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Ebrille E, Lucciola MT, Amellone C, Ballocca F, Suppo M, Antonacci G, Gotta F, Birolo M, Orlando F, Favro E, Giammaria M. Deep sedation with dexmedetomidine administered by electrophysiologists during COVID-19 pandemic compared with propofol administered by anesthesiologists for ablation of atrial fibrillation. Europace 2022. [PMCID: PMC9384089 DOI: 10.1093/europace/euac053.098] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Funding Acknowledgements Type of funding sources: None. Background COVID-19 pandemic, limiting the availability of anesthesiologists, has impacted heavily on the organization of invasive cardiac procedures such as transcatheter atrial fibrillation (AF) ablation. Purpose We compared the safety and efficacy of deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision, against the standard protocol performed with propofol. Methods We retrospectively included all AF ablation procedures performed in 2020: 23 patients sedated with 1% propofol (2 ml bolus followed by infusion starting at 1 mg/Kg/h), 26 patients with dexmedetomidine (infusion starting at 0.7 mcg/Kg/h). Both groups additionally received 1 mcg/Kg of midazolam as a single bolus and 0.05 mg single boluses of fentanyl prior to ablation on each pair of pulmonary veins (PV). Primary outcomes were oxygen desaturation (< 90%) or need for assisted ventilation/intubation, bradycardia (heart rate < 45 bpm) and persistent hypotension (systolic blood pressure < 90 mmHg). Results Baseline characteristics and hemodynamic variables did not differ between the two groups (all p > 0.05). In 8/23 (35%) patients propofol infusion velocity reduction was necessary to maintain the hemodynamic values, compared to 7/26 (27%) with dexmedetomidine. Inter-group comparison of hemodynamic variables during the procedure showed no statistically significant difference, despite a trend in favor of dexmedetomidine (3 respiratory depressions and 3 persistent hypotension episodes with propofol vs. 0 with dexmedetomidine; p = 0.057). Conclusion Deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision is safe and effective for AF transcatheter ablation. A trend towards a lower incidence of hypotension and respiratory depression was noted when compared to propofol.
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Affiliation(s)
- E Ebrille
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - MT Lucciola
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - C Amellone
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - F Ballocca
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - M Suppo
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - G Antonacci
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - F Gotta
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - M Birolo
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - F Orlando
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - E Favro
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
| | - M Giammaria
- Maria Vittoria Hospital, Cardiology Department, Turin, Italy
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Russo V, Nesti M, Brunacci M, Tola G, Santobuono VE, Dendramis G, Picciolo G, Lucciola MT, D'Onofrio A, Ricci R, de Ponti R. Cardiac electrophysiology and pacing educational and training needs among early-career cardiologists: a national survey of the Young Committee of the Italian Association of Arrhythmology and Cardiac Pacing. J Cardiovasc Med (Hagerstown) 2021; 22:744-750. [PMID: 34487053 DOI: 10.2459/jcm.0000000000001169] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Over the past three decades, cardiac electrophysiology and pacing, including device therapy and catheter ablation of arrhythmias, has rapidly developed as a subspecialty in cardiology. Currently, there is no clear perception about the needs in cardiac electrophysiology and pacing among early-career cardiologists. METHODS To address these concerns, the Young Committee of the Italian Association of Arrhythmology and Cardiac Pacing (AIAC) carried out a survey among those under the age of 40 years to obtain detailed information on practical activities and formal lessons during the fellowship in cardiology and their satisfaction and proficiency level at the end of the fellowship. RESULTS We obtained 334 answers to the survey. In invasive cardiac electrophysiology and pacing, the percentage of participants attending the activity for a longer time (3-6 months) is lower compared with those in noninvasive subspecialties. About 40% of participants did not receive lessons on interventional cardiology, cardiac electrophysiology and pacing. On the contrary, 71% of participants received an adequate number of lessons on clinical arrhythmology. The vast majority of the participants expressed satisfaction for the education received in the echocardiographic, cardiac interventional laboratories and clinical arrhythmology, but about half of the participants were unsatisfied with the education received in cardiac electrophysiology and pacing. In interventional arrhythmology, the majority of the participants declare their lack of proficiency with two peaks for more complex procedures, namely interventional electrophysiology procedures (82%) and cardiac resynchronization therapy (CRT) procedures (76%). CONCLUSION The present survey among Italian early-career cardiologists suggests that the majority of participants consider themselves not confident in performing cardiac electrophysiology and pacing procedures. Due to the complexity of the treatment for heart rhythm disorders and the long learning curve, structured additional training in cardiac electrophysiology and pacing procedures is required after cardiology fellowship.
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Affiliation(s)
- Vincenzo Russo
- University of Campania 'Luigi Vanvitelli' - Monaldi Hospital, Naples
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Forleo GB, Amellone C, Sacchi R, Lombardi L, Lucciola MT, Scotti V, Viecca M, Schiavone M, Giacopelli D, Giammaria M. Factors affecting signal quality in implantable cardiac monitors with long sensing vector. J Arrhythm 2021; 37:1061-1068. [PMID: 34386133 PMCID: PMC8339108 DOI: 10.1002/joa3.12585] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 04/16/2021] [Revised: 05/20/2021] [Accepted: 06/04/2021] [Indexed: 12/04/2022] Open
Abstract
PURPOSE Electrical artefacts are frequent in implantable cardiac monitors (ICMs). We analyzed the subcutaneous electrogram (sECG) provided by an ICM with a long sensing vector and factors potentially affecting its quality. METHODS Consecutive ICM recipients underwent a follow-up where demographics, body mass index (BMI), implant location, and surface ECG were collected. The sECG was then analyzed in terms of R-wave amplitude and P-wave visibility. RESULTS A total of 84 patients (43% female, median age 68 [58-76] years) were enrolled at 3 sites. ICMs were positioned with intermediate inclination (n = 44, 52%), parallel (n = 35, 43%), or perpendicular (n = 5, 6%) to the sternum. The median R-wave amplitude was 1.10 (0.72-1.48) mV with P waves readily visible in 69.2% (95% confidence interval, CI: 57.8%-79.2%), partially visible in 23.1% [95% CI: 14.3%-34.0%], and never visible in 7.7% [95% CI: 2.9%-16.0%] of patients. Men had higher R-wave amplitudes compared to women (1.40 [0.96-1.80] mV vs 1.00 [0.60-1.20] mV, P = .001), while obese people tended to have lower values (0.80 [0.62-1.28] mV vs 1.10 [0.90-1.50] mV, P = .074). The P-wave visibility reached 86.2% [95% CI: 68.3%-96.1%] in patients with high-voltage P waves (≥0.2 mV) at surface ECG. The sECG quality was not affected by implant site. CONCLUSION In ordinary clinical practice, ICMs with long sensing vector provided median R-wave amplitude above 1 mV and reliable P-wave visibility of nearly 70%, regardless of the position of the device. Women and obese patients showed lower but still very good signal quality.
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Affiliation(s)
- Giovanni B. Forleo
- Cardiology UnitASST‐Fatebenefratelli SaccoLuigi Sacco University HospitalMilanItaly
| | | | | | - Leonida Lombardi
- Cardiology UnitASST‐Fatebenefratelli SaccoLuigi Sacco University HospitalMilanItaly
| | | | | | - Maurizio Viecca
- Cardiology UnitASST‐Fatebenefratelli SaccoLuigi Sacco University HospitalMilanItaly
| | - Marco Schiavone
- Cardiology UnitASST‐Fatebenefratelli SaccoLuigi Sacco University HospitalMilanItaly
| | - Daniele Giacopelli
- Clinical Research UnitBIOTRONIK ItaliaVimodrone, MilanItaly
- Department of Cardiac, Thoracic, Vascular Sciences & Public HealthPadovaItaly
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Melis F, Guido M, Amellone C, Suppo M, Bonanno M, Bovio C, Pessia A, Savio K, Lucciola MT, Ebrille E, Guastamacchia G, Cassano D, Filippi P, Milano E, Giammaria M, Imperiale D. Prevalence and predictors of atrial fibrillation in patients with embolic stroke of undetermined source: a real-life single-center retrospective study. Neurol Sci 2021; 42:3707-3714. [PMID: 33443664 DOI: 10.1007/s10072-020-04963-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 08/21/2020] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Up to one-third of ischemic strokes remained cryptogenic despite extensive investigations. Atrial fibrillation may be detected in a significant proportion of patients with embolic stroke of undetermined source, particularly after the introduction of implantable loop recorder in clinical practice. METHODS We retrospectively included all the consecutive patients with embolic stroke of undetermined source referred to our units in the period November 2013 to December 2018 and in which an implantable loop recorder was positioned within 6 months from stroke event. Prevalence and predictors of atrial fibrillation were investigated. RESULTS One hundred thirty-eight patients with embolic stroke of undetermined source fulfilling inclusion criteria were identified. The crude prevalence of atrial fibrillation at the end of observation period was of 45.7%. Incidence rates at 6, 12, 18, 24, and 36 months resulted, respectively, 31.8% (95% CI, 30.4-46.7), 38.0% (95% CI, 30.4-46.9), 42.6% (95% CI, 34.5-51.6), 46.6% (95% CI, 38.2-55.8), and 50.4% (95% CI, 41.6-59.9). On multivariate analysis, only excessive supraventricular electric activity and left atrial enlargement resulted to be significant predictors of atrial fibrillation (p = 0.037 and p < 0.0001, respectively). CONCLUSIONS Atrial fibrillation may be detected in a relevant proportion (up to 50%) of patients with embolic stroke of undetermined source if a careful and extensive diagnostic work-up is employed. Excessive supraventricular electric activity and left atrial enlargement are significant predictors of the occurrence of atrial fibrillation in these patients.
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Affiliation(s)
- Fabio Melis
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Marilena Guido
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | | | - Marco Suppo
- SC Cardiologia 1 - Ospedale Maria Vittoria, Torino, Italy
| | - Maria Bonanno
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Consuelo Bovio
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Andrea Pessia
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Katia Savio
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | | | - Elisa Ebrille
- SC Cardiologia 1 - Ospedale Maria Vittoria, Torino, Italy
| | - Giulia Guastamacchia
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Daniela Cassano
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Paola Filippi
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | - Eva Milano
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy
| | | | - Daniele Imperiale
- SC Neurologia 1 - Ospedale Maria Vittoria, Via Cibrario 72, 10144, Torino, Italy.
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Affiliation(s)
- Elisa Ebrille
- Cardiology Division, Maria Vittoria Hospital, Turin, Italy
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Gaido L, Beqaraj F, Lucciola MT, Forsennati PG, Zingarelli E, Daniele L, Gagnor A, Giammaria M. [Infero-postero-lateral acute myocardial infarction caused by left ventricular myxoma embolism]. G Ital Cardiol (Rome) 2019; 20:117-119. [PMID: 30747927 DOI: 10.1714/3093.30859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The majority of myxomas are located in the left atrium (75%) followed by the right atrium (20%). In rare cases, myxomas can be found in the ventricles, with 2.5% reported for myxomas in the left ventricle. Systemic emboli, mostly cerebral, occur in two thirds of such patients, while coronary emboli are rare. Here we report a case of left ventricular myxoma causing infero-postero-lateral myocardial infarction, successfully treated by intracoronary thromboaspiration of myxoma embolus.
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Affiliation(s)
- Luca Gaido
- Divisione di Cardiologia, Dipartimento di Scienze Mediche, A.O.U. Città della Salute e della Scienza, Università degli Studi, Torino
| | - Federico Beqaraj
- Divisione di Cardiologia, Dipartimento di Medicina Interna, Ospedale Maria Vittoria, Torino
| | - Maria Teresa Lucciola
- Divisione di Cardiologia, Dipartimento di Medicina Interna, Ospedale Maria Vittoria, Torino
| | | | | | - Lorenzo Daniele
- Divisione di Anatomia Patologica, Ospedale Mauriziano Umberto I, Torino
| | - Andrea Gagnor
- Divisione di Cardiologia, Dipartimento di Medicina Interna, Ospedale Maria Vittoria, Torino
| | - Massimo Giammaria
- Divisione di Cardiologia, Dipartimento di Medicina Interna, Ospedale Maria Vittoria, Torino
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Pullara A, Chinaglia A, Giammaria M, Bequaraj F, Orlando F, Coda L, Lucciola MT, Forno D, Ravera L, Cecchi E, Gaita F, Belli R. Takotsubo cardiomyopathy: real life management in the intensive coronary care unit. Minerva Med 2013; 104:537-544. [PMID: 24101111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
AIM Takotsubo cardiomyopathy is a cardiac syndrome characterized by reversible left ventricular dysfunction, ischemic changes on electrocardiogram, elevation of cardiac biomarkers, absence of obstructive coronary artery disease in the setting of various stressing conditions. To date, little is known on best clinical management of this syndrome in coronary care units. Whe thus aimed to present our experience in a real life takotsubo population. METHODS We identified all patients with Takotsubo cardiomyopathy at our center Maria Vittoria Hospital, Turin, between October 2006 and February 2012. Patients where considered to have Takotsubo syndrome if they presented chest pain on admission, new elettrocardiographic changes suggestive of myocardial ischemia, evidence of apical balloning with hyperkinesis of basal segments on echocardiography, rise in troponin I and, after coronary angiography, no coronary artery disease. We adjudicated the following clinical events: death and recurrence of ischemic events; we also made a detailed analysis of the stressing conditions leading to clinical syndrome. RESULTS A total of 26 patients were included, 4 (15%) males and 22 (85%) females; mean age was 71±13. After more than 1 year median follow-up the incidence of death was 7.7% (2 deaths), with all deaths, due to cardiogenic shock, occurring in the first 10 days of hospitalization; 2 patients (8%) experienced recurrence of ischemic event. Leading cause of Takostubo was major depressive episode (16%), followed by mourning (12%), falling down with difficulties in standing up (12%), vomiting (8%) and pulmonary infection (8%). In the coronary care unit major complications of patients with Takotsubo syndrome were acute hearth failure (62%), cardiogenic shock (27%), sepsis (31%), pulmonary aedema (27%) and anemia (12%). Two patients needed non-invasive ventilation support and one intra-aortic balloon conterpulasation. In addition one patient developed rabdomyolysis and one left heart thrombus. Cornerstone drug therapy was as follows: 96% of patients took aspirin, 58% beta blockers, 54% nitroglicerine, 46% intravenous heparin, 27% dopamine. CONCLUSION Takotsubo syndrome is an important safety issue occurring predominantly in post-menopausal women undergoing specific stressing condition. Heart failure and cardiogenic shock are the most serious clinical complication and leading cause of death in the short period, good prognosis is seen thereafter.
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Affiliation(s)
- A Pullara
- Division of Cardiology, Maria Vittoria Hospital, Turin, Italy -
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Moretti C, Biondi-Zoccai GG, Sciuto F, Omedè P, Lucciola MT, Morena L, Grosso Marra W, Trevi GP, Sheiban I. Appraising the pathophysiologic impact of coronary collaterals as measured by fractional flow reserve on symptoms and signs of myocardial ischemia. J Cardiovasc Med (Hagerstown) 2009; 9:1120-6. [PMID: 18852584 DOI: 10.2459/jcm.0b013e32830c6c64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The purpose of coronary revascularization in stable patients is anginal relief, yet there is no linear relationship between stenosis severity and clinical significance. A major factor in this complex lesion-myocardium interaction is collateral flow. We aimed to define which collateral flow cut-offs separate asymptomatic from symptomatic patients during coronary occlusion. METHODS Patients undergoing percutaneous transluminal coronary angioplasty for a single stenotic lesion were selected, collaterals were appraised angiographically, and fractional flow reserve was used during prolonged balloon occlusion to measure collateral flow index (FFRcoll). Changes in anginal symptoms, ST-T segment, and left ventricular wall motion were appraised before and during/shortly after balloon dilation. Receiver-operating-characteristic curves and area under the curve were computed to identify the most appropriate FFRcoll cut-offs. RESULTS Twenty consecutive patients were enrolled. At baseline, 10 patients had angiographic evidence of collaterals, whereas 10 had no angiographic evidence of collateral flow distal to the target lesion. FFRcoll had an excellent discriminatory performance for the presence of angiographic collaterals (area under the curve = 0.90, P = 0.003), a good discriminatory performance for the occurrence of angina (area under the curve = 0.80, P = 0.025), and a trend toward a good discriminatory performance for the occurrence of asynergy (area under the curve = 0.81, P = 0.06). On the basis of receiver-operating-characteristic curves, an FFRcoll cut-off greater than 0.26 could reliably distinguish patients with adequate collaterals (sensitivity = 0.90, specificity = 0.80), whereas a greater than 0.41 cut-off distinguished patients having angina or wall motion abnormalities from those remaining asymptomatic. CONCLUSION This study shows that distal collateral pressure greater than 41% of proximal perfusion pressure protects from anginal symptoms or regional systolic dysfunction during coronary occlusion, whereas a greater than 26% cut-off is more appropriate to identify angiographically evident collaterals ensuring distal myocardial viability.
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Moretti C, Teresa Lucciola M, Morena L, Biondi-Zoccai G, Laudito A, Anselmino M, Paolo Trevi G, Sheiban I. Idiopathic thrombocytopenic purpura and percutaneous coronary stenting: A dangerous duo? Int J Cardiol 2008; 130:e96-7. [PMID: 17854925 DOI: 10.1016/j.ijcard.2007.06.141] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2007] [Accepted: 06/30/2007] [Indexed: 02/08/2023]
Abstract
Dual antiplatelet therapy is a mainstay in the management of patients undergoing coronary stenting. Whether this is also appropriate in patients with a diagnosis of idiopathic thrombocytopenic purpura (ITP) is unclear. We report the case of a 66-year-old man with ITP admitted for an acute coronary syndrome. On admission platelets were 110 x 10(9)/L without petechiae or purpura, and coronary angiography revealed multivessel disease with significant left main involvement. Given the unfeasibility of surgical revascularization with cardiopulmonary bypass because of ITP, a staged percutaneous revascularization strategy was chosen. Both left circumflex and right coronary arteries were treated with bare-metal stenting during the index admission. After 4 weeks of strict clinical monitoring and evidence of a stable total platelet count on oral prednisone, percutaneous coronary intervention with drug-eluting stenting was performed in the left main and left anterior descending arteries. He was then discharged on lifelong aspirin and a 6-month clopidogrel regimen without thrombotic or bleeding complications. Given the paucity of data on ITP and stenting, no strict recommendations can be proposed and treatment should be individualized to minimize both bleeding and thrombosis risks. Nonetheless, this case suggests the feasibility of percutaneous revascularization in selected patients with multivessel coronary disease and ITP.
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Sheiban I, Lucciola MT, Moretti C, Migliaretti A, Sciuto F, Marra WG, Omedè P, Truffa A, Shoheib A, Trevi G. 1082-185 Functional evaluation of coronary collateral flow in patients with severe coronary artery disease by intracoronary pressure wire. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)92019-0] [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: 11/26/2022]
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Sheiban I, Moretti C, Prathap K, Sciuto F, Gagnor A, Omedè P, Truffa A, Marra WG, Shoheib A, Lucciola MT, Trevi G. 1003-95 Thrombus aspiration for the treatment of No-reflow phenomenon complicating primary angioplasty for acute myocardial infarction. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)91055-8] [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: 10/26/2022]
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