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Verma Y, Arachchige ASPM. Revolutionizing cardiovascular care: the power of histotripsy. J Ultrasound 2024:10.1007/s40477-023-00848-7. [PMID: 38217765 DOI: 10.1007/s40477-023-00848-7] [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: 09/28/2023] [Accepted: 11/13/2023] [Indexed: 01/15/2024] Open
Abstract
Histotripsy, an innovative ultrasonic technique, is poised to transform the landscape of cardiovascular disease management. This review explores the multifaceted applications of histotripsy across various domains of cardiovascular medicine. In thrombolysis, histotripsy presents a non-invasive, drug-free, and precise method for recanalizing blood vessels obstructed by clots, minimizing the risk of vessel damage and embolism. Additionally, histotripsy showcases its potential in congenital heart defect management, offering a promising alternative to invasive procedures by creating intracardiac communications noninvasively. For patients with calcified aortic stenosis, histotripsy demonstrates its effectiveness in softening calcified bioprosthetic valves, potentially revolutionizing valve interventions. In the realm of arrhythmias, histotripsy could play an important role in scar-based ventricular tachycardia ablation, eliminating channel-like isthmuses of slowly conducting myocardium. Histotripsy`s potential applications also extend to structural heart interventions, enabling the safe sectioning of basal chordae and potentially addressing mitral regurgitation. Furthermore, it showcases its versatility by safely generating ventricular septal defects, providing a non-invasive means of creating intracardiac communications in neonates with congenital heart disease. Yet, most supporting studies are in-vitro or animal studies and there are possible challenges in translating experimental data on cardiac histotripsy to the clinical level. As histotripsy continues to evolve and mature, its remarkable potential in cardiovascular disease management holds promise for improving patient outcomes and reducing the burden of invasive procedures in the field of cardiology.
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Affiliation(s)
- Yash Verma
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
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2
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Ravi V, Winterfield J, Liang J, Larsen T, Dye C, Sanders D, Skeete J, Payne J, Trohman RG, Aksu T, Sharma PS, Huang HD. Solving the Reach Problem: A Review of Present and Future Approaches for Addressing Ventricular Arrhythmias Arising from Deep Substrate. Arrhythm Electrophysiol Rev 2023; 12:e04. [PMID: 37600155 PMCID: PMC10433105 DOI: 10.15420/aer.2022.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/26/2022] [Indexed: 08/22/2023] Open
Abstract
Ventricular tachycardia (VT) is a significant cause of morbidity and mortality in patients with ischaemic and non-ischaemic cardiomyopathies. In most patients, the primary strategy of VT catheter ablation is based on the identification of critical components of reentry circuits and modification of abnormal substrate which can initiate reentry. Despite technological advancements in catheter design and improved ability to localise abnormal substrates, putative circuits and site of origins of ventricular arrhythmias (VAs), current technologies remain inadequate and durable success may be elusive when the critical substrate is deep or near to critical structures that are at risk of collateral damage. In this article, we review the available and potential future non-surgical investigational approaches for treatment of VAs and discuss the viability of these modalities.
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Affiliation(s)
- Venkatesh Ravi
- Saint Francis Heart and Vascular Institute, Tulsa, OK, US
| | - Jeffrey Winterfield
- Department of Cardiology, Medical University of South Carolina, Charleston, SC, US
| | - Jackson Liang
- Department of Cardiology, University of Michigan, Ann Arbor, MI, US
| | - Timothy Larsen
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Cicely Dye
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - David Sanders
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Jamario Skeete
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Josh Payne
- Department of Cardiology, University of Michigan, Ann Arbor, MI, US
| | - Richard G Trohman
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Parikshit S Sharma
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Henry D Huang
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
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Huang W, Ning C, Zhang R, Xu J, Chen B, Li Z, Cui Y, Shao W. Evaluation of the dual-frequency transducer for controlling thermal ablation morphology using frequency shift keying signal. Int J Hyperthermia 2022; 39:1344-1357. [PMID: 36223887 DOI: 10.1080/02656736.2022.2130999] [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: 10/17/2022] Open
Abstract
PURPOSE The catheter-based ultrasound (CBUS) can reach the target tissue directly and achieve rapid treatment. The frequency shift keying (FSK) signal is proposed to regulate and evaluate tumor ablation by a miniaturized dual-frequency transducer. METHODS A dual-frequency transducer prototype (3 × 7 × 0.4 mm) was designed and fabricated for the CBUS applicator (OD: 3.8 mm) based on the fundamental frequency of 5.21 MHz and the third harmonic frequency of 16.88 MHz. Then, the acoustic fields and temperature field distributions using the FSK signals (with 0, 25, 50, 75, and 100% third harmonic frequency duty ratios) were simulated by finite element analysis. Finally, tissue ablation and temperature monitoring were performed in phantom and ex vivo tissue, respectively. RESULTS At the same input electrical power (20 W), the output acoustic power of the fundamental frequency of the transducer was 10.03 W (electroacoustic efficiencies: 50.1%), and that of the third harmonic frequency was 6.19 W (30.6%). As the third harmonic frequency duty ratios increased, the shape of thermal lesions varied from strip to droplet in simulated and phantom experimental results. The same trend was observed in ex vivo tests. CONCLUSION Dual-frequency transducers excited by the FSK signal can control the morphology of lesions. SIGNIFICANCE The acoustic power deposition of CBUS was optimized to achieve precise ablation.
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Affiliation(s)
- Wenchang Huang
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Suzhou, Jiangsu, China.,Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu, China
| | - Chuanlong Ning
- College of Mechanical and Electrical Engineering, Hohai University, Changzhou, Jiangsu, China
| | - Rui Zhang
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Suzhou, Jiangsu, China.,Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu, China
| | - Jie Xu
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu, China
| | - Beiyi Chen
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Suzhou, Jiangsu, China.,Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu, China
| | - Zhangjian Li
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu, China
| | - Yaoyao Cui
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu, China
| | - Weiwei Shao
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, Jiangsu, China
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Ren F, Sui Y, Gong X, Xing Q, Wang Z. High-Intensity Focused Ultrasound in Interventricular Septal Myocardial Ablation. Int Heart J 2022; 63:1158-1165. [DOI: 10.1536/ihj.22-162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Fei Ren
- Qingdao Women and Children's Hospital, Cheeloo College of Medicine, Shandong University
| | - Yulong Sui
- Qingdao Women and Children's Hospital, Qingdao University
| | - Xiaobo Gong
- National State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University
| | - Quansheng Xing
- Qingdao Women and Children's Hospital, Cheeloo College of Medicine, Shandong University
| | - Zhibiao Wang
- National State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University
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Nazer B, Giraud D, Zhao Y, Qi Y, Mason O, Jones PD, Diederich CJ, Gerstenfeld EP, Lindner JR. Microbubble-Facilitated Ultrasound Catheter Ablation Causes Microvascular Damage and Fibrosis. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:131-138. [PMID: 33092899 PMCID: PMC8211318 DOI: 10.1016/j.ultrasmedbio.2020.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/30/2020] [Accepted: 09/08/2020] [Indexed: 06/11/2023]
Abstract
High-intensity ultrasound (US) ablation produces deeper myocardial lesions than radiofrequency ablation. The presence of intravascular microbubble (MB) contrast agents enhances pulsed-wave US ablation via cavitation-related histotripsy, potentially facilitating ablation in persistently perfused/conducting myocardium. US ablation catheters were developed and tested in the presence of MBs using ex vivo and in vivo models. High-frame-rate videomicroscopy and US imaging of gel phantom models confirmed MB destruction by inertial cavitation. MB-facilitated US ablation in an ex vivo perfused myocardium model generated shallow (2 mm) lesions and, in an in vivo murine hindlimb model, reduced perfusion by 42% with perivascular hemorrhage and inflammation, but no myonecrosis.
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Affiliation(s)
- Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA.
| | - David Giraud
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Yan Zhao
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Yue Qi
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - O'Neil Mason
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Peter D Jones
- Thermal Therapy Research Group, Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA
| | - Chris J Diederich
- Thermal Therapy Research Group, Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA
| | - Edward P Gerstenfeld
- Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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Nazer B, Giraud D, Zhao Y, Hodovan J, Elman MR, Masri A, Gerstenfeld EP, Lindner JR. High-intensity ultrasound catheter ablation achieves deep mid-myocardial lesions in vivo. Heart Rhythm 2020; 18:623-631. [PMID: 33385570 DOI: 10.1016/j.hrthm.2020.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/17/2020] [Accepted: 12/23/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radiofrequency ablation of epicardial and mid-myocardial ventricular arrhythmias is limited by lesion depth. OBJECTIVE The purpose of this study was to generate deep mid-interventricular septal (IVS) lesions using high-intensity ultrasound (US) from an endocardial catheter-based approach. METHODS Irrigated US catheters (12 F) were fabricated with 3 × 5 mm transducers of 5.0, 6.5, and 8.0 MHz frequencies and compared in an ex vivo perfused myocardial ablation model. In vivo septal ablation in swine (n = 12) was performed via femoral venous access to the right ventricle. Lesions were characterized by echocardiography, cardiac magnetic resonance imaging, and electroanatomic voltage mapping pre- and post-ablation, and at 30 days. Four animals were euthanized immediately post-ablation to compare acute and chronic lesion histology and gross pathology. RESULTS In ex vivo models, maximal lesion depth and volume was achieved by 6.5 MHz catheters, which were used in vivo. Lesion depth by gross pathology was similar post-ablation (10.8 mm; 95% confidence interval [CI] 9.9-12.4 mm) and at 30 days (11.2 mm; 95% CI 10.6-12.4 mm) (P = .56). Lesion volume decreased post-ablation to 30 days (from 255 [95% CI 198-440] to 162 [95% CI 133-234] mm3; P = .05), yet transmurality increased from 58% (95% CI 50%-76%) to 81% (95% CI 74%-93%), attributable to a reduction in IVS thickness (from 16.0 ± 1.7 to 10.6 ± 2.4 mm; P = .007). Magnetic resonance imaging confirmed dense septal ablation by delayed enhancement, with increased T1 time post-ablation and at 30 days and increased T2 time only post-ablation. Voltage mapping of both sides of IVS demonstrated reduced unipolar (but not bipolar) voltage along the IVS. CONCLUSION High-intensity US catheter ablation may be an effective treatment of mid-myocardial or epicardial ventricular arrhythmias from an endocardial approach.
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Affiliation(s)
- Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon.
| | - David Giraud
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Yan Zhao
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - James Hodovan
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Miriam R Elman
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon; School of Public Health, OHSU/Portland State University, Portland, Oregon
| | - Ahmad Masri
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Edward P Gerstenfeld
- Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
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7
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Edward JA, Nguyen DT. Patient Selection for Epicardial Ablation-Part II: The Epicardial Approach and Current Challenges Associated with Epicardial Ablation. J Innov Card Rhythm Manag 2020; 10:3906-3912. [PMID: 32477711 PMCID: PMC7252684 DOI: 10.19102/icrm.2019.101105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/29/2019] [Indexed: 12/03/2022] Open
Abstract
Since their inception, percutaneous epicardial approaches have become increasingly common in clinical practice with the advent of new technology and the growth of catheter ablation for both ventricular and supraventricular arrhythmias. In addition to identifying the arrhythmogenic foci, there remain challenges to successful epicardial ablation such as the choice of energy source, optimizing irrigation during ablation, and anatomic barriers such as epicardial fat and coronary vessels. The performance of continued translational studies to understand how each of these factors contribute to lesion formation will be essential to guide future advances in the field of epicardial ablation.
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Affiliation(s)
- Justin A Edward
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Denver, Aurora, CO, USA
| | - Duy T Nguyen
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Denver, Aurora, CO, USA
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Qian PC, Barry MA, Tran VT, Lu J, McEwan A, Thiagalingam A, Thomas SP. Irrigated Microwave Catheter Ablation Can Create Deep Ventricular Lesions Through Epicardial Fat With Relative Sparing of Adjacent Coronary Arteries. Circ Arrhythm Electrophysiol 2020; 13:e008251. [PMID: 32299229 DOI: 10.1161/circep.119.008251] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radiofrequency ablation depth can be inadequate to reach intramural or epicardial substrate, and energy delivery in the pericardium is limited by penetration through epicardial fat and coronary anatomy. We hypothesized that open irrigated microwave catheter ablation can create deep myocardial lesions endocardially and epicardially though fat while acutely sparing nearby the coronary arteries. METHODS In-house designed and constructed irrigated microwave catheters were tested in in vitro phantom models and in 15 sheep. Endocardial ablations were performed at 140 to 180 W for 4 minutes; epicardial ablations via subxiphoid access were performed at 90 to 100 W for 4 minutes at sites near coronary arteries. RESULTS Epicardial ablations at 90 to 100 W produced mean lesion depth of 10±4 mm, width 18±10 mm, and length 29±8 mm through median epicardial fat thickness of 1.2 mm. Endocardial ablations at 180 W reached depths of 10.7±3.3 mm, width of 16.6±5 mm, and length of 20±5 mm. Acute coronary occlusion or spasm was not observed at a median separation distance of 2.7 mm (IQR, 1.2-3.4 mm). Saline electrodes recorded unipolar and bipolar electrograms; microwave ablation caused reductions in voltage and changes in electrogram morphology with loss of pace-capture. In vitro models demonstrated the heat sink effect of coronary flow, as well as preferential microwave coupling to myocardium and blood as opposed to lung and epicardial fat phantoms. CONCLUSIONS Irrigated microwave catheter ablation may be an effective ablation modality for deep ventricular lesion creation with capacity for fat penetration and sparing of nearby coronary arteries because of cooling endoluminal flow. Clinical translation could improve the treatment of ventricular tachycardia arising from mid myocardial or epicardial substrates.
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Affiliation(s)
- Pierre C Qian
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,Sydney Medical School (P.C.Q., A.T., S.P.T.), University of Sydney, Australia.,The Westmead Institute for Medical Research (P.C.Q., A.T., S.P.T.), University of Sydney, Australia
| | - Michael A Barry
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,School of Electrical and Information Engineering (M.A.B., A.M.), University of Sydney, Australia
| | - Vu T Tran
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia
| | - Juntang Lu
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia
| | - Alistair McEwan
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,School of Electrical and Information Engineering (M.A.B., A.M.), University of Sydney, Australia
| | - Aravinda Thiagalingam
- Sydney Medical School (P.C.Q., A.T., S.P.T.), University of Sydney, Australia.,The Westmead Institute for Medical Research (P.C.Q., A.T., S.P.T.), University of Sydney, Australia
| | - Stuart P Thomas
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,Sydney Medical School (P.C.Q., A.T., S.P.T.), University of Sydney, Australia.,The Westmead Institute for Medical Research (P.C.Q., A.T., S.P.T.), University of Sydney, Australia
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Tuohy CV, Kaul S, Song HK, Nazer B, Heitner SB. Hypertrophic cardiomyopathy: the future of treatment. Eur J Heart Fail 2020; 22:228-240. [PMID: 31919938 DOI: 10.1002/ejhf.1715] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 10/19/2019] [Accepted: 11/21/2019] [Indexed: 01/06/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a heterogeneous genetic disorder most often caused by sarcomeric mutations resulting in left ventricular hypertrophy, fibrosis, hypercontractility, and reduced compliance. It is the most common inherited monogenic cardiac condition, affecting 0.2% of the population. Whereas currently available therapies for HCM have been effective in reducing morbidity, there remain important unmet needs in the treatment of both the obstructive and non-obstructive phenotypes. Novel pharmacotherapies directly target the molecular underpinnings of HCM, while innovative procedural techniques may soon offer minimally-invasive alternatives to current septal reduction therapy. With the advent of embryonic gene editing, there now exists the potential to correct underlying genetic mutations that may result in disease. This article details the recent developments in the treatment of HCM including pharmacotherapy, septal reduction procedures, mitral valve manipulation, and gene-based therapies.
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Affiliation(s)
- C Vaughan Tuohy
- Oregon Health and Sciences University (OHSU), Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Portland, OR, USA
| | - Sanjiv Kaul
- Oregon Health and Sciences University (OHSU), Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Portland, OR, USA
| | - Howard K Song
- Oregon Health and Sciences University (OHSU), Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Portland, OR, USA
| | - Babak Nazer
- Oregon Health and Sciences University (OHSU), Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Portland, OR, USA
| | - Stephen B Heitner
- Oregon Health and Sciences University (OHSU), Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Portland, OR, USA
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Sugrue A, Maor E, Ivorra A, Vaidya V, Witt C, Kapa S, Asirvatham S. Irreversible electroporation for the treatment of cardiac arrhythmias. Expert Rev Cardiovasc Ther 2018; 16:349-360. [DOI: 10.1080/14779072.2018.1459185] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Alan Sugrue
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elad Maor
- Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Antoni Ivorra
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Vaibhav Vaidya
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Chance Witt
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Suraj Kapa
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samuel Asirvatham
- Department of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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