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El-Chami MF, Garweg C, Clementy N, Al-Samadi F, Iacopino S, Martinez-Sande JL, Roberts PR, Tondo C, Johansen JB, Vinolas-Prat X, Cha YM, Grubman E, Bordachar P, Stromberg K, Fagan DH, Piccini JP. Leadless pacemakers at 5-year follow-up: the Micra transcatheter pacing system post-approval registry. Eur Heart J 2024; 45:1241-1251. [PMID: 38426911 PMCID: PMC10998730 DOI: 10.1093/eurheartj/ehae101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/04/2024] [Accepted: 02/05/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND AIMS Prior reports have demonstrated a favourable safety and efficacy profile of the Micra leadless pacemaker over mid-term follow-up; however, long-term outcomes in real-world clinical practice remain unknown. Updated performance of the Micra VR leadless pacemaker through five years from the worldwide post-approval registry (PAR) was assessed. METHODS All Micra PAR patients undergoing implant attempts were included. Endpoints included system- or procedure-related major complications and system revision rate for any cause through 60 months post-implant. Rates were compared through 36 months post-implant to a reference dataset of 2667 transvenous pacemaker patients using Fine-Gray competing risk models. RESULTS 1809 patients were enrolled between July 2015 and March 2018 and underwent implant attempts from 179 centres in 23 countries with a median follow-up period of 51.1 months (IQR: 21.6-64.2). The major complication rate at 60 months was 4.5% [95% confidence interval (CI): 3.6%-5.5%] and was 4.1% at 36 months, which was significantly lower than the 8.5% rate observed for transvenous systems (HR: .47, 95% CI: .36-.61; P < .001). The all-cause system revision rate at 60 months was 4.9% (95% CI: 3.9%-6.1%). System revisions among Micra patients were mostly for device upgrades (41.2%) or elevated thresholds (30.6%). There were no Micra removals due to infection noted over the duration of follow-up. At 36 months, the system revision rate was significantly lower with Micra vs. transvenous systems (3.2% vs. 6.6%, P < .001). CONCLUSIONS Long-term outcomes with the Micra leadless pacemaker continue to demonstrate low rates of major complications and system revisions and an extremely low incidence of infection.
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Affiliation(s)
- Mikhael F El-Chami
- Division of Cardiology, Section of Electrophysiology, Emory University, Atlanta, Georgia
| | - Christophe Garweg
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Nicolas Clementy
- Department of Cardiologic Medicine, Centre Hospitalier Regional Universitaire de Tours—Hopital Trousseau, Tours, France
| | - Faisal Al-Samadi
- Department of Medicine, King Salman Heart Center—King Fahad Medical City, Riyadh, Saudi Arabia
| | - Saverio Iacopino
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Department of Biomedical, Surgical, and Dental Sciences, University of Milan, Milan, Italy
| | - Jose Luis Martinez-Sande
- Arrhythmia Unit, Cardiology Service, University Clinical Hospital of Santiago de Compostela, CIBER-CV, IDIS, Santiago de Compostela, Spain
| | - Paul R Roberts
- Department of Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Claudio Tondo
- Monzino Cardiac Center, IRCCS, Department of Clinical Sciences and Community, University of Milan, Milan, Italy
| | | | | | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric Grubman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Pierre Bordachar
- Cardio-Thoracic Unit, Bordeaux University Hospital, Pessac-Bordeaux, France
| | | | | | - Jonathan P Piccini
- Electrophysiology Section, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
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Ong E, Grubman E, Rosenfeld LE. An alternating QRS: How does it go even though it's pretty slow? J Electrocardiol 2023; 81:214-217. [PMID: 37832325 DOI: 10.1016/j.jelectrocard.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/04/2023] [Accepted: 10/01/2023] [Indexed: 10/15/2023]
Abstract
We present the case of a 42 year old patient with a history of childhood lymphoma treated with chemotherapy and radiation who underwent combined aortic and mitral valve replacements and who postoperatively developed an interesting ECG which showed complete heart block and an alternating left bundle branch and narrow complex QRS pattern at a heart rate of 69 beats per minute (bpm). We discuss potential mechanisms for this interesting pattern.
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Affiliation(s)
- Emily Ong
- Section of Cardiovascular Medicine, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, United States of America.
| | - Eric Grubman
- Section of Cardiovascular Medicine, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, United States of America.
| | - Lynda E Rosenfeld
- Section of Cardiovascular Medicine, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, United States of America.
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Rickard J, Jackson K, Gold M, Biffi M, Ziacchi M, Silverstein J, Ramza B, Metzl M, Grubman E, Abben R, Varma N, Tabbal G, Jensen C, Wouters G, Ghosh S, Vernooy K. Electrocardiogram Belt guidance for left ventricular lead placement and biventricular pacing optimization. Heart Rhythm 2022; 20:537-544. [PMID: 36442824 DOI: 10.1016/j.hrthm.2022.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with ischemic cardiomyopathy, non-left bundle branch block, or QRS duration <150 ms have a lower response rate to cardiac resynchronization therapy (CRT) than did other indicated patients. The ECG Belt system (EBS) is a novel surface mapping system designed to measure electrical dyssynchrony via the standard deviation of the activation times of the left ventricle. OBJECTIVES The objectives of this study were to evaluate the efficacy of the EBS in patients less likely to respond to CRT and to determine whether EBS use in lead placement guidance and device programming was superior to standard CRT care. METHODS This was a prospective randomized trial of patients with heart failure and EBS-guided CRT implantation and programming vs standard CRT care. The primary end point was relative change in left ventricular end-systolic volume from baseline to 6 months postimplantation. RESULTS A total of 408 patients from centers in Europe and North America were randomized. Although both patients with EBS and control patients had a mean improvement in left ventricular end-systolic volume, there was no significant difference in relative change from baseline (P = .26). While patients with a higher baseline standard deviation of the activation times derived greater left ventricular reverse remodeling, improvement in electrical dyssynchrony did not correlate with the extent of reverse remodeling. CONCLUSION The findings of the present study do not support EBS-guided therapy for CRT management of heart failure with reduced ejection fraction.
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Affiliation(s)
- John Rickard
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Kevin Jackson
- Section of Cardiac Electrophysiology, Division of Cardiovascular Disease, Duke University Medical Center, Durham, North Carolina
| | - Michael Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Mauro Biffi
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Ziacchi
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Brian Ramza
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Mark Metzl
- Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Eric Grubman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Richard Abben
- Cardiac Interventions and Cardiac Arrythmia Center, Cardiovascular Institute of the South, Houma, Louisiana
| | - Niraj Varma
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ghiyath Tabbal
- Cardiac Interventions and Cardiac Arrythmia Center, Cardiovascular Institute of the South, Houma, Louisiana
| | - Cory Jensen
- Department of Cardiac Electrophysiology, Heartland Cardiology, Wichita, Kansas
| | - Griet Wouters
- Department of Cardiac Rhythm Management, Medtronic Inc., Mounds View, Minnesota
| | - Subham Ghosh
- Department of Cardiac Rhythm Management, Medtronic Inc., Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
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El-Chami MF, Garweg C, Iacopino S, Al-Samadi F, Martinez-Sande JL, Tondo C, Johansen JB, Prat XV, Piccini JP, Cha YM, Grubman E, Bordachar P, Roberts PR, Soejima K, Stromberg K, Fagan DH, Clementy N. Leadless Pacemaker Implant, Anticoagulation Status, and Outcomes: Results From The Micra Transcatheter Pacing System Post-Approval Registry. Heart Rhythm 2021; 19:228-234. [PMID: 34757189 DOI: 10.1016/j.hrthm.2021.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/22/2021] [Accepted: 10/22/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Early results from the Micra investigational trial and Micra post-approval registry (PAR) demonstrated excellent safety and device performance; however, outcomes based upon anticoagulation status at implant have not been evaluated. OBJECTIVE To report implant characteristics, perforation rate and vascular related events based upon perioperative oral anticoagulation (AC) strategy in patients undergoing Micra implant. METHODS We compared procedure characteristics, major complications, and vascular events, including pericardial effusion, stratified by any AE (including major complications, minor complications and observations) or major complication only according to AC status in the Micra PAR. RESULTS Among 1795 patients with AC status available, 585 were not on AC, 795 had AC interrupted, and 415 had AC continued during Micra implant. Non-AC patients tended to be younger, with less history of AF and COPD, and more history of dialysis than interrupted and continued patients. The implant success rate was similar for all groups (99.1%-99.8%). Through 30 days post implant, the overall major complication rate was 3.1% for the non-AC group, 2.6% for the interrupted group, and 1.5% for the continued group. The combined rate for any vascular or pericardial effusion AE did not differ significantly between AC strategies (6.5%, 4.8%, and 3.6% respectively). CONCLUSION Implant of Micra appears to be safe and feasible regardless of an interrupted or continued peri-procedural oral anticoagulation strategy, with no increased risk of perforation rate or vascular complications.
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Affiliation(s)
- Mikhael F El-Chami
- Division of Cardiology, Section of Electrophysiology, Emory University, Atlanta, Georgia.
| | | | - Saverio Iacopino
- Electrophysiology Unit, Arrhythmology Department, Maria Cecelia Hospital, Cotignola, Italy
| | - Faisal Al-Samadi
- King Salman Heart Center - King Fahad Medical City, Riyadh, Saudi Arabia
| | - Jose Luis Martinez-Sande
- Unidad de Arritmias, Servicio de Cardiologia, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Claudio Tondo
- Monzino Cardiac Center, IRCCS, Department of Clinical Sciences and Community, University of Milan, Milan, Italy
| | | | | | - Jonathan P Piccini
- Electrophysiology Section, Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | | | - Eric Grubman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Pierre Bordachar
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Université Bordeaux, Bordeaux, France
| | - Paul R Roberts
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | | | | | | | - Nicolas Clementy
- Department of Cardiologic Medicine, Centre Hospitalier Régional Universitaire de Tours - Hôpital Trousseau, Tours, France
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Garweg C, Iacopino S, El-Chami M, Veltmann C, Clementy N, Grubman E, Johansen J, Knops R, Schalij M, Piccini J, Soejima K, Stromberg K, Fagan D, Roberts P. Leadless pacemaker implant in patients with a history of open heart surgery: experience with the Micra transcatheter pacemaker. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
The Micra transcatheter pacemaker has demonstrated a favorable safety and efficacy profile relative to transvenous pacing. Patients with a history of open heart surgery have a higher risk of complications with transvenous pacemakers during follow-up. The experience with leadless pacemakers among a large cohort of patients with a history of open heart surgery has not been reported.
Objective
To report outcomes in patients with a history of open heart surgery undergoing Micra implant.
Methods
Patients undergoing Micra implant from the Micra Transcatheter Pacing Post-Approval Registry (PAR) were included in the analysis. Baseline and procedural characteristics, major complications, and electrical performance were compared among patients with vs. without history of cardiac surgery.
Results
A total of 331 out of 1815 (18.2%) patients had a history of open heart surgery, underwent Micra implant, and were followed for 19.4±10.4 months. The mean age was 74.6±13.5 years, 40% were female. The most common cardiac surgery was aortic valve surgery (71%) followed by mitral valve surgery (39%). Patients with prior open-heart surgery were more likely to have contraindications to transvenous pacing, were more likely to be on oral anticoagulants, and had more co-morbidities including atrial fibrillation, heart failure, and coronary artery disease (all p<0.005). Implantation was successful in 327 of 331 patients (98.8%) with a median procedure time of 29 minutes. Mean pacing capture thresholds (PCTs) at implant were 0.66±0.51V and remained stable through follow-up. There were 11 major complications in 10 cardiac surgery patients, with no device or procedure-related infections reported. The major complication rate was 3.1% (Figure) and was not significantly different than that of patients without a history of open heart surgery (HR: 0.85, P=0.640). There was 1 cardiac perforation (with no intervention required) in the open heart surgery group (0.3%) and there were 14 cardiac perforations (0.94%, P=0.332) in the non-open heart surgery group of which 10 required intervention.
Conclusion
The Micra transcatheter pacemaker can be safely implanted in patients with a history of open heart surgery, with a similar long-term safety profile to patients without a history of open heart surgery. Importantly, there were no device-related infections reported in either group.
Risk of Major Complication
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Medtronic, Inc.
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Affiliation(s)
- C Garweg
- University Hospitals (UZ) Leuven, Cardiology, Leuven, Belgium
| | - S Iacopino
- Maria Cecilia Hospital, Cotignola, Italy
| | - M.F El-Chami
- Emory University, Atlanta, United States of America
| | - C Veltmann
- Hannover Medical School, Hannover, Germany
| | - N Clementy
- University Hospital of Tours, Tours, France
| | - E Grubman
- Yale University, New Haven, United States of America
| | | | - R Knops
- Academic Medical Center, Amsterdam, Netherlands (The)
| | - M.J Schalij
- Leiden University Medical Center, Leiden, Netherlands (The)
| | - J.P Piccini
- Duke University Medical Center, Durham, United States of America
| | - K Soejima
- Kyorin University School of Medicine, Tokyo, Japan
| | - K Stromberg
- Medtronic, Mounds View, United States of America
| | - D.H Fagan
- Medtronic, Mounds View, United States of America
| | - P.R Roberts
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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Rosenfeld LE, Obasare ER, Bader E, Grubman E. Spontaneous Conversion of Long-Standing Atrial Fibrillation/Flutter. Am J Cardiol 2020; 131:122-124. [PMID: 32718546 DOI: 10.1016/j.amjcard.2020.06.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/09/2020] [Accepted: 06/16/2020] [Indexed: 11/24/2022]
Abstract
There have been no recent descriptions of the spontaneous conversion of long-standing atrial fibrillation (AF) or flutter (AFl) to sinus rhythm which, in the past, has been associated with rheumatic mitral valve disease and treatment with digoxin. We present 3 contemporary cases, all of whom progressed from AF to slow AFl and then spontaneously converted to slow sinus or junctional rhythm. None of these patients had rheumatic heart disease or were treated with digoxin. In conclusion, we believe that they provide support for the broader view that this uncommon phenomenon is associated with a severe atrial myopathy due to scar and inflammation.
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Affiliation(s)
- Lynda E Rosenfeld
- Section of Cardiovascular Medicine, Dana 3, Yale University School of Medicine, New Haven, Connecticut.
| | - Edinrin R Obasare
- Section of Cardiovascular Medicine, Dana 3, Yale University School of Medicine, New Haven, Connecticut
| | - Eric Bader
- Section of Cardiovascular Medicine, Dana 3, Yale University School of Medicine, New Haven, Connecticut
| | - Eric Grubman
- Section of Cardiovascular Medicine, Dana 3, Yale University School of Medicine, New Haven, Connecticut
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Workman V, Grubman E, Rosenfeld LE. Fast and Slow, Long and Shorter. Circulation 2019; 140:1952-1956. [PMID: 31790296 DOI: 10.1161/circulationaha.119.044053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Virginia Workman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Eric Grubman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Lynda E Rosenfeld
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
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Afzal MR, Daoud EG, Cunnane R, Mulpuru SK, Koay A, Hussain A, Omar R, Wei KK, Amin A, Kidwell G, Patel N, Love C, Lloyd M, Sterliński M, Goldbarg S, Leal MA, Gabriels J, Patel A, Jadonath R, Grubman E, Crossley G, Pepper C, Lakkireddy D, Okabe T, Hummel JD, Augostini RS. Techniques for successful early retrieval of the Micra transcatheter pacing system: A worldwide experience. Heart Rhythm 2018; 15:841-846. [DOI: 10.1016/j.hrthm.2018.02.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Indexed: 11/16/2022]
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Grubman E, Pavri BB, Lyle S, Reynolds C, Denofrio D, Kocovic DZ. Histopathologic effects of radiofrequency catheter ablation in previously infarcted human myocardium. J Cardiovasc Electrophysiol 1999; 10:336-42. [PMID: 10210495 DOI: 10.1111/j.1540-8167.1999.tb00680.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The use of catheter-based radiofrequency (RF) ablation for the treatment of ventricular tachyarrhythmias due to previous myocardial infarction has been steadily increasing. The histopathologic changes caused by this technique are not well described in humans. METHODS AND RESULTS Three patients with hemodynamically tolerated ventricular tachycardias (VTs) due to previous myocardial infarction underwent endocardial mapping and catheter based RF ablation. All patients received between 5 and 11 RF lesions each of 60-second duration. One patient underwent myocardial resection of a left ventricular aneurysm 1 day following RF ablation, one expired 7 days after RF ablation, and one expired 9 months after RF ablation. None of the deaths occurred as a result of RF ablation. Pathologic specimens obtained early after RF ablation revealed areas of focal acute inflammation and fibrin deposition. Later specimens revealed several focal areas of fibrosis and granulation tissue. Specimens obtained late after RF ablation revealed a dense band of fibrosis, measuring 17 x 17 x 5 mm (1,250 mm3). CONCLUSION Catheter-based RF ablation of ischemic VT in humans causes lesions that initially resemble coagulation necrosis. This is followed by the development of an inflammatory infiltrate and, finally, the development of fibrosis. Repeated application of RF ablation may result in much larger lesions than have been previously reported.
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Affiliation(s)
- E Grubman
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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Grubman E, Loh E, Kocovic DZ. An algorithm for rate adaptive AV delay in patients with heart failure. J Am Coll Cardiol 1996. [DOI: 10.1016/s0735-1097(96)81815-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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