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Karacan MN, Doi SN, Yafasova A, Thune JJ, Nielsen JC, Haarbo J, Bruun NE, Gustafsson F, Eiskjær H, Hassager C, Svendsen JH, Høfsten DE, Pehrson S, Køber L, Butt JH. New York Heart Association functional class and implantable cardioverter-defibrillator in non-ischaemic heart failure with reduced ejection fraction: Extended follow-up of the DANISH trial. Eur J Heart Fail 2024. [PMID: 38733253 DOI: 10.1002/ejhf.3239] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/30/2024] [Accepted: 03/30/2024] [Indexed: 05/13/2024] Open
Abstract
AIMS Current guidelines recommend implantable cardioverter-defibrillator (ICD) therapy in patients with heart failure, a left ventricular ejection fraction of ≤35%, and New York Heart Association (NYHA) class II-III. However, the evidence regarding the benefit of primary prevention ICD is less consistent in patients with NYHA class III. We investigated the long-term effects of primary prevention ICD implantation according to NYHA class in an extended follow-up study of the DANISH trial. METHODS AND RESULTS The DANISH trial randomized 1116 patients with non-ischaemic heart failure with reduced ejection fraction (HFrEF) to ICD implantation or usual care. Outcomes were analysed according to NYHA class at baseline (NYHA class II and III/IV). The primary outcome was all-cause mortality. Of the 1116 patients randomized in the DANISH trial, 597 (53.5%) were in NYHA class II at baseline, 505 (45.3%) in NYHA class III, and 14 (1.3%) in NYHA class IV. During a median follow-up of 9.5 years, NYHA class III/IV, compared with NYHA class II, were associated with a greater long-term rate of all-cause mortality (hazard ratio [HR] 1.52, 95% confidence interval [CI] 1.20-1.93) and cardiovascular death (HR 1.95 [1.47-2.60]). ICD implantation, compared with usual care, did not reduce the long-term rate of all-cause mortality (all participants: HR 0.89 [95% CI 0.74-1.08]; NYHA class II: HR 0.85 [0.64-1.13]; NYHA class III/IV: HR 0.89 [0.69-1.14]; pinteraction = 0.78) or cardiovascular death (all participants: HR 0.87 [95% CI 0.70-1.09]; NYHA class II: HR 0.78 [0.54-1.12]; NYHA class III/IV: HR 0.89 [0.67-1.19]; pinteraction = 0.58), irrespective of NYHA class. Similarly, NYHA class did not modify the beneficial effects of ICD implantation on sudden cardiovascular death (all participants: HR 0.60 [95% CI 0.40-0.92]; NYHA class II: HR 0.73 [0.40-1.36]; NYHA class III/IV: HR 0.52 [0.29-0.94]; pinteraction = 0.39). CONCLUSIONS In patients with non-ischaemic HFrEF, ICD implantation, compared with usual care, did not reduce the overall mortality rate, but it did reduce sudden cardiovascular death, regardless of baseline NYHA class. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT00542945.
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Affiliation(s)
- Munise N Karacan
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Seiko N Doi
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Adelina Yafasova
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jens Jakob Thune
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jens C Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Haarbo
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Niels E Bruun
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jesper H Svendsen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Dan E Høfsten
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Steen Pehrson
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jawad H Butt
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
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Trenson S, Voros G, Martens P, Ingelaere S, Betschart P, Voigt JU, Dupont M, Breitenstein A, Steffel J, Willems R, Ruschitzka F, Mullens W, Winnik S, Vandenberk B. Long-term outcome after upgrade to cardiac resynchronization therapy: A propensity score-matched analysis. Eur J Heart Fail 2024; 26:511-520. [PMID: 37905357 DOI: 10.1002/ejhf.3073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 10/20/2023] [Accepted: 10/21/2023] [Indexed: 11/02/2023] Open
Abstract
AIM Cardiac resynchronization therapy (CRT) is a cornerstone in the management of chronic heart failure in patients with a broad or paced QRS. However, data on long-term outcome after upgrade to CRT are scarce. METHODS AND RESULTS This international, multicentre retrospective registry included 2275 patients who underwent a de novo or upgrade CRT implantation with a mean follow-up of 3.6 ± 2.7 years. The primary composite endpoint included all-cause mortality, heart transplantation, or ventricular assist device implantation. The secondary endpoint was first heart failure admission. Multivariable Cox regression and propensity score matching (PSM) analyses were performed. Patients who underwent CRT upgrade (n = 605, 26.6%) were less likely female (19.7% vs. 28.8%, p < 0.001), more often had ischeemic cardiomyopathy (49.8% vs. 40.2%, p < 0.001), and had worse renal function (median estimated glomerular filtration rate 50.3 ml/min/1.73 m2 [35.8-69.5] vs. 59.9 ml/min/1.73 m2 [43.0-76.5], p < 0.001). The incidence rate of the composite endpoint was 10.8%/year after CRT upgrade versus 7.1%/year for de novo implantations (p < 0.001). PSM for the primary endpoint resulted in 488 pairs. After propensity score matching, upgrade to CRT was associated with a higher chance to reach the composite endpoint (multivariable hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.08-1.70), for both upgrade from pacemaker (multivariable HR 1.33, 95% CI 1.03-1.70) and implantable cardioverter-defibrillator (ICD) (multivariable HR 1.40, 95% CI 1.01-1.95). PSM for the secondary endpoint resulted in 277 pairs. After PSM, upgrade to CRT was associated with a higher chance for heart failure admission (HR 1.74, 95% CI 1.26-2.41). CONCLUSION In this retrospective analysis, the outcome of patients who underwent upgrades to CRT differed significantly from patients who underwent de novo CRT implantation, particularly for upgrades from ICD. Importantly, this difference in outcome does not imply a causal relation between therapy and outcome but rather a difference between two different patient populations.
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Affiliation(s)
- Sander Trenson
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, Sint-Jan Hospital Bruges, Bruges, Belgium
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Gabor Voros
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Pascal Betschart
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Jan Steffel
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Rik Willems
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Life Sciences, Hasselt University, Hasselt, Belgium
| | - Stephan Winnik
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Bert Vandenberk
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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Libbus I, Stubbs SR, Mazar ST, Mindrebo S, KenKnight BH, DiCarlo LA. Effect of defibrillation on the performance of an implantable vagus nerve stimulation system. Bioelectron Med 2021; 7:3. [PMID: 33722304 PMCID: PMC7962382 DOI: 10.1186/s42234-021-00064-w] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/09/2021] [Indexed: 01/06/2023] Open
Abstract
Background Vagus Nerve Stimulation (VNS) delivers Autonomic Regulation Therapy (ART) for heart failure (HF), and has been associated with improvement in cardiac function and heart failure symptoms. VNS is delivered using an implantable pulse generator (IPG) and lead with electrodes placed around the cervical vagus nerve. Because HF patients may receive concomitant cardiac defibrillation therapy, testing was conducted to determine the effect of defibrillation (DF) on the VNS system. Methods DF testing was conducted on three ART IPGs (LivaNova USA, Inc.) according to international standard ISO14708-1, which evaluated whether DF had any permanent effects on the system. Each IPG was connected to a defibrillation pulse generator and subjected to a series of high-energy pulses. Results The specified series of pulses were successfully delivered to each of the three devices. All three IPGs passed factory electrical tests, and interrogation confirmed that software and data were unchanged from the pre-programmed values. No shifts in parameters or failures were observed. Conclusions Implantable VNS systems were tested for immunity to defibrillation, and were found to be unaffected by a series of high-energy defibrillation pulses. These results suggest that this VNS system can be used safely and continue to function after patients have been defibrillated.
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Affiliation(s)
- Imad Libbus
- LivaNova USA, Inc, 100 Cyberonics Blvd., TX, 77058, Houston, USA.
| | - Scott R Stubbs
- LivaNova USA, Inc, 100 Cyberonics Blvd., TX, 77058, Houston, USA
| | - Scott T Mazar
- LivaNova USA, Inc, 100 Cyberonics Blvd., TX, 77058, Houston, USA
| | - Scott Mindrebo
- LivaNova USA, Inc, 100 Cyberonics Blvd., TX, 77058, Houston, USA
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Stiles MK, Fauchier L, Morillo CA, Wilkoff BL. 2019 HRS/EHRA/APHRS/LAHRS focused update to 2015 expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing. J Arrhythm 2019; 35:485-493. [PMID: 31293697 DOI: 10.1002/joa3.12178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The 2015 HRS/EHRA/APHRS/SOLAECE Expert Consensus Statement on Optimal Implantable Cardioverter-Defibrillator Programming and Testing provided guidance on bradycardia programming, tachycardia detection, tachycardia therapy, and defibrillation testing for implantable cardioverter-defibrillator (ICD) patient treatment. The 32 recommendations represented the consensus opinion of the writing group, graded by Class of Recommendation and Level of Evidence. In addition, Appendix B provided manufacturer-specific translations of these recommendations into clinical practice consistent with the recommendations within the parent document. In some instances, programming guided by quality evidence gained from studies performed in devices from some manufacturers was translated such that this programming was approximated in another manufacturer's ICD programming settings. The authors found that the data, although not formally tested, were strong, consistent, and generalizable beyond the specific manufacturer and model of ICD. As expected, because these recommendations represented strategic choices to balance risks, there have been reports in which adverse outcomes were documented with ICDs programmed to Appendix B recommendations. The recommendations have been reviewed and updated to minimize such adverse events. Notably, patients who do not receive unnecessary ICD therapy are not aware of being spared potential harm, whereas patients in whom their ICD failed to treat life-threatening arrhythmias have their event recorded in detail. The revised recommendations employ the principle that the randomized trials and large registry data should guide programming more than anecdotal evidence. These recommendations should not replace the opinion of the treating physician who has considered the patient's clinical status and desired outcome via a shared clinical decision-making process.
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Affiliation(s)
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau Université François Rabelais Tours France
| | - Carlos A Morillo
- Libin Cardiovascular Institute of Alberta University of Calgary Calgary Canada
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Marçalo J, Menezes Falcão L. Arrhythmogenic right ventricular dysplasia: Atypical clinical presentation. Rev Port Cardiol 2017; 36:217.e1-217.e10. [PMID: 28214153 DOI: 10.1016/j.repc.2016.05.009] [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: 01/18/2016] [Revised: 05/01/2016] [Accepted: 05/13/2016] [Indexed: 11/16/2022] Open
Abstract
A 67-year-old man was admitted to our hospital after episodes of syncope preceded by malaise and diffuse neck and chest discomfort. No family history of cardiac disease was reported. Laboratory workup was within normal limits, including D-dimers, serum troponin I and arterial blood gases. The electrocardiogram showed sinus rhythm with T-wave inversion in leads V1 to V3. Computed tomography angiography to investigate pulmonary embolism showed no abnormal findings. Transthoracic echocardiography (TTE) displayed massive enlargement of the right ventricle with intact interatrial septum and no pulmonary hypertension. Cardiac magnetic resonance imaging (MRI) confirmed right ventricular (RV) dilatation and revealed marked hypokinesia/akinesia of the lateral wall. Exercise stress testing was negative for ischemia. According to the 2010 Task Force criteria for arrhythmogenic right ventricular dysplasia (ARVD), this patient presented two major criteria (global or regional dysfunction and structural alterations: by MRI, regional RV akinesia or dyskinesia or dyssynchronous RV contraction and RV ejection fraction ≤40%, and repolarization abnormalities: inverted T waves in right precordial leads [V1, V2, and V3]); and one minor criterion (>500 ventricular extrasystoles per 24 hours by Holter), and so a diagnosis of ARVD was made. After electrophysiologic study (EPS) the patient received an implantable cardioverter-defibrillator (ICD). This late clinical presentation of ARVD highlights the importance of TTE screening, possibly complemented by MRI. The associated risk of sudden death was assessed by EPS leading to the implantation of an ICD. Genetic association studies should be offered to the offspring of all ARVD patients.
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Affiliation(s)
- José Marçalo
- Serviço de Endocrinologia, Hospital de Santa Maria/CHLN, Lisboa, Portugal
| | - Luiz Menezes Falcão
- Serviço de Endocrinologia, Hospital de Santa Maria/CHLN, Lisboa, Portugal; Departamento de Medicina, Hospital de Santa Maria/CHLN, Faculdade de Medicina de Lisboa, Lisboa, Portugal.
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Ribeiro S, Leite L, Oliveira J, Pereira MJ, Pinheiro C, Ermida P, António N, Ventura M, Cristóvão J, Elvas L, Providência L. Transvenous removal of cardiac implantable electronic device leads. Rev Port Cardiol 2015; 34:739-44. [PMID: 26596378 DOI: 10.1016/j.repc.2015.07.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 03/13/2012] [Revised: 01/31/2015] [Accepted: 07/01/2015] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION AND OBJECTIVE The number and complexity of cardiac implantable electronic devices (CIEDs) have increased, as has the number of related complications, often leading to removal of the implanted system. The aim of this study was to characterize transvenous explantation/extraction of CIED leads in a reference center. METHODS This was a descriptive observational study of patients consecutively admitted from January 2009 to May 2014 for transvenous lead extraction. RESULTS The sample consisted of 109 patients, with a mean age of 64.6±16.62 years, 73.1% male. The main indication for lead extraction was CIED infection. The mean time from first implantation to lead removal was 5.6±4.89 years. Blood cultures were positive in 32.8% of cases and 29% of patients had vegetations on echocardiography. A total of 228 cardiac leads were removed, of which 58.8% were ventricular, 32.4% atrial and 8.8% coronary sinus. Complete clinical success was achieved in 97.2% of cases, while procedural success was complete in 93.4% and partial in 5.3%. The complications reported were three cases of significant pocket hematoma, one of subclavian vein thrombosis and three of cardiac tamponade, effectively treated by pericardiocentesis. CONCLUSIONS Transvenous explantion or extraction of CIED leads was highly effective. A high level of experience is an essential factor in the success and safety of the procedure.
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Affiliation(s)
- Sílvia Ribeiro
- Serviço de Cardiologia, Hospital de Guimarães, Guimarães, Portugal.
| | - Luís Leite
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - João Oliveira
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Maria João Pereira
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Carla Pinheiro
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Paulo Ermida
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Natália António
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Miguel Ventura
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - João Cristóvão
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Luís Elvas
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Luís Providência
- Serviço de Cardiologia, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
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Galvão P, Cavaco D, Adragão P, Costa F, Carmo P, Morgado F, Bernardo R, Nunes M, Abecasis M, Neves J, Mendes M. Subcutaneous implantable cardioverter-defibrillator: Initial experience. Rev Port Cardiol 2014; 33:511-7. [PMID: 25242675 DOI: 10.1016/j.repc.2014.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 06/09/2013] [Revised: 12/22/2013] [Accepted: 01/28/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) are important tools in the prevention of sudden death, but implantation requires transvenous access, which is associated with complications. Subcutaneous implantable cardioverter-defibrillators (S-ICDs) may prevent some of these complications. AIM To evaluate the therapeutics and complications associated with S-ICD systems. METHODS S-ICD implantation was planned in 23 patients, for whom the indications were vascular access problems, increased risk of infection or young patients with long predicted follow-up. The population consisted of four patients with ischemic heart disease, three of them on hemodialysis (two with subclavian vein thrombosis), five with left ventricular noncompaction, four with Brugada syndrome, three with arrhythmogenic right ventricular cardiomyopathy, one with transposition of the great vessels, two with dilated cardiomyopathy and four with hypertrophic cardiomyopathy. RESULTS S-ICDs were implanted in 21 patients, two having failed to fulfil the initial screening criteria. Mean implantation time was 77 minutes, with no complications. Defibrillation tests were performed, and in one patient the generator had to be repositioned to obtain an acceptable threshold. In a mean follow-up of 14 months, 10 patients had S-ICD shocks, which were appropriate in half of them; one developed infection, one needed early replacement due to loss of telemetry and one patient died of noncardiac cause. CONCLUSIONS S-ICD implantation can be performed by cardiologists with a high success rate. Initial experience appears favorable, but further studies are needed with longer follow-up times to assess the safety and efficacy of this strategy compared to conventional devices.
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Affiliation(s)
- Pedro Galvão
- Serviço de Cardiologia, Hospital de Santa Cruz, Carnaxide, Portugal.
| | - Diogo Cavaco
- Serviço de Cardiologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Pedro Adragão
- Serviço de Cardiologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Francisco Costa
- Serviço de Cardiologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Pedro Carmo
- Serviço de Cardiologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | | | - Ricardo Bernardo
- Serviço de Cardiologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Manuela Nunes
- Serviço Anestesiologia, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Miguel Abecasis
- Serviço de Cirurgia Cardiotorácica, Hospital de Santa Cruz, Carnaxide, Portugal
| | - José Neves
- Serviço de Cirurgia Cardiotorácica, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Miguel Mendes
- Serviço de Cardiologia, Hospital de Santa Cruz, Carnaxide, Portugal
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