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Sanna GD, Nusdeo G, Marini A, Ganga ML, Mura E, Pisano M, Sabino G, Parodi G. Outcomes of single‑lead VDD pacemakers in atrioventricular blocks: The OSCAR study. Int J Cardiol 2020; 325:62-68. [PMID: 32987050 DOI: 10.1016/j.ijcard.2020.09.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/17/2020] [Accepted: 09/22/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND VDD pacemakers are regarded as a second choice in patients with atrio-ventricular blocks mainly due to the potential failure of atrial sensing, leading to a loss of atrio-ventricular synchrony. This single-centre study aimed to evaluate the prevalence of loss of atrial sensing and its potential determinants in patients with VDD pacemakers. METHOD 142 patients with an implanted VDD device underwent long-term follow-up with clinical evaluation, electrocardiogram, device interrogation and echocardiogram. RESULTS Over a long follow-up period [median 110 (68-156) months], 17 patients (12%) in sinus rhythm presented loss of atrial sensing. This was most often intermittent, but three patients required a permanent switch to VVI mode. ECG showed higher prevalence of interatrial blocks (50% vs 26.6%, p = 0.057) and longer P wave duration (116 ± 19 vs 105 ± 15 ms, p = 0.019) in patients with loss of atrial sensing. Echocardiography revealed larger left atrial (LA) volumes (p < 0.05) in patients with loss of atrial sensing, and lower LA ejection fraction (0.40 vs 0.47, p = 0.0037) and expansion index (0.63 ± 0.26 vs 0.90 ± 0.31, p = 0.003). P wave duration on ECG proved to be independently associated with loss of atrial sensing on multivariable analysis (OR 1.062, 95% CI 1.015-1.110; p = 0.008). The prevalence of atrial fibrillation and subsequent switch to VVI mode was high (16%). CONCLUSIONS In the long-term follow-up, the loss of atrial sensing is present in 12% of patients with implanted VDD pacemakers. ECG and echocardiographic parameters may serve as screening tools for the detection of atrial myopathy which is associated with the loss of atrial sensing.
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Affiliation(s)
- Giuseppe D Sanna
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy.
| | - Giuseppe Nusdeo
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy.
| | - Alessandro Marini
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Maria Luisa Ganga
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Enrico Mura
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Mauro Pisano
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Giuseppe Sabino
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Guido Parodi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy.
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Chan WK, Danon A, Wijeysundera HC, Singh SM. Single Versus Dual Lead Atrioventricular Sequential Pacing for Acquired Atrioventricular Block During Transcatheter Aortic Valve Implantation Procedures. Am J Cardiol 2018; 122:633-637. [PMID: 30205889 DOI: 10.1016/j.amjcard.2018.04.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/23/2018] [Accepted: 04/23/2018] [Indexed: 11/25/2022]
Abstract
Atrioventricular block (AVB) after transcatheter aortic valve implantation (TAVI) is common. Pacing platforms that preserve atrioventricular (AV) synchrony may be beneficial in these patients. Single lead AV sequential pacemakers (VDD) allow AV synchrony and, by virtue of implanting a single lead, can be advantageous when compared with traditional dual lead (DDD) pacemakers. The objective of this retrospective case-controlled study was to compare the strategy of AV sequential pacing with a VDD versus DDD pacemaker in consecutive TAVI patients (n = 120) with acquired AVB. Patients were classified as receiving a VDD (n = 73) or DDD (n = 47) pacemaker. Procedure characteristics, complications, and the need for long-term ventricular pacing reported. Pacemaker implantation time (51 vs 66 minutes and p <0.001), fluoroscopy time (3.7 vs 7.8 minutes and p = 0.004), and radiation exposure (dose area product: 6.5 vs 15.3 mGy/cm2 and p = 0.006) were lower in patients receiving VDD pacemakers. Procedural complications were similar in the 2 groups. Overall, 59% of the cohort required ≥50% ventricular pacing at 1-year follow-up. In conclusion, VDD pacemaker implantation was associated with shorter procedure times, lower radiation exposure, and similar safety outcomes when compared with DDD pacemaker implantation in TAVI patients with acquired AVB.
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Palmisano P, Ziacchi M, Biffi M, Ricci RP, Landolina M, Zoni-Berisso M, Occhetta E, Maglia G, Botto G, Padeletti L, Boriani G. Clinically oriented device programming in bradycardia patients. J Cardiovasc Med (Hagerstown) 2018; 19:170-180. [DOI: 10.2459/jcm.0000000000000629] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Liao JN, Chao TF, Tuan TC, Kong CW, Chen SA. Long-term outcome in patients receiving permanent pacemaker implantation for atrioventricular block: Comparison of VDD and DDD pacing. Medicine (Baltimore) 2016; 95:e4668. [PMID: 27583889 PMCID: PMC5008573 DOI: 10.1097/md.0000000000004668] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A permanent pacemaker (PPM) with dual chamber pacing (DDD) offers atrioventricular synchronization for patients with atrioventricular block (AVB). Single lead atrial synchronous ventricular pacing mode (VDD) is an alternative, but there are concerns about its efficacy and risk of atrial undersensing. Whether VDD can be a good alternative in patients with AVB remains unknown. The aim of the present study was to compare the long-term risk of mortality of VDD with DDD pacing.A total of 207 patients undergoing PPM implantations for AVB with VDD mode were enrolled from 2000 to 2013. Another 828 age- and sex-matched patients undergoing DDD implantations during the same period of time were selected as the control group in a 1 to 4 ratio. The study endpoint was mortality.A total of 1035 patients (64.3% male) were followed up for 46.5 ± 43.2 months. The mean ages were 75.0 years for VDD, and 74.9 years for DDD. The Kaplan-Meier survival analysis showed no significant difference in long-term survival between the VDD and DDD groups (log-rank P = 0.313). After adjustment for baseline characteristics, the VDD and DDD groups had a similar long-term prognosis with an adjusted hazard ratio of 0.875 (P = 0.445). Further analyses for the risk of cardiovascular and noncardiovascular deaths also showed no significant differences between the 2 groups.The long-term prognosis of VDD mode is comparable to that of DDD mode. Single lead VDD can be considered as an alternative choice in patients with AVB without sinus nodal dysfunction.
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Affiliation(s)
- Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University
- Division of Cardiology, Taipei Municipal Gan-Dau Hospital
- Correspondence: Ta-Chuan Tuan, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan (e-mail: )
| | - Chi-Woon Kong
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University
- Division of Cardiology, Department of Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University
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5
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Wiegand UKH. Single-lead VDD pacing--a serious alternative for atrioventricular synchronous pacing in patients with atrioventricular block? Europace 2011; 14:461-2. [DOI: 10.1093/europace/eur408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Marchandise S, Scavee C, le Polain de Waroux JB, de Meester C, Vanoverschelde JL, Debbas N. Long-term follow-up of DDD and VDD pacing: a prospective non-randomized single-centre comparison of patients with symptomatic atrioventricular block. Europace 2011; 14:496-501. [DOI: 10.1093/europace/eur345] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Nowak B, Przibille O. Atrial undersensing in VDD pacing: should we blame calcium-channel blockers? Europace 2010; 12:1205-6. [DOI: 10.1093/europace/euq281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Huang CC, Tuan TC, Fong MC, Lee WS, Kong CW. Predictors of inappropriate atrial sensing in long-term VDD-pacing systems. Europace 2010; 12:1251-5. [DOI: 10.1093/europace/euq190] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nowak B, Misselwitz B, Erdogan A, Funck R, Irnich W, Israel CW, Olbrich HG, Schmidt H, Sperzel J, Zegelman M. Do gender differences exist in pacemaker implantation?--results of an obligatory external quality control program. Europace 2009; 12:210-5. [PMID: 19864309 DOI: 10.1093/europace/eup312] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS The aim of the study was to evaluate the effects of patient gender onto primary pacemaker implantation, evaluating the database of the Institute of Quality Assurance Hessen in the federal state of Hessen, Germany. METHODS AND RESULTS The database of the obligatory external quality control program for the years 2003-2006 was evaluated retrospectively. In 72 centres, 17 826 patients undergoing stationary primary pacemaker implantation have been registered. Male patients had more AV blocks when compared with women and less sick sinus syndrome and atrial fibrillation with bradycardia. In patients being 80 years and older, men received significantly more dual-chamber devices than women for the indications: AV block and sick sinus syndrome. In women, atrial pacing thresholds were significantly higher and P-wave amplitudes were significantly lower. Women had, independent from age or pacing system implanted, significantly more acute complications than men, with significant differences for pneumothorax and pocket haematoma. CONCLUSION This large-scale real-life patient cohort of primary stationary pacemaker implantation showed that gender has an impact onto pacemaker implantation, with less favourable outcomes for women.
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Affiliation(s)
- Bernd Nowak
- Cardiovascular Centre Bethanien, Im Pruefling 23, D-60389 Frankfurt a.M, Germany.
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Nowak B, Misselwitz B. Effects of increasing age onto procedural parameters in pacemaker implantation: results of an obligatory external quality control program. Europace 2008; 11:75-9. [DOI: 10.1093/europace/eun293] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Eberhardt F, Bonnemeier H, Lipphardt M, Hofmann UG, Schunkert H, Wiegand UKH. Atrial near-field and ventricular far-field analysis by automated signal processing at rest and during exercise. Ann Noninvasive Electrocardiol 2006; 11:118-26. [PMID: 16630085 PMCID: PMC7479926 DOI: 10.1111/j.1542-474x.2006.00092.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Sophisticated monitoring of atrial activity is a prerequisite for modern pacemaker therapy. Ideally, near-fields and ventricular far-fields ought to be distinguished by beat-to-beat template analysis of the atrial signal. A prerequisite is that atrial signals are stable under different conditions. METHODS AND RESULTS A Matlab routine was developed to analyze atrial electrograms of 23 patients at least 3 months after implantation of a dual chamber pacemaker under several conditions including at rest, bipolar at rest, in an upright position, during treadmill exercise, and postexercise. A near-field and far-field template was created and amplitudes, widths, and slew rates were measured. In bipolar configuration, near-field amplitude at rest was 3.04 +/- 0.94 mV (unipolar)/3.36 +/- 1.0 mV (bipolar) versus 3.18 +/- 1.0 mV (bipolar) at peak exercise. Far-field amplitude at rest was 1.66 +/- 1.18 (unipolar)/0.47 +/- 0.27 mV (bipolar) and 0.41 +/- 0.21 mV (bipolar) at peak exercise (n.s. for bipolar measurements). No overall significant changes were observed for near- and far-field widths and slew rates during exercise. Shorter tip-ring distances of the atrial bipole, lead position, and the presence of sinus node disease did not have any impact on overall near- and far-field signal characteristics. Intraindividual differences between rest and peak exercise were moderate (range: near-field +0.15 to -0.54 mV; range: far-field +0.05 to -0.18 mV). CONCLUSIONS Atrial near and far fields can be automatically classified and quantified by automated signal processing. Signals did not change during exercise or change of posture. This is a prerequisite for the implementation of beat-to-beat template analysis into pacemakers.
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Affiliation(s)
- Frank Eberhardt
- University Hospital Schleswig Holstein, Campus Luebeck, Medicine II, Luebeck, Germany.
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Eberhardt F, Bode F, Bonnemeier H, Boguschewski F, Schlei M, Peters W, Wiegand UKH. Long term complications in single and dual chamber pacing are influenced by surgical experience and patient morbidity. Heart 2005; 91:500-6. [PMID: 15772212 PMCID: PMC1768857 DOI: 10.1136/hrt.2003.025411] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE To determine how short and long term complication rates after pacemaker implantation are influenced by patient morbidity, operator experience, and choice of pacing system. DESIGN Retrospective analysis of 1884 patients who received VVI (n = 610), VDD (n = 371), or DDD devices (n = 903) between 1990 and 2001. Follow up period was 64 (34) months. The influence of age, sex, coronary artery disease, myocardial infarction, reduced left ventricular (LV) function, right ventricular (RV) dilatation, atrial fibrillation, device type, and operator experience on operation time and complication rate were analysed. RESULTS Operation time was prolonged in patients with coronary artery disease, inferior myocardial infarction, reduced LV function, and RV dilatation. Implantation of DDD pacemakers prolonged operation time, particularly among operators with a low or medium level of experience. The overall complication rate was 4.5%. Sixty seven per cent of these complications occurred within the first three months. Complication rate was increased by age, reduced LV function, and RV dilatation. Implantation of DDD systems led to a higher complication rate (6.3%) than implantation of VVI (2.6%) or VDD pacemakers (3.2%). These differences were present only among operators with a low or medium level of experience. CONCLUSIONS Operation time and complication rate increased with age, impaired LV function, and RV dilatation. Complication rates were higher with DDD than with VVI or VDD implantation and were excessive among inexperienced but not experienced operators.
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Affiliation(s)
- F Eberhardt
- Universitätsklinik Schleswig Holstein, Campus Luebeck, Medizinische Klinik II, Ratzeburger Allee 160, 23538 Luebeck, Germany.
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Wiegand UKH, Bode F, Bonnemeier H, Eberhard F, Schlei M, Peters W. Long-Term Complication Rates in Ventricular, Single Lead VDD, and Dual Chamber Pacing. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2003; 26:1961-9. [PMID: 14516336 DOI: 10.1046/j.1460-9592.2003.00303.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A higher incidence of pacemaker related complications has been reported in DDD systems as compared to VVI devices. The implantation of single lead VDD pacemakers might reduce the complication rate of physiological pacing in patients with AV block. In a retrospective study, the data records of 1,214 consecutive patients with pacemaker implantation for AV block between 1990 and 2001 (VVI 36.5%, DDD 32.9%, VDD 30.6%) were analyzed. Complications requiring surgical interventions were compared during a follow-up period of 64 +/- 31 months. Operation and fluoroscopic times were longer in DDD pacemaker implantation compared to VDD and VVI devices:58 +/- 23 versus 39 +/- 10 and 37 +/- 13 minutes (P<0.001), 9.2 +/- 5.2 versus 4.1 +/- 2.4 and 3.5 +/- 2.3 minutes, respectively. Differences remained significant after correction for covariates. In a multivariate Cox regression model, the corrected complication hazard of a DDD pacemaker implantation was increased by 3.9 (1.4-11.3) compared to VVI and increased by 2.3 (1.1-4.5) compared to VDD pacing. Higher complication rates in DDD pacing were mainly due to a higher incidence of early reoperation for atrial lead dysfunction, whereas the long-term complication rate was not different from VDD or VVI pacing. Early and long-term complication rates did not differ between VDD and VVI pacemaker systems. In conclusion, operation time and complication rates of physiological pacing are reduced by VDD pacemaker implantation achieving values comparable to VVI pacing. Thus, single lead VDD pacing can be recommended for patients with AV block.
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Affiliation(s)
- Uwe K H Wiegand
- University of Lübeck, Medizinische Klinik II, Lübeck, Germany.
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Higashi Y, Sato T, Shimojima H, Takeyama Y, Goto K, Mitsuya T, Sagawa F, Ishikawa R, Ishikawa Y. Mechanism of decrease in the atrial potential after implantation of a single-lead VDD pacemaker: atrial histological changes after implantation of a VDD pacemaker lead in dogs. Pacing Clin Electrophysiol 2003; 26:685-91. [PMID: 12698668 DOI: 10.1046/j.1460-9592.2003.00118.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The single-lead VDD pacemaker system (VDDPS) enables atrial synchronous ventricular pacing with only one lead in patients with an atrioventricular block. There are some cases in which the atrial potential decreases after implantation of a VDDPS, making physiological pacing difficult. The mechanism of this decrease has not been elucidated yet. To elucidate the possible relationship between the decrease of the atrial potential after implantation of a VDDPS and histopathological changes of the atrium. We implanted a VDDPS from the jugular vein under anesthesia in 10 adult dogs. The tip of the pacing lead was fixed in the right ventricular apex of the heart under fluoroscopic guidance. Then, the lead was ligated and fixed to the jugular vein at a point where a favorable atrial potential was obtained. The end of the lead was passed from the neck to the back subcutaneously; then pulled outside and fixed there to measure the atrial potential. The atrial potential was measured using a pacing system analyzer under anesthesia on days 3 (n = 9) and 7 (n = 8), as well as on weeks 2 (n = 6), 3 (n = 4), and 4 (n = 3), after the implantation. The heart was removed from the dogs on day 3 (n = 2), day 7 (n = 2), week 2 (n = 2), and week 4 (n = 4) to examine the atrial histological findings. The atrial potential was 2.7 +/- 0.7 mV at the time of the implantation, 1.7 +/- 1.1 mV (P < 0.05) on day 3, and 1.7 +/- 0.7 mV on week 4 after the implantation. Macroscopically, the pacemaker lead was covered with thrombus, and adhered to the atrial wall in 80% of animals. Microscopically, the endocardium was hypertrophic due to fibrous tissue; besides RBC extravasation, inflammatory cells infiltration and degeneration of myocardial cells, were observed under the endocardium. Inflammatory changes developed in the atrial wall after implantation of the VDDPS, and this seemed to be one of the mechanisms for the decrease of the atrial potential of the VDDPS.
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Affiliation(s)
- Yukei Higashi
- Cardiovascular Division, Showa University Fujigaoka Hospital, 1-30 Fujigaoka Aoba-ku, Yokohama, Japan 227-8501.
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Pollak WM, Simmons JD, Interian A, Castellanos A, Myerburg RJ, Mitrani RD. Pacemaker diagnostics: a critical appraisal of current technology. Pacing Clin Electrophysiol 2003; 26:76-98. [PMID: 12685144 DOI: 10.1046/j.1460-9592.2003.00154.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Diagnostic information retrieved from a pacemaker offers the ability to improve patient care. Pacemaker diagnostic data provides information regarding pacemaker function and activity, lead function, arrhythmia occurrence, and data to aid in optimal pacemaker programming. Current pacemakers incorporate greater storage capabilities, more efficient means of storing and presenting data between follow-up visits, and more options for programming diagnostic functions and algorithms. The cardiac rhythm of the paced patient can be evaluated via real-time intracardiac electrograms at interrogation, surface electrocardiograms, ambulatory electrocardiograms, and by pacemaker stored diagnostic function that may include stored intracardiac electrograms. This article focuses on the various methods of obtaining diagnostic information regarding pacemaker activity, pacemaker function, and diagnostic information on cardiac arrhythmias. The current clinical applicability and limitations of these methods and the use of stored diagnostic data in the clinical follow-up and study of patients with pacemakers is discussed.
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Affiliation(s)
- Wayne M Pollak
- Department of Medicine, Division of Cardiology, University of Miami Medical Center, Miami, Florida, USA
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Chiladakis JA, Patsouras N, Agelopoulos G, Nikolopoulos N, Manolis AS. Comparative three-year performance of chronic atrial sensing among eight different VDD systems. Am J Cardiol 2002; 89:1215-8. [PMID: 12008181 DOI: 10.1016/s0002-9149(02)02310-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- John A Chiladakis
- Cardiology Department, Patras University Hospital, Rio, Patras, Greece
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