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Jáuregui B, Fernández-Armenta J, Acosta J, Penela D, Terés C, Ordóñez A, Soto-Iglesias D, Silva E, Chauca A, Carreño JM, Scherer C, Pedrote A, Berruezo A. MANual vs. automatIC local activation time annotation for guiding Premature Ventricular Complex ablation procedures (MANIaC-PVC study). Europace 2021; 23:1285-1294. [PMID: 33846728 DOI: 10.1093/europace/euab080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/17/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS To assess potential benefits of a local activation time (LAT) automatic acquisition protocol using wavefront annotation plus an ECG pattern matching algorithm [automatic (AUT)-arm] during premature ventricular complex (PVC) ablation procedures. METHODS AND RESULTS Prospective, randomized, controlled, and international multicentre study (NCT03340922). One hundred consecutive patients with indication for PVC ablation were enrolled and randomized to AUT (n = 50) or manual (MAN, n = 50) annotation protocols using the CARTO3 navigation system. The primary endpoint was mapping success. Clinical success was defined as a PVC-burden reduction of ≥80% in the 24-h Holter within 6 months after the procedure. Mean age was 56 ± 14 years, 54% men. The mean baseline PVC burden was 25 ± 13%, and mean left ventricular ejection fraction (LVEF) 55 ± 11%. Baseline characteristics were similar between the groups. The most frequent PVC-site of origin were right ventricular outflow tract (41%), LV (25%), and left ventricular outflow tract (17%), without differences between groups. Radiofrequency (RF) time and number of RF applications were similar for both groups. Mapping and procedure times were significantly shorter in the AUT-arm (25.5 ± 14.3 vs. 32.8 ± 12.6 min, P = 0.009; and 54.8 ± 24.8 vs. 67.4 ± 25.2, P = 0.014, respectively), while more mapping points were acquired [136 (94-222) AUT vs. 79 (52-111) MAN; P < 0.001]. Mapping and clinical success were similar in both groups. There were no procedure-related complications. CONCLUSION The use of a complete automatic protocol for LAT annotation during PVC ablation procedures allows to achieve similar clinical endpoints with higher procedural efficiency when compared with conventional, manual annotation carried out by expert operators.
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Affiliation(s)
- Beatriz Jáuregui
- Heart Institute, Teknon Medical Center, C/Vilana, 12, 08022 Barcelona, Spain
| | | | - Juan Acosta
- Virgen del Rocío University Hospital, Sevilla, Spain
| | - Diego Penela
- Heart Institute, Teknon Medical Center, C/Vilana, 12, 08022 Barcelona, Spain.,Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Cheryl Terés
- Heart Institute, Teknon Medical Center, C/Vilana, 12, 08022 Barcelona, Spain
| | - Augusto Ordóñez
- Heart Institute, Teknon Medical Center, C/Vilana, 12, 08022 Barcelona, Spain
| | - David Soto-Iglesias
- Heart Institute, Teknon Medical Center, C/Vilana, 12, 08022 Barcelona, Spain
| | | | - Alfredo Chauca
- Heart Institute, Teknon Medical Center, C/Vilana, 12, 08022 Barcelona, Spain
| | - José M Carreño
- Heart Institute, Teknon Medical Center, C/Vilana, 12, 08022 Barcelona, Spain
| | - Claudia Scherer
- Heart Institute, Teknon Medical Center, C/Vilana, 12, 08022 Barcelona, Spain
| | | | - Antonio Berruezo
- Heart Institute, Teknon Medical Center, C/Vilana, 12, 08022 Barcelona, Spain
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Su C, Xue Y, Li T, Liu M, Liu Y, Deng H, Li J, Jiang J, Ma Y, Feng C, Liu J, Tang A, Dong Y, He J, Wang L. Electrophysiological characteristics of epicardial to endocardial breakthrough in intractable cavotricuspid isthmus-dependent atrial flutter. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:462-471. [PMID: 33433929 DOI: 10.1111/pace.14164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/24/2020] [Accepted: 01/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Epicardial to endocardial breakthrough (EEB) exists widely in atrial arrhythmia and is a cause for intractable cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL). This study aimed to investigate the electrophysiological features of EEB in EEB-related CTI dependent AFL. METHODS Six patients with EEB-related CTI-dependent AFL were identified among 142 consecutive patients who underwent CTI-dependent AFL catheter ablation with an ultra-high-density, high-resolution mapping system in three institutions. Activation maps and ablation procedure were analyzed. RESULTS A total of seven EEBs were found in six patients. Four EEBs (including three at the right atrial septum and one in paraseptal isthmus) were recorded in three patients during tachycardia. The other three EEBs were identified at the inferolateral right atrium (RA) during pacing from the coronary sinus. The conduction characteristics through the EEB-mediated structures were evaluated in three patients. Two patients only showed unidirectional conduction. Activation maps indicated that CTI-dependent AFL with EEB at the atrial septum was actually bi-atrial macro-reentrant atrial tachycardia (BiAT). Intensive ablation at the central isthmus could block CTI bidirectionally in four cases. However, ablation targeted at the inferolateral RA EEB was required in two cases. Meanwhile, local potentials at the EEB location gradually split into two components with a change in activation sequence. CONCLUSIONS EEB is an underlying cause for intractable CTI-dependent AFL. EEB-mediated structure might show unidirectional conduction. CTI-dependent AFL with EEB at the atrial septum may represent BiAT. Intensive ablation targeting the central isthmus or EEB at the inferolateral RA could block the CTI bidirectionally.
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Affiliation(s)
- Chen Su
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yumei Xue
- Department of Cardiology, The People's Hospital of Guangdong Province, Guangzhou, Guangdong, People's Republic of China
| | - Teng Li
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Science (Shenzhen, Shenzhen, Guangdong, People's Republic of China
| | - Menghui Liu
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yang Liu
- Department of Cardiology, The People's Hospital of Guangdong Province, Guangzhou, Guangdong, People's Republic of China
| | - Hai Deng
- Department of Cardiology, The People's Hospital of Guangdong Province, Guangzhou, Guangdong, People's Republic of China
| | - Jie Li
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Jingzhou Jiang
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yuedong Ma
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Chong Feng
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Jun Liu
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Anli Tang
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yugang Dong
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Jiangui He
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Lichun Wang
- Department of Cardiology, Key Laboratory on Assisted Circulation, Ministry of Health, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
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Campbell T, Bennett RG, Kotake Y, Kumar S. Updates in Ventricular Tachycardia Ablation. Korean Circ J 2021; 51:15-42. [PMID: 33377327 PMCID: PMC7779814 DOI: 10.4070/kcj.2020.0436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
Sudden cardiac death (SCD) due to recurrent ventricular tachycardia is an important clinical sequela in patients with structural heart disease. As a result, ventricular tachycardia (VT) has emerged as a major clinical and public health problem. The mechanism of VT is predominantly mediated by re-entry in the presence of arrhythmogenic substrate (scar), though focal mechanisms are also important. Catheter ablation for VT, when compared to standard medical therapy, has been shown to improve VT-free survival and burden of device therapies. Approaches to VT ablation are dependent on the underlying disease process, broadly classified into idiopathic (no structural heart disease) or structural heart disease (ischemic or non-ischemic heart disease). This update aims to review recent advances made for the treatment of VT ablation, with respect to current clinical trials, peri-procedure risk assessments, pre-procedural cardiac imaging, electro-anatomic mapping and advances in catheter and non-catheter based ablation techniques.
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Affiliation(s)
- Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia.
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Ng J, Chhachhi B, Stobie P, Keren A, Popal S, Reichlin T. Noncentrifugal activation patterns in focal RVOT PVC/VT: New insights from high density multielectrode mapping. J Cardiovasc Electrophysiol 2020; 32:102-109. [PMID: 33118678 DOI: 10.1111/jce.14796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/15/2020] [Accepted: 10/18/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Activation from an automatic focus is thought to show centrifugal spread. In patients with premature ventricular complex/ventricular tachycardia (PVC/VT) from the right ventricular outflow tract (RVOT), the presence of preferential conduction and epicardial connections could however also lead to noncentrifugal wavefront propagation. OBJECTIVE To study endocardial activation in RVOT PVC/VT using high-resolution 3D activation mapping. METHODS Consecutive patients with frequent idiopathic PVC/VT were studied. High-resolution 3D activation maps were acquired using a multielectrode mapping catheter (Orion, Rhythmia, Boston Scientific). Noncentrifugal activation was defined as a pattern of wavefront propagation which does not show uniform propagation in all directions from one focus. Patients without sustained ablation success and patients with a left-sided PVC origin or with insufficient map density were excluded from the analysis. RESULTS Sixteen patients (44% female) with a median age of 54 years (interquartile range [IQR], 47-64) and a median PVC burden of 19% (IQR, 15-27) were studied. High-resolution activation maps consisting of a median number of 1863 mapping points (IQR, 1195-2463 points) demonstrated a centrifugal activation in 6/16 (38%) and a noncentrifugal activation in 10/16 (62%). When comparing patients with centrifugal and noncentrifugal activation, patients with centrifugal activation were older (p = .01), but no differences were found in age, gender, QRS duration of the PVC's and sites of origin in the RVOT. No procedural complications occurred. CONCLUSIONS High-resolution multielectrode mapping demonstrates the presence of noncentrifugal activation patterns in some of the patients with idiopathic RVOT PVC/VT. This may indicate the presence of preferential conduction and or epicardial/intramural connections in the outflow tract.
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Affiliation(s)
- Justin Ng
- Sir Charles Gairdner Hospital, Nedlands, Australia
| | | | - Paul Stobie
- Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Arieh Keren
- Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Sohail Popal
- Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Liu M, Yang D, Su C, Li J, Jiang J, Ma Y, Feng C, Liu J, Tang A, Dong Y, He J, Wang L. Automatic annotation of local activation time was improved in idiopathic right ventricular outflow tract ventricular arrhythmia by novel electrogram "Lumipoint" algorithm. J Interv Card Electrophysiol 2020; 61:79-85. [PMID: 32468325 DOI: 10.1007/s10840-020-00773-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Precise automatic annotation of local activation time (LAT) is crucial for rapid high-density activation mapping in arrhythmia. However, it is still challenging in voltage-transitional areas where local low-amplitude near-field potentials are often obscured by large far-field potentials. The aim of this study was to explore the viability and validity of automatic identification of the earliest activation (EA) in idiopathic right ventricular outflow tract ventricular arrhythmias (RVOT VAs) using a novel Lumipoint algorithm. METHODS AND RESULTS Twenty-seven patients with RVOT VAs were mapped with Rhythmia mapping system. Lumipoint algorithms were applied to reannotate the initial activation regions retrospectively. The results showed that LATs were reannotated in 35.0 ± 11.4% points in the initial activation area from bipolar activation breakout time (BBO) to the its 40 ms earlier timepoint. The automatically determined bipolar earliest activation time after Lumipoint reannotation (BEAT-lu: - 111.26 ± 12.13 ms) was significantly earlier than that before (BEAT: - 108.67 ± 12.25 ms, P = 0.000). Compared with manually corrected earliest activation time (EAT), the difference between EAT and BEAT-lu (DEAT-BEAT-lu: 6 (2-7) ms) was significantly smaller than that between EAT and BEAT (DEAT-BEAT/DEAT-UEA: 7 (4-11) ms, P = 0.000). The incidence of EAT and BEAT-lu being the same site was significantly higher than that between EAT and BEAT (48.15% vs 18.52%, P = 0.021). CONCLUSIONS RVOT VAs often originate from voltage-transitional zone, and automatic annotation of LAT usually located at later high-amplitude far-field potential. Lumipoint algorithms could improve the accuracy of LAT automatic annotation, and it was plausible to ablate RVOT VAs just according to the automatically annotated BEAS-lu.
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Affiliation(s)
- Menghui Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Daya Yang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Chen Su
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jie Li
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jingzhou Jiang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Yuedong Ma
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Chong Feng
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jun Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Anli Tang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jiangui He
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. .,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China.
| | - Lichun Wang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. .,Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, 510080, Guangdong, People's Republic of China.
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Campbell T, Trivic I, Bennett RG, Anderson RD, Turnbull S, Pham T, Nalliah C, Kizana E, Watts T, Lee G, Kumar S. Catheter ablation of ventricular arrhythmia guided by a high-density grid catheter. J Cardiovasc Electrophysiol 2020; 31:474-484. [PMID: 31930658 DOI: 10.1111/jce.14351] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/12/2019] [Accepted: 12/15/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Minimal data exist on the Advisor HD Grid (HDG) catheter and the Precision electroanatomic mapping (EAM) system for ventricular arrhythmia (VA) procedures. Using the HDG catheter, the EAM uses the high-density (HD) wave mapping and best duplicate software to compare the maximum peak-to-peak bipolar voltages within a small zone independent of wavefront direction and catheter orientation. This study aimed to summarize the procedural experience for VAs using the HDG catheter. METHODS Clinical and procedural characteristics of VA ablation procedures were retrospectively reviewed that used the HDG catheter and the Precision EAM over a 12-month period. RESULTS A total of 22 patients, 18 with sustained ventricular tachycardia and 4 with premature ventricular contractions were included. Clinically indicated left and/or right ventricular (LV, RV, respectively), and aortic maps were created. LV substrate maps (n = 13) used a median 1700 points (interquartile range [IQR]25%-75% , 1427-2412) out of a median 18 573 (IQR25%-75% , 15 713-41 067) total points collected. RV substrate maps (n = 11) used a median 1435 points (IQR25%-75% , 1114-1871) out of a median 16 005 (IQR25%-75% , 11 063-21 405) total points collected. Total point utilization, used vs collected, was 9%. Mean mapping time was 43 ± 17 minutes (substrate, 34 ± 18 minutes; activation/pace mapping, 9 ± 13 minutes). Acute success was achieved in 56 (86%) and short-term success achieved in 16 patients (73%) at a median follow-up of 145 days (IQR25%-75% , 62-273 days). There were no procedural complications. CONCLUSION HD wave mapping using the novel HDG catheter integrated with the Precision EAM is safe and feasible in VA procedures in the LV, RV, and aorta. Mapping times are consistent with other multielectrode mapping catheters.
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Affiliation(s)
- Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Ivana Trivic
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Robert D Anderson
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Timmy Pham
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Chrishan Nalliah
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Eddy Kizana
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
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