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Załucka L, Świerżyńska E, Orczykowski M, Dutkowski K, Szymański J, Kuriata J, Dąbrowski R, Kołsut P, Szumowski Ł, Sterliński M. Ventricular Arrhythmias in Left Ventricular Assist Device Patients-Current Diagnostic and Therapeutic Considerations. Sensors (Basel) 2024; 24:1124. [PMID: 38400282 PMCID: PMC10893394 DOI: 10.3390/s24041124] [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] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/18/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Left ventricular assist devices (LVAD) are used in the treatment of advanced left ventricular heart failure. LVAD can serve as a bridge to orthotopic heart transplantation or as a destination therapy in cases where orthotopic heart transplantation is contraindicated. Ventricular arrhythmias are frequently observed in patients with LVAD. This problem is further compounded as a result of diagnostic difficulties arising from presently available electrocardiographic methods. Due to artifacts from LVAD-generated electromagnetic fields, it can be challenging to assess the origin of arrhythmias in standard ECG tracings. In this article, we will review and discuss common mechanisms, diagnostics methods, and therapeutic strategies for ventricular arrhythmia treatment, as well as numerous problems we face in LVAD implant patients.
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Affiliation(s)
- Laura Załucka
- Department of Cardiac Surgery and Transplantology, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland; (L.Z.); (J.S.); (P.K.)
| | - Ewa Świerżyńska
- 1st Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland
- Doctoral School, Medical University of Warsaw, 61 Zwirki I Wigury Street, 02-091 Warsaw, Poland
| | - Michał Orczykowski
- 1st Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland
| | - Krzysztof Dutkowski
- Department of Cardiac Surgery and Transplantology, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland; (L.Z.); (J.S.); (P.K.)
| | - Jarosław Szymański
- Department of Cardiac Surgery and Transplantology, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland; (L.Z.); (J.S.); (P.K.)
| | - Jarosław Kuriata
- Department of Cardiac Surgery and Transplantology, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland; (L.Z.); (J.S.); (P.K.)
| | - Rafał Dąbrowski
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland
| | - Piotr Kołsut
- Department of Cardiac Surgery and Transplantology, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland; (L.Z.); (J.S.); (P.K.)
| | - Łukasz Szumowski
- 1st Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland
| | - Maciej Sterliński
- 1st Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland
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2
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Świerżyńska E, Hawryluk Ł, Szołkiewicz A, Pytkowski M, Szumowski Ł, Sterliński M. Creatine kinase-MB is not a reliable indicator of thermal myocardial injury in patients with a cardiac implantable electronic device undergoing magnetic resonance imaging. Heart Rhythm 2024; 21:228-229. [PMID: 38194238 DOI: 10.1016/j.hrthm.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 01/10/2024]
Affiliation(s)
- Ewa Świerżyńska
- Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland; Doctoral School, Medical University of Warsaw, Warsaw, Poland.
| | - Łukasz Hawryluk
- Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Alicja Szołkiewicz
- Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Pytkowski
- Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Łukasz Szumowski
- Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Maciej Sterliński
- Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
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3
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Marczak M, Świerżyńska E, Śpiewak M, Bodusz D, Klotzka A, Mitkowski P, Tajstra M, Hryniewiecki T, Serafin Z, Sterliński M, Michałowska I. Magnetic resonance imaging in patients with implanted cardiac electrotherapy devices: a statement from experts of the Polish Medical Society of Radiology, the Polish Society of Cardiology, and the Polish Society of Electroradiology. Pol J Radiol 2024; 89:e1-e5. [PMID: 38371889 PMCID: PMC10867977 DOI: 10.5114/pjr.2023.133306] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/11/2023] [Indexed: 02/20/2024] Open
Abstract
The year 2023 marks 60 years since the first pacemaker was implanted in Poland. The number of implantable cardiac electrotherapy devices (CIEDs), including pacemakers, cardioverter-defibrillators, and resynchronization therapy systems, has been systematically increasing in the subsequent decades. It is estimated that nearly 500,000 Poles have an implanted cardiac electrotherapy device, making optimal diagnostic imaging with the use of magnetic resonance imaging (MRI) a clinically and epidemiologically important issue. MRI has become a gold diagnostic standard in many disease states. In this situation, it is believed that 50-70% of patients who have a cardiac electrotherapy device may have indications for an MRI examination later in life. For many years, an implanted cardiac electrotherapy device was considered a definite contraindication to MRI. However, MRI has become possible in most patients with CIED if certain procedures and precautions are followed. In these guidelines, we describe the basic rules that should be followed in order to perform a safe MRI examination in patients with different CIEDs. Despite all the risks and organizational factors described in the text, it seems that for many MRI departments, MRI in patients with CIEDs is achievable and should be implemented immediately. A second important issue is the need for dedicated financial support for these procedures from public health insurance.
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Affiliation(s)
- Magdalena Marczak
- The Cardinal Stefan Wyszyński National Institute of Cardiology, Warsaw, Poland
| | - Ewa Świerżyńska
- The Cardinal Stefan Wyszyński National Institute of Cardiology, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Mateusz Śpiewak
- The Cardinal Stefan Wyszyński National Institute of Cardiology, Warsaw, Poland
| | - Dawid Bodusz
- Department of Radiotherapy, National Research Institute of Oncology, Gliwice, Poland
| | - Aneta Klotzka
- 1 Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Przemysław Mitkowski
- 1 Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Tomasz Hryniewiecki
- The Cardinal Stefan Wyszyński National Institute of Cardiology, Warsaw, Poland
| | - Zbigniew Serafin
- Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland
| | - Maciej Sterliński
- The Cardinal Stefan Wyszyński National Institute of Cardiology, Warsaw, Poland
| | - Ilona Michałowska
- The Cardinal Stefan Wyszyński National Institute of Cardiology, Warsaw, Poland
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Sterliński M, Świerżyńska E. Permanent cardiac pacing: evidence, beliefs, and habits. Pol Arch Intern Med 2023; 133:16631. [PMID: 38126243 DOI: 10.20452/pamw.16631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
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Świerżyńska E, Oręziak A, Zakrzewska-Koperska J, Szumowski Ł, Sterliński M. Diagnostic electrocardiographic trap: A case of conduction system pacing. J Electrocardiol 2023; 81:163-166. [PMID: 37738714 DOI: 10.1016/j.jelectrocard.2023.09.007] [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: 07/12/2023] [Revised: 09/03/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023]
Abstract
His-bundle pacing (HBP) is a relatively new method of cardiac pacing, with recent studies showing an association between HBP and a lower risk of developing right ventricular heart failure compared to classical pacing methods. However, HBP is also associated with a higher risk of lead dislodgement, undersensing, and loss of capture. As such, a detailed assessment of pacing effectiveness in pacemaker patients is vital. In the presented case, an electrocardiogram (ECG) recording seems to present successful selective His-bundle pacing, while pacemaker follow-up demonstrated the loss of ventricular capture. In conclusion, patients receiving HBP should undergo ECG alongside pacing parameter analysis and pacing electrograms, as differences in successful and unsuccessful pacing ECG can be very subtle.
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Affiliation(s)
- Ewa Świerżyńska
- 1st Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland; Doctoral School, Medical University of Warsaw, 61 Zwirki i Wigury Street, 02-091 Warsaw, Poland.
| | - Artur Oręziak
- 1st Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland
| | - Joanna Zakrzewska-Koperska
- 1st Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland
| | - Łukasz Szumowski
- 1st Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland
| | - Maciej Sterliński
- 1st Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska Street, 04-628 Warsaw, Poland
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Świerżyńska E, Oręziak A, Główczyńska R, Rossillo A, Grabowski M, Szumowski Ł, Caprioglio F, Sterliński M. Rate-Responsive Cardiac Pacing: Technological Solutions and Their Applications. Sensors (Basel) 2023; 23:s23031427. [PMID: 36772467 PMCID: PMC9920425 DOI: 10.3390/s23031427] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 05/12/2023]
Abstract
Modern cardiac pacemakers are equipped with a function that allows the heart rate to adapt to the current needs of the patient in situations of increased demand related to exercise and stress ("rate-response" function). This function may be based on a variety of mechanisms, such as a built-in accelerometer responding to increased chest movement or algorithms sensing metabolic demand for oxygen, analysis of intrathoracic impedance, and analysis of the heart rhythm (Q-T interval). The latest technologies in the field of rate-response functionality relate to the use of an accelerometer in leadless endocavitary pacemakers; in these devices, the accelerometer enables mapping of the mechanical wave of the heart's work cycle, enabling the pacemaker to correctly sense native impulses and stimulate the ventricles in synchrony with the cycles of atria and heart valves. Another modern system for synchronizing pacing rate with the patient's real-time needs requires a closed-loop system that continuously monitors changes in the dynamics of heart contractions. This article discusses the technical details of various solutions for detecting and responding to situations related to increased oxygen demand (e.g., exercise or stress) in implantable pacemakers, and reviews the results of clinical trials regarding the use of these algorithms.
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Affiliation(s)
- Ewa Świerżyńska
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
- Correspondence:
| | - Artur Oręziak
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
| | - Renata Główczyńska
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Antonio Rossillo
- Department of Cardiology, San Bortolo Hospital, 36100 Vicenza, Italy
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Łukasz Szumowski
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
| | | | - Maciej Sterliński
- Department of Arrhythmia, The Cardinal Stefan Wyszynski National Institute of Cardiology, 04-628 Warsaw, Poland
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Świerżyńska E, Główczyńska R, Sterliński M, Krauze N, Cacko A, Kołodzińska A, Opolski G, Szumowski Ł, Grabowski M. Application and optimization of the rate response function in dual-chamber pacemakers: Prospective, randomized, cross-over clinical trial study protocol. Kardiol Pol 2022; 80:1139-1141. [PMID: 36172994 DOI: 10.33963/kp.a2022.0230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 12/05/2022]
Affiliation(s)
- Ewa Świerżyńska
- 1st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland. .,1st Department of Arrhythmia, National Institute of Cardiology, Warszawa, Poland. .,Doctoral School, Medical University of Warsaw, Warszawa, Poland.
| | - Renata Główczyńska
- 1st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Maciej Sterliński
- 1st Department of Arrhythmia, National Institute of Cardiology, Warszawa, Poland
| | - Natasza Krauze
- 1st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Andrzej Cacko
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, Warszawa, Poland
| | | | - Grzegorz Opolski
- 1st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Łukasz Szumowski
- 1st Department of Arrhythmia, National Institute of Cardiology, Warszawa, Poland
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
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Sawicki S, Mierzyńska A, Krauze A, Dobrowolski P, Świerżyńska E, Prejbisz A, Michałek P, Bilińska M, Lutyńska A, Januszewicz A, Sterliński M. Silent atrial fibrillation episodes and cognitive impairment in patients with cardiac implantable devices. Protocol of the SAFE-COG ongoing observational single-center non-experimental case-control clinical study. Kardiol Pol 2021; 79:1362-1364. [PMID: 34845712 DOI: 10.33963/kp.a2021.0162] [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] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Stefan Sawicki
- Rapid Diagnosis Department, National Institute of Cardiology, Warszawa, Poland.
| | - Anna Mierzyńska
- Department of Rehabilitation, Medical Center of Postgraduate Education, Gruca Orthopedic and Trauma Teaching Hospital, Warszawa, Poland
| | - Agnieszka Krauze
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warszawa, Poland
| | - Piotr Dobrowolski
- Department of Hypertension, National Institute of Cardiology, Warszawa, Poland
| | - Ewa Świerżyńska
- 1st Department of Arrhythmia, National Institute of Cardiology, Warszawa, Poland
| | - Aleksander Prejbisz
- Department of Hypertension, National Institute of Cardiology, Warszawa, Poland
| | - Piotr Michałek
- Rapid Diagnosis Department, National Institute of Cardiology, Warszawa, Poland
| | - Maria Bilińska
- 1st Department of Arrhythmia, National Institute of Cardiology, Warszawa, Poland
| | - Anna Lutyńska
- Department of Medical Biology, National Institute of Cardiology, Warszawa, Poland
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warszawa, Poland
| | - Maciej Sterliński
- 1st Department of Arrhythmia, National Institute of Cardiology, Warszawa, Poland
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Tajstra M, Wojtaszczyk A, Sterliński M, Świerżyńska E, Szumowski Ł, Tomasiuk M, Grabowski M, Januszkiewicz ŁJ, Romanek J, Przybylski A, Mitkowski P, Klotzka A, Szafranek A, Gąsior M, Kalarus Z, Kowalski O. Patients with heart failure and an implanted cardioverter-defibrillator during the coronavirus disease 2019 pandemic: insights from a multicenter registry in Poland. Kardiol Pol 2021; 79:562-565. [PMID: 34125930 DOI: 10.33963/kp.15918] [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] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Mateusz Tajstra
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland.
| | - Adam Wojtaszczyk
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland.,Department of Electrocardiology, Medical University of Lodz, Łódź, Poland
| | | | - Ewa Świerżyńska
- Department of Arrhythmia Institute of Cardiology, Warszawa, Poland.,1st Department of Cardiology, Doctoral School, Medical University of Warsaw, Warszawa, Poland
| | - Łukasz Szumowski
- Department of Arrhythmia Institute of Cardiology, Warszawa, Poland.,Cardinal Stefan Wyszynski University in Warsaw, Warszawa, Poland
| | - Mikołaj Tomasiuk
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | | | - Janusz Romanek
- Cardiology Department with the Acute Coronary Syndromes Subdivision, Clinical Provincial Hospital No. 2, Faculty of Medicine, University of Rzeszow, Rzeszów, Poland
| | - Andrzej Przybylski
- Cardiology Department with the Acute Coronary Syndromes Subdivision, Clinical Provincial Hospital No. 2, Faculty of Medicine, University of Rzeszow, Rzeszów, Poland
| | - Przemysław Mitkowski
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Aneta Klotzka
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Andrzej Szafranek
- Computer Science Laboratory, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Mariusz Gąsior
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Oskar Kowalski
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland.,Department of Dietetics, School of Public Health in Bytom, Medical University of Silesia, Katowice, Poland
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Świerżyńska E, Sterliński M, Syska P, Sadowski K, Szumowski Ł. Use of an exercise test to enhance sensing vector assessment and prevent inadequate subcutaneous implantable cardioverter-defibrillator discharges. J Electrocardiol 2021; 67:73-76. [PMID: 34090117 DOI: 10.1016/j.jelectrocard.2021.05.013] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/21/2021] [Indexed: 10/21/2022]
Abstract
Subcutaneous implantable cardioverter-defibrillators are a modern alternative to classic cardioverter-defibrillators. Prior to implantation of the device, qualification based on assessment of the heart's specific rhythm shape during a resting electrocardiogram examination must be performed. In the presented case, a patient with a subcutaneous implantable cardioverter-defibrillator experienced numerous discharges during exercise. An exercise test was performed, which revealed a bundle branch block that appeared during exercise. The wide QRS complex was double- or triple-counted by the device, resulting in an inaccurate heart rate estimation and multiple discharges. Optimising the sensing vectors during exercise solved this problem.
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Affiliation(s)
- Ewa Świerżyńska
- 1(st) Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska St., 04-628 Warsaw, Poland; 1(st) Department of Cardiology, Doctoral School, Medical University of Warsaw, 61 Żwirki i Wigury St., 02-091 Warsaw, Poland.
| | - Maciej Sterliński
- 1(st) Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska St., 04-628 Warsaw, Poland
| | - Paweł Syska
- 2(nd) Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska St., 04-628 Warsaw, Poland
| | - Krzysztof Sadowski
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, 42 Alpejska St., 04-628 Warsaw, Poland
| | - Łukasz Szumowski
- 1(st) Department of Arrhythmia, National Institute of Cardiology, 42 Alpejska St., 04-628 Warsaw, Poland
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Świerżyńska E, Mitkowski P, Zakrzewska-Koperska J, Oręziak A, Baranowski R, Bilińska M, Sterliński M. Spatial separation of left and right ventricular leads adjusted to the left ventricular end‑diastolic dimension does not affect the change of the paced QRS complex duration in resynchronization therapy. Kardiol Pol 2020; 78:1159-1161. [PMID: 32897037 DOI: 10.33963/kp.15595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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