hara
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Jean Champagne
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | | | - Michael Glikson
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | | | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Noa Lashevsky
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Yan Y Liu
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Wang SX, Bai J, Ma R, Lan RF, Zheng J, Xu W. Fever and neck pain after pacemaker lead extraction: A case report. World J Clin Cases 2019; 7:2103-2109. [PMID: 31423444 PMCID: PMC6695544 DOI: 10.12998/wjcc.v7.i15.2103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/14/2019] [Accepted: 06/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Venous thrombosis (VT) is one of the minor complications of pacemaker lead extraction. It is often found due to the swelling of the limbs after the extraction. It is easy to be neglected or even misdiagnosed in the absence of typical clinical symptoms. The incidence, risk factors, and long-term impact of this complication are still unclear. Herein, we report a case of deep VT caused by transvenous lead extraction, which is easily misdiagnosed.
CASE SUMMARY A 66-year-old woman underwent a pacemaker lead extraction at our hospital because of a pacemaker pocket infection. After the extraction, she began to experience intermittent fever accompanied by sweating. The highest body temperature recorded was 37.9 °C. Additionally, she reported migratory pain that made her uncomfortable. The pain was mistakenly thought to be caused by operation trauma. At first, the pain radiated from the left chest to the mandible. Then, the pain in the left chest was alleviated, but pain in the left neck and throat appeared. Finally, the pain was confined to the mandible and a submandibular mass was palpated with no other abnormalities upon physical examination. Computed tomography venography and angiography finally indicated that the fever and pain were the symptoms of thrombophlebitis caused by lead extraction. The patient was then treated with rivaroxaban for more than three months and has shown no symptoms since she left the hospital.
CONCLUSION The possibility of thrombosis should be considered when pain and recurrent fever occur after pacemaker lead extraction.
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Affiliation(s)
- Shao-Xian Wang
- Department of Cardiology, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, Jiangsu Province, China
| | - Jian Bai
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Rui Ma
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Rong-Fang Lan
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Jia Zheng
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Wei Xu
- Department of Cardiology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
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Keyser A, Schopka S, Jungbauer C, Foltan M, Schmid C. Early-BYRD: alternative early pacing and defibrillation lead replacement avoiding venous puncture. J Cardiothorac Surg 2018; 13:102. [PMID: 30285786 PMCID: PMC6169062 DOI: 10.1186/s13019-018-0795-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 09/26/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In cases of lead failure after implantation of pacemakers (PM) or implantable cardioverter defibrillators (ICD) early lead replacement may be challenging. Puncture of the subclavian vein bears possible complications such as pneumothorax, hematothorax, and damage of leads to be left in place. To avoid venous puncture PM or ICD leads were replaced using a flexible polypropylene sheath (Byrd-sheath). METHOD From January 2010 through December 2017, 55 patients underwent early lead exchange avoiding venous puncture. Early lead exchange for this study was defined as a reintervention within 14 days after the initial lead implantation. The connector of the malfunctioning lead was cut off, and stabilized by a stiff stylet. After having cut off the plastic knob of the stylet, the lead was passed through the polypropylene sheath and the latter advanced into the subclavian vein with gentle rotational movements to gain access to the subclavian vein. After lead removal the polypropylene sheath was replaced by a peel away sheath a new lead inserted. RESULTS Overall, 23 defibrillation leads and 34 pacing leads (16 right atrial leads, 17 right ventricular leads, and 1 left ventricular lead) were successfully explanted. Access to the subclavian vein was uneventful, and blood loss minimal. Radiation exposure and fluoroscopy time were also negligible. CONCLUSION The Byrd-sheath technique proved to be safe and successful in providing vein access within 2 weeks after initial lead implantation using the previously implanted lead and thus avoiding puncture of the subclavian vein.
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Affiliation(s)
- Andreas Keyser
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Simon Schopka
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Carsten Jungbauer
- Department of Internal Medicine II/Cardiology, University Medical Center, Regensburg, Germany
| | - Maik Foltan
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
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Bleeding risk of submuscular ICD implantation with continued oral anticoagulation versus heparin bridging therapy. Heart Vessels 2017; 33:441-446. [PMID: 29030709 DOI: 10.1007/s00380-017-1064-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
Recent studies have shown that subcutaneous or subfascial pacemaker- and ICD implantation with continued oral anticoagulation therapy is associated with lower risk for bleeding complications, when compared to heparin bridging strategies. However, ICD generators are often implanted submuscularly. We therefore compared the bleeding risk with continued phenprocoumon therapy vs. heparin bridging in patients receiving submuscular ICD implantation. Between 01/2013 and 12/2013, 104 patients with need for oral anticoagulation received submuscular ICD or CRT-D implantation in our institution. 46 patients were implanted under continued phenprocoumon therapy while 58 patients received heparin bridging for implantation procedure. All ICD generators were placed submuscularly. The primary outcome of the study was clinically significant bleeding or device pocket hematoma with need for surgical revision. Mean patients age was 63.7 years, 72.1% were male. In patients with heparin bridging therapy, preoperative INR prior to ICD implantation was 1.2 ± 0.31 while in the group of patients on continued phenprocoumon therapy, mean pre-OP INR was 2.4 ± 0.47. In heparin bridging group, 8 (13.8%) patients experienced a clinically relevant pocket hematoma, while only 1 (2.2%) patient on continued phenprocoumon therapy needed surgical revision for pocket hematoma (P = 0.04). No further bleeding complications or clinically relevant pericardial effusion was observed in any of the groups and no perioperative thromboembolic event occurred. Submuscular ICD implantation under continued phenprocoumon therapy was safe and feasible. Compared to patients with heparin bridging therapy, those with continued phenprocoumon therapy had a lower incidence of clinically relevant bleeding complications.
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He H, Ke BB, Li Y, Han FS, Li X, Zeng YJ. Perioperative management of antithrombotic therapy in patients receiving cardiovascular implantable electronic devices: a network meta-analysis. J Interv Card Electrophysiol 2017; 50:65-83. [PMID: 28842832 DOI: 10.1007/s10840-017-0280-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/10/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Network meta-analysis (NMA) has advantages including being able to simultaneously compare and rank multiple treatments over traditional meta-analysis. We evaluated by a NMA the optimal antithrombotic strategy during the perioperative period of implantation of cardiovascular implantable electronic devices (CIEDs). METHODS We performed a network meta-analysis of observational studies (cohort and case-control studies). The eligible studies tested the following antithrombotic therapy during the CIED placement: aspirin, clopidogrel, warfarin, novel oral anticoagulants (NOACs), and heparin bridging. RESULTS Thirty-one observational studies with 119 study arms were included (41,174 patients receiving long-term antithrombotic therapy; median age, 72.6 years; 70.1% males; median follow-up, 3.6 years). Aspirin (4.26 [2.88-7.22]), warfarin (3.37 [2.17-5.23]), and clopidogrel (3.30 [1.49-5.88]) reduced the risk of bleeding as compared with heparin bridging, and there was no significance difference between continued NOACs and heparin bridging (0.67 [0.21-2.18]). The comparison of commonly used protocols in the management of anticoagulant therapy revealed that continued warfarin (0.38 [0.20-0.74]), continued NOACs (0.19 [0.04-0.89]), and heparin bridging therapy (0.01 [0.05-0.21]) increased the risk of bleeding as compared that of control, and continued warfarin (3.74 [1.96-7.16]), interrupted warfarin (4.89 [2.20-10.88]), and interrupted NOACs (12.5 [1.25-100]) reduced the risk of bleeding compared with that of heparin bridging. CONCLUSIONS Among various antithrombotic drugs, aspirin had the lowest bleeding risk, followed by warfarin, clopidogrel and NOACs, and heparin, with the greatest bleeding risk. NOACs therapy appears safe and effective, and interrupted NOACs may be the optimal anticoagulation protocol for use during the perioperative period of CIED implantation.
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Affiliation(s)
- Hua He
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China.
| | - Bing-Bing Ke
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yan Li
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, 100029, China
| | - Fu-Sheng Han
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Xiaodong Li
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
| | - Yu-Jie Zeng
- Department of Emergency Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road Second, Chaoyang District, Beijing, 100029, People's Republic of China
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Deer TR, Pope JE, Hayek SM, Lamer TJ, Veizi IE, Erdek M, Wallace MS, Grider JS, Levy RM, Prager J, Rosen SM, Saulino M, Yaksh TL, De Andrés JA, Abejon Gonzalez D, Vesper J, Schu S, Simpson B, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks. Neuromodulation 2017; 20:155-176. [DOI: 10.1111/ner.12579] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/22/2016] [Accepted: 12/07/2016] [Indexed: 01/12/2023]
Affiliation(s)
| | | | - Salim M. Hayek
- University Hospitals Cleveland Medical Center, Case Western Reserve University; Cleveland OH USA
| | | | - Ilir Elias Veizi
- Veterans Administration Medical Center, Case Western Reserve University; Cleveland OH USA
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- UK HealthCare Pain Services, University of Kentucky College of Medicine; Lexington KY USA
| | | | - Joshua Prager
- Center for the Rehabilitation of Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology, University of California; San Diego CA USA
| | - Jose A. De Andrés
- Valencia School of Medicine, Hospital General Universitario; Valencia Spain
| | | | - Jan Vesper
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf; Germany
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
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Bhargava K. Identifying the predictors of hematoma after device implantation: Closing in on the suspects with an aim to prevent the menace? Indian Pacing Electrophysiol J 2016; 16:157-158. [PMID: 27979374 PMCID: PMC5153436 DOI: 10.1016/j.ipej.2016.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 11/28/2016] [Indexed: 11/21/2022] Open
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