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Dandel M. Monitoring of the right ventricular responses to pressure overload: prognostic value and usefulness of echocardiography for clinical decision-making. Cardiovasc Diagn Ther 2024; 14:193-222. [PMID: 38434557 PMCID: PMC10904302 DOI: 10.21037/cdt-23-380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/10/2023] [Indexed: 03/05/2024]
Abstract
Regardless of whether pulmonary hypertension (PH) results from increased pulmonary venous pressure in left-sided heart diseases or from vascular remodeling and/or obstructions in pre-capillary pulmonary vessels, overload-induced right ventricular (RV) dysfunction and its final transition into right-sided heart failure is a major cause of death in PH patients. Being particularly suited for non-invasive monitoring of the right-sided heart, echocardiography has become a useful tool for optimizing the therapeutic decision-making and evaluation of therapy results in PH. The review provides an updated overview on the pathophysiological insights of heart-lung interactions in PH of different etiology, as well as on the diagnostic and prognostic value of echocardiography for monitoring RV responses to pressure overload. The article focuses particularly on the usefulness of echocardiography for predicting life-threatening aggravation of RV dysfunction in transplant candidates with precapillary PH, as well as for preoperative prediction of post-operative RV failure in patients with primary end-stage left ventricular (LV) failure necessitating heart transplantation or a LV assist device implantation. In transplant candidates with refractory pulmonary arterial hypertension, a timely prediction of impending RV decompensation can contribute to reduce both the mortality risk on the transplant list and the early post-transplant complications caused by severe RV dysfunction, and also to avoid combined heart-lung transplantation. The review also focuses on the usefulness of echocardiography for monitoring the right-sided heart in patients with acute respiratory distress syndrome, particularly in those with refractory respiratory failure requiring extracorporeal membrane oxygenation support. Given the pathophysiologic particularity of severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection to be associated with a high incidence of thrombotic microangiopathy-induced increase in the pulmonary resistance, echocardiography can improve the selection of temporary mechanical cardio-respiratory support strategies and can therefore contribute to the reduction of mortality rates. On the whole, the review aims to provide a theoretical and practical basis for those who are or intend in the future to be engaged in this highly demanding field.
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Kummerow M, von Dossow V, Pasero D, Martinez Lopez de Arroyabe B, Abrams B, Kowalsky M, Wilkey BJ, Subramanian K, Martin AK, Marczin N, de Waal EEC. PERSUADE Survey-PERioperative AnestheSia and Intensive Care Management of Left VentricUlar Assist DevicE Implantation in Europe and the United States. J Cardiothorac Vasc Anesth 2024; 38:197-206. [PMID: 37980193 DOI: 10.1053/j.jvca.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 11/20/2023]
Abstract
OBJECTIVE To comprehensively assess relevant institutional variations in anesthesia and intensive care management during left ventricular assist device (LVAD) implantation. DESIGN The authors used a prospective data analysis. SETTING This was an online survey. PARTICIPANTS Participants were from LVAD centers in Europe and the US. INTERVENTIONS After investigating initial interest, 91 of 202 European and 93 of 195 US centers received a link to the survey targeting institutional organization and experience, perioperative hemodynamic monitoring, medical management, and postoperative intensive care aspects. MEASUREMENTS AND MAIN RESULTS The survey was completed by 73 (36.1%) European and 60 (30.8%) US centers. Although most LVAD implantations were performed in university hospitals (>5 years of experience), significant differences were observed in the composition of the preoperative multidisciplinary team and provision of intraoperative care. No significant differences in monitoring or induction agents were observed. Propofol was used more often for maintenance in Europe (p < 0.001). The choice for inotropes changed significantly from preoperatively (more levosimendan in Europe) to intraoperatively (more use of epinephrine in both Europe and the US). The use of quantitative methods for defining right ventricular (RV) function was reported more often from European centers than from US centers (p < 0.05). Temporary mechanical circulatory support for the treatment of RV failure was more often used in Europe. Nitric oxide appeared to play a major role only intraoperatively. There were no significant differences in early postoperative complications reported from European versus US centers. CONCLUSIONS Although the perioperative practice of care for patients undergoing LVAD implantation differs in several aspects between Europe and the US, there were no perceived differences in early postoperative complications.
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Affiliation(s)
- Maren Kummerow
- Department of Anesthesiology and Intensive Care Medicine, Mathias-Spital Rheine, Rheine, Germany
| | - Vera von Dossow
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center North Rhine-Westphalia, University Clinic of the Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Daniela Pasero
- Department of Anesthesiology and Intensive Care, University Hospital, Sassari, Italy
| | | | - Benjamin Abrams
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Markus Kowalsky
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Barbara J Wilkey
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Kathirvel Subramanian
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, UPMC Presbyterian Hospital, Pittsburgh, PA
| | - Archer K Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Jacksonville, FL
| | - Nandor Marczin
- Division of Anaesthesia, Pain Medicine and Intensive Care, Imperial College London, Royal Brompton & Harefield Hospitals, Guy's & St. Thomas' NHS, London, United Kingdom; Department of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary
| | - Eric E C de Waal
- Department of Anesthesiology, University Medical Center Utrecht, Utrecht, the Netherlands.
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Arjomandi Rad A, Fleet B, Zubarevich A, Nanchahal S, Naruka V, Subbiah Ponniah H, Vardanyan R, Sardari Nia P, Loubani M, Moorjani N, Schmack B, Punjabi PP, Schmitto J, Ruhparwar A, Weymann A. Left ventricular assist device implantation and concomitant mitral valve surgery: A systematic review and meta-analysis. Artif Organs 2024; 48:16-27. [PMID: 37822301 DOI: 10.1111/aor.14659] [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] [Received: 06/16/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND The management of concomitant valvular lesions in patients undergoing left ventricular assist device (LVAD) implantation remains a topic of debate. This systematic review and meta-analysis aimed to evaluate the existing evidence on postoperative outcomes following LVAD implantation, with and without concomitant MV surgery. METHODS A systematic database search was conducted as per PRISMA guidelines, of original articles comparing LVAD alone to LVAD plus concomitant MV surgery up to February 2023. The primary outcomes assessed were overall mortality and early mortality, while secondary outcomes included stroke, need for right ventricular assist device (RVAD) implantation, postoperative mitral valve regurgitation, major bleeding, and renal dysfunction. RESULTS The meta-analysis included 10 studies comprising 32 184 patients. It revealed that concomitant MV surgery during LVAD implantation did not significantly affect overall mortality (OR:0.83; 95% CI: 0.53 to 1.29; p = 0.40), early mortality (OR:1.17; 95% CI: 0.63 to 2.17; p = 0.63), stroke, need for RVAD implantation, postoperative mitral valve regurgitation, major bleeding, or renal dysfunction. These findings suggest that concomitant MV surgery appears not to confer additional benefits in terms of these clinical outcomes. CONCLUSION Based on the available evidence, concomitant MV surgery during LVAD implantation does not appear to have a significant impact on postoperative outcomes. However, decision-making regarding MV surgery should be individualized, considering patient-specific factors and characteristics. Further research with prospective studies focusing on specific patient populations and newer LVAD devices is warranted to provide more robust evidence and guide clinical practice in the management of valvular lesions in LVAD recipients.
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Affiliation(s)
- Arian Arjomandi Rad
- Medical Sciences Division, University of Oxford, Oxford, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ben Fleet
- School of Medicine, Lancaster University, Lancaster, UK
| | - Alina Zubarevich
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Sukanya Nanchahal
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Vinci Naruka
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Robert Vardanyan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth NHS Trust, Cambridge, UK
| | - Bastian Schmack
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Prakash P Punjabi
- Department of Cardiothoracic Surgery, National Heart and Lung Institute, Imperial College London, London, UK
| | - Jan Schmitto
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Weymann
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Rodenas-Alesina E, Brahmbhatt DH, Mak S, Ross HJ, Luk A, Rao V, Billia F. Value of Invasive Hemodynamic Assessments in Patients Supported by Continuous-Flow Left Ventricular Assist Devices. JACC. HEART FAILURE 2024; 12:16-27. [PMID: 37804313 DOI: 10.1016/j.jchf.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 10/09/2023]
Abstract
Left ventricular assist devices (LVADs) are increasingly used in patients with end-stage heart failure (HF). There is a significant risk of HF admissions and hemocompatibility-related adverse events that can be minimized by optimizing the LVAD support. Invasive hemodynamic assessment, which is currently underutilized, allows personalization of care for patients with LVAD, and may decrease the need for recurrent hospitalizations. It also aids in triaging patients with persistent low-flow alarms, evaluating reversal of pulmonary vasculature remodeling, and assessing right ventricular function. In addition, it can assist in determining the precipitant for residual HF symptoms and physical limitation during exercise and is the cornerstone of the assessment of myocardial recovery. This review provides a comprehensive approach to the use of invasive hemodynamic assessments in patients supported with LVADs.
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Affiliation(s)
- Eduard Rodenas-Alesina
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Cardiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Darshan H Brahmbhatt
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Mount Sinai Hospital, Toronto Ontario, Canada
| | - Susanna Mak
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Cardiology, Mount Sinai Hospital, Toronto Ontario, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adriana Luk
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Rao
- Division of Cardiac Surgery, Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Filio Billia
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Sennhauser S, Sridharan L. Left Ventricular Assist Device Emergencies: Diagnosis and Management. Crit Care Clin 2024; 40:159-177. [PMID: 37973352 DOI: 10.1016/j.ccc.2023.06.004] [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: 11/19/2023]
Abstract
Durable left ventricular assist devices (LVADs) are a virtually limitless advanced therapy option for an increasingly growing population of patients with end-stage advanced heart failure. As of 2019, 30% to 40% of all patients diagnosed with heart failure were categorized as New York Heart Association class III or IV. In 2018 more than 3.2 million office visits and 1.4 million emergency department visits carried a primary diagnosis of heart failure. Given the rapid growth of the LVAD population, facility in the diagnosis and management of common perioperative and outpatient LVAD emergencies has become of paramount importance in a variety of clinical settings.
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Affiliation(s)
- Susie Sennhauser
- Division of Cardiology, Department of Medicine, Emory University School of Medicine
| | - Lakshmi Sridharan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine.
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Wei J, Franke J, Kee A, Dukes R, Leonardo V, Flynn BC. Postoperative Pulmonary Artery Pulsatility Index Improves Prediction of Right Ventricular Failure After Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2024; 38:214-220. [PMID: 37973507 DOI: 10.1053/j.jvca.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES This study evaluated whether the postoperative pulmonary artery pulsatility index (PAPi) is associated with postoperative right ventricular dysfunction after durable left ventricular assist device (LVAD) implantation. DESIGN Single-center retrospective observational cohort study. SETTING The University of Kansas Medical Center, a tertiary-care academic medical center. PARTICIPANTS Sixty-seven adult patients who underwent durable LVAD implantation between 2017 and 2019. INTERVENTIONS All patients underwent open cardiac surgery with cardiopulmonary bypass under general anesthesia with pulmonary artery catheter insertion. MEASUREMENTS AND MAIN RESULTS Clinical and hemodynamic data were collected before and after surgery. The Michigan right ventricular failure risk score and the European Registry for Patients with Mechanical Circulatory Support score were calculated for each patient. The primary outcome was right ventricular failure, defined as a composite of right ventricular mechanical circulatory support, inhaled pulmonary vasodilator therapy for 48 hours or greater, or inotrope use for 14 days or greater or at discharge. Thirty percent of this cohort (n = 20) met the primary outcome. Preoperative transpulmonary gradient (odds ratio [OR] 1.15, 95% CI 1.02-1.28), cardiac index (OR 0.83, 95% CI 0.71-0.98), and postoperative PAPi (OR 0.85, 95% CI 0.75-0.97) were the only hemodynamic variables associated with the primary outcome. The addition of postoperative PAPi was associated with improvement in the predictive model performance of the Michigan score (area under the receiver operating characteristic curve 0.73 v 0.56, p = 0.03). An optimal cutoff point for postoperative PAPi of 1.56 was found. CONCLUSIONS The inclusion of postoperative PAPi offers more robust predictive power for right ventricular failure in patients undergoing durable LVAD implantation, compared with the use of existing risk scores alone.
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Affiliation(s)
- Johnny Wei
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
| | - Jack Franke
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Abigail Kee
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Rachel Dukes
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Vincent Leonardo
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | - Brigid C Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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7
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Bartoszko J, Omran AS, Ng W. Advancing intraoperative assessment of the right ventricle through three-dimensional transesophageal echocardiography. Can J Anaesth 2023; 70:1549-1559. [PMID: 37752377 DOI: 10.1007/s12630-023-02562-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/11/2023] [Accepted: 05/21/2023] [Indexed: 09/28/2023] Open
Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Ahmad S Omran
- Department of Anesthesia and Pain Management, University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - William Ng
- Department of Anesthesia and Pain Management, University Health Network, Sinai Health System, Women's College Hospital, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anaesthesia and Pain Management, The Hospital for Sick Children, Toronto, ON, Canada
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8
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Suero AG, Xie LX. Optimization of Left Ventricular Assist Device Support. Tex Heart Inst J 2023; 50:e238231. [PMID: 37622288 PMCID: PMC10660412 DOI: 10.14503/thij-23-8231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
| | - Lola X. Xie
- Department of Cardiology, Baylor College of Medicine, Houston, Texas
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Masarone D, Houston B, Falco L, Martucci ML, Catapano D, Valente F, Gravino R, Contaldi C, Petraio A, De Feo M, Tedford RJ, Pacileo G. How to Select Patients for Left Ventricular Assist Devices? A Guide for Clinical Practice. J Clin Med 2023; 12:5216. [PMID: 37629257 PMCID: PMC10455625 DOI: 10.3390/jcm12165216] [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: 07/22/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
In recent years, a significant improvement in left ventricular assist device (LVAD) technology has occurred, and the continuous-flow devices currently used can last more than 10 years in a patient. Current studies report that the 5-year survival rate after LVAD implantation approaches that after a heart transplant. However, the outcome is influenced by the correct selection of the patients, as well as the choice of the optimal time for implantation. This review summarizes the indications, the red flags for prompt initiation of LVAD evaluation, and the principles for appropriate patient screening.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Brian Houston
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC 158155, USA (R.J.T.)
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Maria L. Martucci
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Dario Catapano
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Fabio Valente
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Rita Gravino
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Carla Contaldi
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Transplant, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Marisa De Feo
- Cardiac Surgery Unit, Department of Cardiac Surgery and Transplant, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
| | - Ryan J. Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC 158155, USA (R.J.T.)
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN Dei Colli-Monaldi Hospital, 84121 Naples, Italy
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