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Schulz S, Harzheim L, Hübner C, Lorke M, Jünger S, Woopen C. Patient-centered empirical research on ethically relevant psychosocial and cultural aspects of cochlear, glaucoma and cardiovascular implants - a scoping review. BMC Med Ethics 2023; 24:68. [PMID: 37641094 PMCID: PMC10464431 DOI: 10.1186/s12910-023-00945-6] [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: 03/03/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND The significance of medical implants goes beyond technical functioning and reaches into everyday life, with consequences for individuals as well as society. Ethical aspects associated with the everyday use of implants are relevant for individuals' lifeworlds and need to be considered in implant care and in the course of technical developments. METHODS This scoping review aimed to provide a synthesis of the existing evidence regarding ethically relevant psychosocial and cultural aspects in cochlear, glaucoma and cardiovascular implants in patient-centered empirical research. Systematic literature searches were conducted in EBSCOhost, Philpapers, PsycNET, Pubmed, Web of Science and BELIT databases. Eligible studies were articles in German or English language published since 2000 dealing with ethically relevant aspects of cochlear, glaucoma and passive cardiovascular implants based on empirical findings from the perspective of (prospective) implant-wearers and their significant others. Following a descriptive-analytical approach, a data extraction form was developed and relevant data were extracted accordingly. We combined a basic numerical analysis of study characteristics with a thematically organized narrative synthesis of the data. RESULTS Sixty-nine studies were included in the present analysis. Fifty were in the field of cochlear implants, sixteen in the field of passive cardiovascular implants and three in the field of glaucoma implants. Implant-related aspects were mainly found in connection with autonomy, freedom, identity, participation and justice, whereas little to no data was found with regards to ethical principles of privacy, safety or sustainability. CONCLUSIONS Empirical research on ethical aspects of implant use in everyday life is highly relevant, but marked by ambiguity and unclarity in the operationalization of ethical terms and contextualization. A transparent orientation framework for the exploration and acknowledgment of ethical aspects in "lived experiences" may contribute to the improvement of individual care, healthcare programs and research quality in this area. Ethics-sensitive care requires creating awareness for cultural and identity-related issues, promoting health literacy to strengthen patient autonomy as well as adjusting healthcare programs accordingly. More consideration needs to be given to sustainability issues in implant development and care according to an approach of ethics-by-design.
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Affiliation(s)
- Sabine Schulz
- Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (CERES), University of Cologne and University Hospital of Cologne, Universitätsstraße 91, 50931, Cologne, Germany.
| | - Laura Harzheim
- Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (CERES), University of Cologne and University Hospital of Cologne, Universitätsstraße 91, 50931, Cologne, Germany
| | - Constanze Hübner
- Center for Life Ethics, University of Bonn, 53113, Bonn, Germany
| | - Mariya Lorke
- Faculty of Engineering and Mathematics, University of Applied Sciences and Arts (HSBI), 33619, Bielefeld, Germany
| | - Saskia Jünger
- Department of Community Health, University of Applied Health Sciences Bochum, Gesundheitscampus 6-8, 44801, Bochum, Germany
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Taj J, Taylor EP. End-Stage/Advanced Heart Failure: Geriatric Palliative Care Considerations. Clin Geriatr Med 2023; 39:369-378. [PMID: 37385689 DOI: 10.1016/j.cger.2023.04.010] [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] [Indexed: 07/01/2023]
Abstract
Heart failure remains a condition with high morbidity and mortality affecting 23 million people globally with a cost burden equivalent to 5.4% of the total health care budget in the United States. These costs include repeated hospitalizations as the disease advances and care that may not align with individual wishes and values. The coincidence of comorbid conditions with advanced heart failure poses significant challenges in the geriatric population. Advance care planning, medication education, and minimizing polypharmacy are primary palliative opportunities leading to specialist palliative care such as symptom management at end of life and timing of referral to hospice.
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Affiliation(s)
- Jabeen Taj
- Division of Hospice and Palliative Medicine, Department of Family Medicine, Emory University School of Medicine, Emory University Hospital, 1364 Clifton Road, Atlanta, GA 30322, USA.
| | - Emily Pinto Taylor
- Division of General Internal Medicine, Department of Family Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Drive Southeast, Atlanta, GA 30303, USA; Division of Hospice and Palliative Medicine, Department of Family Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Drive Southeast, Atlanta, GA 30303, USA
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Astărăstoae V, Rogozea LM. Reimplantation of Implantable Cardiac Devices-An Ethical Controversy? Am J Ther 2023; Publish Ahead of Print:00045391-990000000-00156. [PMID: 37285587 DOI: 10.1097/mjt.0000000000001646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cardiovascular diseases are an important public health problem, the main cause of death in both men and women, with a continuous increasing prevalence and consequences upon morbidity in economic, physical, and psychological terms.The new technology have made possible the development of innovative devices, which have increased the possibility of therapeutic interventions today, extending the life of the population with cardiovascular pathology, transforming the patient care, and providing a complex, personalized therapeutic approach. FIELDS OF UNCERTAINTY The aim of the study was to evaluate from an ethical perspective the need, feasibility, and safety of reusing cardiac pacemakers to revise the legal terms and requirements.In recent years, the problem of accessibility to cardiovascular drugs has been increasingly accompanied by the accessibility to technology, interventional cardiology advancing recently, and becoming an increasingly important standard of care. DATA SOURCES A review of the specialized literature was performed in March 2023, using keywords such as implantable cardiac devices, reuse, ethics from PubMed, Scopus, Web of Science, and Google Scholar, as well as official documents issued at the international level (World Health Organization). ETHICS AND THERAPEUTIC ADVANCES An ethical analysis assesses the extent to which a medical act (PM reimplantation) is covered by the 4 universally accepted principles: nonmaleficence, beneficence, autonomy (respect for the person), and social justice, the analysis addressing to the risk-benefit ratio based on studies that analyzed the phenomenon over the past 50 years. The ethical analyzed issues start from the fact that although 80% of pacemakers, most of them working perfectly, with a battery life of more than 7 years are buried with their owners, while approximately 3 million patients die annually due to the lack of access to these devices in undeveloped and developing countries.But beyond the ethical issues, legal practice has meant that in many countries, reusing of these devices is prohibited, mostly being single-use devices. Low-income countries continue to accept this practice as the only one economically accessible to them, considering the prohibition of reusing them to be an economic rather than a medical issue. CONCLUSIONS Reusing implantable cardiac devices is of great interest because of the costs, being in certain situations, the only possibility that certain people can have access to a therapeutic method that ensures their health recovery and increases their quality of life. But this is not possible without clear procedures, without clear criteria on how sterilization should be performed, how the technique should be performed, without obtaining a truly informed consent, and especially without a proper patient's follow-up.
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Affiliation(s)
| | - Liliana M Rogozea
- Basic, Preventive and Clinical Sciences Department, Transilvania University, Brasov, Romania
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Lima NDA, Rocha EA, Damasceno A, Costa IP, Ricardo JRB, Lopes FJ, Dias L, Soares MBDPC, Puroll E, Eagle KA, Crawford TC. Pacemaker Reuse in Portuguese Speaking Countries: A Clinical Reflection. Arq Bras Cardiol 2023; 120:e20210941. [PMID: 36921183 DOI: 10.36660/abc.20210941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 09/01/2022] [Indexed: 03/06/2023] Open
Abstract
There is a gap between high-income countries and others in terms of access to medical cardiac devices, such as pacemakers and implantable cardioverter defibrillators. Costs are one of the main barriers to the use of cardiac devices in these countries. There are international initiatives that aim to reduce the gap. The reuse of pacemakers has been discussed as a possible alternative to this problem. The concept of reusing pacemakers is not new; however, recent studies have proven to be safe, ethical, and effective for those who need cardiac implantable electronic devices and cannot afford them. Part of the Portuguese-speaking countries, especially in Africa, need an immediate response that benefits their countless patients who suffer from treatable arrhythmias.
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Affiliation(s)
| | - Eduardo Arrais Rocha
- Universidade Federal do Ceará - Hospital Universitário Walter Cantídio - Programa de Pós-graduação em Ciências Cardiovasculares da Faculdade de Medicina da UFC, Fortaleza, CE - Brasil
| | | | - Ieda Prata Costa
- Universidade Federal do Ceará - Hospital Universitário Walter Cantídio - Programa de Pós-graduação em Ciências Cardiovasculares da Faculdade de Medicina da UFC, Fortaleza, CE - Brasil
| | | | | | - Luis Dias
- Hospital Agostinho Neto, Praia - Cabo Verde
| | | | - Eric Puroll
- University of Michigan Medicine, Ann Arbor, Michigan - EUA
| | - Kim A Eagle
- University of Michigan Medicine - Frankel Cardiovascular Center, Ann Arbor, Michigan - EUA
| | - Thomas C Crawford
- University of Michigan Medicine - Frankel Cardiovascular Center, Ann Arbor, Michigan - EUA
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Lorenzo Ruiz I, Arrizabalaga Arostegi H, Fernández Atucha A. Battery life of cardiac implantable electronic devices explanted in funeral homes: a potential resource for underserved nations. Expert Rev Med Devices 2022; 19:733-737. [PMID: 36171720 DOI: 10.1080/17434440.2022.2130757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Cardiac implantable electronic devices (CIEDs) could still have adequate battery life and functionality when they are explanted after the death of the carrier, supposing an important resource for low- and middle- income countries where patients cannot afford new devices. OBJECTIVE The aim was to analyse the remaining battery life and reusability of CIEDs recovered from funeral homes. METHOD A descriptive study of postmortem explanted CIEDs was conducted. Devices were collected from three funeral homes in the Spanish region of the Basque Country (participation rate 33.3%). Devices with a remaining battery life of >75% or > 4 years, preserved external integrity and no evidence of malfunction were considered reusable. RESULTS A total of 188 CIEDs were collected (175 pacemakers and 13 defibrillators). Of the total number of devices, 95 (50.5%) had enough battery to be interrogated. Among the interrogable devices, a total of 20 pacemakers (22.4%) had an estimated battery life of more than 4 years, as well as preserved integrity and no record of malfunction. CONCLUSIONS A non-negligible number of postmortem explanted devices had battery life, external integrity and functionality to be considered reusable. Postmortem CIED donation could provide treatment to patients unable to afford new devices.
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Affiliation(s)
- Iñigo Lorenzo Ruiz
- Nursing department I, Faculty of Medicine and Nursing, University of the Basque Country, UPV/EHU, Leioa, Spain.,BioCruces-Bizkaia Health Research Institute. Barakaldo, Spain
| | | | - Ainhoa Fernández Atucha
- Nursing department I, Faculty of Medicine and Nursing, University of the Basque Country, UPV/EHU, Leioa, Spain
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Howard M, Hutchinson K. Industry Technicians Embedded in Clinical Teams: Impacts on Medical Knowledge. Hastings Cent Rep 2022; 52:41-48. [PMID: 35476358 DOI: 10.1002/hast.1354] [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] [Indexed: 11/11/2022]
Abstract
Advances in implantable medical devices have increased the role for industry-employed allied professionals (IEAPs) in providing training and support during surgical procedures and follow-up care. The effect of these changes on the organization of medical knowledge and the sharing of information remains largely unexplored. Recent work in social epistemology and the conceptualizing of implantable medical device companies as part of a knowledge-based industry provide a framework for engaging with this issue. In this article, we argue that the insertion of industry technicians into hospitals diminishes epistemically valuable knowledge-sharing practices. This is in part a result of health care professionals' increased dependence on IEAPs, who control access to knowledge about devices, limiting opportunities both for independent learning and for dialogic education practices through which participants work toward a common goal. Ultimately, we claim that overdependence on the IEAP as expert undermines a basic social value regarding knowledge sharing for everyone's benefit.
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Lorenzo Ruiz I. Reuse of cardiac implantable electronic devices in developing countries perspectives: A literature review. Pacing Clin Electrophysiol 2021; 45:241-249. [PMID: 34862987 DOI: 10.1111/pace.14422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/03/2021] [Accepted: 11/28/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES Access to cardiac implantable electronic devices (CIEDs) is limited in developing countries. Postmortem CIED donation from developed countries to developing countries could be an important resource for those who cannot afford a new one. The objective of this paper was to identify and synthesize the perspectives on the donation of CIEDs for potential reuse in patients without resources living in developing countries. METHODS A bibliographic review was carried out in the PubMed, Web of Science and Scopus databases. The search strategy was limited to articles published in English or Spanish. RESULTS Eight publications were analyzed. The main results were grouped into two large frameworks on perceptions, preferences, attitudes and opinions of developed countries and developing countries towards the donation and reuse of CIEDs. Positive perspectives were identified towards the donation of CIEDs for their reuse in the majority of patients with a CIED, relatives, funeral homes and physicians of developed countries, as well as in physicians and potential recipient patients of developing countries. CONCLUSIONS This review highlights the positive perspectives on CIED donation from developed countries to patients in need of developing countries among all studied groups. In view of the feasibility of collecting postmortem devices, we advocate studying the feasibility of more local CIED donation initiatives.
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Affiliation(s)
- Iñigo Lorenzo Ruiz
- Department of Nursing I, Faculty of Medicine and Nursing, University of the Basque Country, UPV/EHU., Lejona, Spain
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Hansson SO. The ethics of explantation. BMC Med Ethics 2021; 22:121. [PMID: 34496854 PMCID: PMC8428100 DOI: 10.1186/s12910-021-00690-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 08/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the increased use of implanted medical devices follows a large number of explantations. Implants are removed for a wide range of reasons, including manufacturing defects, recovery making the device unnecessary, battery depletion, availability of new and better models, and patients asking for a removal. Explantation gives rise to a wide range of ethical issues, but the discussion of these problems is scattered over many clinical disciplines. METHODS Information from multiple clinical disciplines was synthesized and analysed in order to provide a comprehensive approach to the ethical issues involved in the explantation of medical implants. RESULTS Discussions and recommendations are offered on pre-implantation information about a possible future explantation, risk-benefit assessments of explantation, elective explantations demanded by the patient, explantation of implants inserted for a clinical trial, patient registers, quality assurance, routines for investigating explanted implants, and demands on manufacturers to prioritize increased service time in battery-driven implants and to market fewer but more thoroughly tested models of implants. CONCLUSION Special emphasis is given to the issue of control or ownership over implants, which underlies many of the ethical problems concerning explantation. It is proposed that just like transplants, implants that fulfil functions normally carried out by biological organs should be counted as supplemented body parts. This means that the patient has a strong and inalienable right to the implant, but upon explantation it loses that status.
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Affiliation(s)
- Sven Ove Hansson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 171 77, Stockholm, Sweden.
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Walker MJ. On Replacement Body Parts. JOURNAL OF BIOETHICAL INQUIRY 2019; 16:61-73. [PMID: 30565032 DOI: 10.1007/s11673-018-9889-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 12/04/2018] [Indexed: 06/09/2023]
Abstract
Technological advances are making devices that functionally replace body parts-artificial organs and limbs-more widely used, and more capable of providing patients with lives that are close to "normal." Some of the ethical issues this is likely to raise relate to how such prostheses are conceptualized. Prostheses are ambiguous between being inanimate objects and sharing in the status of human bodies-which already have an ambiguous status, as both objects and subjects. At the same time, the possibility of replacing body parts with artificial objects puts pressure on the normative status typically accorded to human bodies, seemingly confirming that body parts are replaceable objects. The paper argues that bodies' normative status relies on the relation of a body to a person and shows that persons could have similar relations to prostheses. This suggests that in approaching ethical issues surrounding prostheses, it is appropriate to regard them as more like body parts than like objects.
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Affiliation(s)
- Mary Jean Walker
- Philosophy Department and ARC Centre of Excellence for Electromaterials Science, Monash University, Clayton, Victoria, 3800, Australia.
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Henschke A. Militaries and the duty of care to enhanced veterans. J ROY ARMY MED CORPS 2019; 165:220-225. [PMID: 30765610 DOI: 10.1136/jramc-2018-001140] [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] [Received: 12/09/2018] [Revised: 01/17/2019] [Accepted: 01/17/2019] [Indexed: 11/04/2022]
Abstract
This article argues that there is a duty of care held by the State to military veterans who have been technologically enhanced as part of their military service. It suggests that enhancements may be permanent, persistent or protracted and demonstrates how enhancements generate additional moral responsibilities from the chain of command. The paper concludes by demonstrating how this institutional duty of care relates to issues such as informed consent.
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Affiliation(s)
- Adam Henschke
- National Security College, Australian National University, Canberra, Australia .,Department of Values, Technology and Innovation, Technische Universiteit Delft, Delft, The Netherlands
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Grundy Q, Hutchison K, Johnson J, Blakely B, Clay-Wlliams R, Richards B, Rogers WA. Device representatives in hospitals: are commercial imperatives driving clinical decision-making? JOURNAL OF MEDICAL ETHICS 2018; 44:589-592. [PMID: 29973390 DOI: 10.1136/medethics-2018-104804] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 06/14/2018] [Accepted: 06/16/2018] [Indexed: 06/08/2023]
Abstract
Despite concerns about the relationships between health professionals and the medical device industry, the issue has received relatively little attention. Prevalence data are lacking; however, qualitative and survey research suggest device industry representatives, who are commonly present in clinical settings, play a key role in these relationships. Representatives, who are technical product specialists and not necessarily medically trained, may attend surgeries on a daily basis and be available to health professionals 24 hours a day, 7 days a week, to provide advice. However, device representatives have a dual role: functioning as commissioned sales representatives at the same time as providing advice on approaches to treatment. This duality raises the concern that clinical decision-making may be unduly influenced by commercial imperatives. In this paper, we identify three key ethical concerns raised by the relationship between device representatives and health professionals: (1) impacts on healthcare costs, (2) the outsourcing of expertise and (3) issues of accountability and informed consent. These ethical concerns can be addressed in part through clarifying the boundary between the support and sales aspects of the roles of device representatives and developing clear guidelines for device representatives providing support in clinical spaces. We suggest several policy options including hospital provision of expert support, formalising clinician conduct to eschew receipt of meals and payments from industry and establishing device registries.
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Affiliation(s)
- Quinn Grundy
- School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Katrina Hutchison
- Department of Philosophy, Macquarie University, Sydney, NSW, Australia
| | - Jane Johnson
- Department of Philosophy, Macquarie University, Sydney, NSW, Australia
| | - Brette Blakely
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Robyn Clay-Wlliams
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | | | - Wendy A Rogers
- Department of Philosophy, Macquarie University, Sydney, NSW, Australia
- Department of Clinical Medicine, Macquarie University, Sydney, NSW, Australia
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Haugaa KH, Potpara TS, Boveda S, Deharo JC, Chen J, Dobreanu D, Fumagalli S, Lenarczyk R, Hernandez Madrid A, Larsen TB, Sciarrafia E, Taborsky M, Tilz RR, Pieragnoli P, Przybylski A, Dagres N. Patients’ knowledge and attitudes regarding living with implantable electronic devices: results of a multicentre, multinational patient survey conducted by the European Heart Rhythm Association. Europace 2017; 20:386-391. [DOI: 10.1093/europace/eux365] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/19/2017] [Indexed: 01/02/2023] Open
Affiliation(s)
- Kristina Hermann Haugaa
- Department of Cardiology and Institute for Surgical Research, Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Serbia
| | - Serge Boveda
- Division of Cardiology, Cardiac Arrhythmias Management Department, Clinique Pasteur, Toulouse, France
| | - Jean-Claude Deharo
- Service de Cardiologie—Hôpital Timone Adultes, 264 Rue Saint Pierre, Marseille, 13385 Cedex 05, France
| | - Jian Chen
- Department of Heart Disease, Haukeland University Hospital, 5021 Bergen, Norway
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
| | - Dan Dobreanu
- Cardiology Clinic, Emergency Institute for Cardiovascular Diseases and Transplant, University of Medicine and Pharmacy, Tirgu Mures, Romania
| | - Stefano Fumagalli
- Intensive Care Unit, Geriatric Cardiology and Medicine Division, Experimental and Clinical Medicine Department, University of Florence and AOU Careggi, Florence, Italy
| | - Radoslaw Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Zabrze, Poland
| | | | - Torben Bjerregaard Larsen
- Department of Cardiology, Thrombosis & Drug Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Elena Sciarrafia
- Department of Cardiology, Institution of Medical Science, Uppsala University, Uppsala, Sweden
| | - Milos Taborsky
- Department of Internal Medicine I—Cardiology, Palacký University Olomouc, Olomouc, Czech Republic
| | - Roland Richard Tilz
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Paolo Pieragnoli
- Unità di Aritmologia, Dipartimento Cardiotoracovascolare, University of Florence, Florence, Italy
| | - Andrzej Przybylski
- Head of the Department of Cardiology, KSW 2, Rzeszów, Poland
- Faculty of Medicine, University of Rzeszów, Rzeszów, Poland
| | - Nikolaos Dagres
- Department of Electrophysiology, University Leipzig - Heart Center, 04289 Leipzig, Germany
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