Publications by authors named "Francesca Salghetti"

52 Publications

Transvenous lead extraction in patients with persistent left superior vena cava.

J Cardiovasc Electrophysiol 2021 May 16;32(5):1407-1410. Epub 2021 Apr 16.

Cardiology Department, Spedali Civili Brescia, Brescia, Italy.

Purpose: Predictors of difficulty and complications of transvenous lead extraction (TLE) have been investigated in several studies; however, little is known about the venous anatomical characteristics that can have an impact on procedural outcomes. Among them, the persistent left superior vena cava (PLSVC) is a common anomaly often discovered incidentally during cardiac device implantation and could raise concerns if TLE is indicated. We report technical considerations and outcomes of TLE for two patients with leads implanted via PLSVC.

Methods And Results: Two cardiac implantable electronic device recipients with isolated PLSVC required TLE due to infective endocarditis in one case and lead failure in the other. In the first case, TLE procedure was performed in a hybrid operating room with minimally invasive video-assisted thoracoscopic monitoring due to the high procedural risk. Two active fixation 20-year-old pacing leads were removed with a relatively short fluoroscopy time. In the second case, we successfully extracted a single-coil active fixation lead without the need of a locking stylet or advanced extraction tools. There were no procedural complications or adverse events at 1-year follow-up.

Conclusion: TLE procedures for two patients with isolated PLSVC were successfully completed with less difficulty and tools than expected based on the characteristics of the targeted leads. If indicated, TLE in the presence of a PLSVC should be considered in experienced centers.
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http://dx.doi.org/10.1111/jce.15021DOI Listing
May 2021

Use of a novel implantable cardioverter-defibrillator multisensor algorithm for heart failure monitoring in a COVID-19 patient: A case report.

Clin Case Rep 2021 Mar 28;9(3):1178-1182. Epub 2021 Jan 28.

Chair and Unit of Cardiology University of Brescia Spedali Civili Hospital Brescia Italy.

We report the case of a patient implanted with an implantable defibrillator endowed with a multisensor algorithm for heart failure monitoring. Automatic measurement of multiple clinical variables allowed to detect impending heart failure decompensation and showed its ability to facilitate differential diagnosis in the context of the current COVID-19 pandemic.
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http://dx.doi.org/10.1002/ccr3.3721DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7981691PMC
March 2021

Short P-Wave Duration is a Marker of Higher Rate of Atrial Fibrillation Recurrences after Pulmonary Vein Isolation: New Insights into the Pathophysiological Mechanisms Through Computer Simulations.

J Am Heart Assoc 2021 Jan 7;10(2):e018572. Epub 2021 Jan 7.

Division of Cardiology Cardiocentro Ticino Lugano Switzerland.

Background Short ECG P-wave duration has recently been demonstrated to be associated with higher risk of atrial fibrillation (AF). The aim of this study was to assess the rate of AF recurrence after pulmonary vein isolation in patients with a short P wave, and to mechanistically elucidate the observation by computer modeling. Methods and Results A total of 282 consecutive patients undergoing a first single-pulmonary vein isolation procedure for paroxysmal or persistent AF were included. Computational models studied the effect of adenosine and sodium conductance on action potential duration and P-wave duration (PWD). About 16% of the patients had a PWD of 110 ms or shorter (median PWD 126 ms, interquartile range, 115 ms-138 ms; range, 71 ms-180 ms). At Cox regression, PWD was significantly associated with AF recurrence (=0.012). Patients with a PWD <110 ms (hazard ratio [HR], 2.20; 95% CI, 1.24-3.88; =0.007) and patients with a PWD ≥140 (HR, 1.87, 95% CI, 1.06-3.30; =0.031) had a nearly 2-fold increase in risk with respect to the other group. In the computational model, adenosine yielded a significant reduction of action potential duration 90 (52%) and PWD (7%). An increased sodium conductance (up to 200%) was robustly accompanied by an increase in conduction velocity (26%), a reduction in action potential duration 90 (28%), and PWD (22%). Conclusions One out of 5 patients referred for pulmonary vein isolation has a short PWD which was associated with a higher rate of AF after the index procedure. Computer simulations suggest that shortening of atrial action potential duration leading to a faster atrial conduction may be the cause of this clinical observation.
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http://dx.doi.org/10.1161/JAHA.120.018572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955300PMC
January 2021

Leadless pacemaker: State of the art and incoming developments to broaden indications.

Pacing Clin Electrophysiol 2020 12 29;43(12):1428-1437. Epub 2020 Nov 29.

Division of Cardiology, Spedali Civili Hospital, University of Brescia, Brescia, Italy.

Theleadless pacemaker (LLPM) therapy has been developed in recent years to overcome the transvenous lead and device pocket-related complications. The LLPMs now available are self-contained right ventricular pacemakers and are limited to single-chamber ventricular pacing modality. This literature review deals with the current status of LLPM technology and current areas of clinical applicability. The safety and efficacy outcomes published from randomized clinical trials and real world registries are analyzed and compared with historical conventional transvenous pacemaker data. Furthermore, new pacing modalities and future perspectives to broaden the clinical use and cover most of pacing indications are discussed. Due to the overall safe and effective profile in the short term and intermediate term, also in fragile patients, the LLPM use is constantly growing in daily clinical practice. Actually, it can be considered a landmark innovation, through which a new era of cardiac pacing has begun.
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http://dx.doi.org/10.1111/pace.14097DOI Listing
December 2020

Arrhythmic safety of hydroxychloroquine in COVID-19 patients from different clinical settings.

Europace 2020 12;22(12):1855-1863

Department of Cardiology, ASST-Fatebenefratelli Sacco, Luigi Sacco Hospital, University of Milan, Milan, Italy.

Aims: The aim of the study was to describe ECG modifications and arrhythmic events in COVID-19 patients undergoing hydroxychloroquine (HCQ) therapy in different clinical settings.

Methods And Results: COVID-19 patients at seven institutions receiving HCQ therapy from whom a baseline and at least one ECG at 48+ h were available were enrolled in the study. QT/QTc prolongation, QT-associated and QT-independent arrhythmic events, arrhythmic mortality, and overall mortality during HCQ therapy were assessed. A total of 649 COVID-19 patients (61.9 ± 18.7 years, 46.1% males) were enrolled. HCQ therapy was administrated as a home therapy regimen in 126 (19.4%) patients, and as an in-hospital-treatment to 495 (76.3%) hospitalized and 28 (4.3%) intensive care unit (ICU) patients. At 36-72 and at 96+ h after the first HCQ dose, 358 and 404 ECGs were obtained, respectively. A significant QT/QTc interval prolongation was observed (P < 0.001), but the magnitude of the increase was modest [+13 (9-16) ms]. Baseline QT/QTc length and presence of fever (P = 0.001) at admission represented the most important determinants of QT/QTc prolongation. No arrhythmic-related deaths were reported. The overall major ventricular arrhythmia rate was low (1.1%), with all events found not to be related to QT or HCQ therapy at a centralized event evaluation. No differences in QT/QTc prolongation and QT-related arrhythmias were observed across different clinical settings, with non-QT-related arrhythmias being more common in the intensive care setting.

Conclusion: HCQ administration is safe for a short-term treatment for patients with COVID-19 infection regardless of the clinical setting of delivery, causing only modest QTc prolongation and no directly attributable arrhythmic deaths.
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http://dx.doi.org/10.1093/europace/euaa216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543547PMC
December 2020

Sinus Node Dysfunction in a Young Patient With COVID-19.

JACC Case Rep 2020 Jul 8;2(9):1240-1244. Epub 2020 Jun 8.

Department of Medical and Surgical Specialties, Institute of Cardiology, University of Brescia, Brescia, Italy.

A 34-year-old man was admitted with acute lung injury and COVID-19 pneumonia. In the intensive care unit, he experienced episodes of prolonged asystole accompanied by hypotension without loss of consciousness. Once reversible causes were excluded, symptoms were related to dysfunction of the sinus node, and the patient underwent implantation of a pacemaker. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.05.067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279757PMC
July 2020

Technical considerations for CRT-D implantation in different varieties of persistent left superior vena cava.

J Interv Card Electrophysiol 2020 Aug 11. Epub 2020 Aug 11.

Spedali Civili Brescia, Brescia, Italy.

Purpose: The persistent left superior vena cava (PLSVC) is usually asymptomatic and creates a challenge when detected incidentally during cardiac resynchronization therapy defibrillator (CRT-D) implantation. The purpose of our cases is to show different anatomical variables of PLSVC and different strategies used for CRT-D implantation.

Methods: Four cases of PLSVC were presented. Pre-procedural bilateral venography was done to define anatomical variant of PLSVC. The side of approach and vein of approach were chosen according to the anatomical variant. Major challenges, electrical parameters, procedural times, long-term follow up, and complications were addressed.

Results: Two cases were de novo CRT-D implantation. One case was an extraction/re-implantation of the coil lead, and one case was an upgrading. In one case, CRT-D implantation was followed by AVN ablation. All cases had successful devices implantation. Two cases had isolated PLSVC: one of them had right approach and the other had left approach. One case had double SVC with no connecting brachiocephalic veins and underwent a left-sided approach. One case had double SVC with a small connecting brachiocephalic vein and had a left approach for implantation with using the small brachiocephalic vein for the RV lead. Electrical parameters were acceptable for all leads implanted. Long-term follow-up was done for 6 months to 5 years. One complication occurred (acute atrial lead dislodgement).

Conclusions: In our case series, the presence of PLSVC did not preclude successful placement of pacemaker/defibrillator leads using standard tools. Bilateral venography helped to decide the side and vein of lead insertion.
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http://dx.doi.org/10.1007/s10840-020-00843-6DOI Listing
August 2020

Electrocardiographic imaging of the arrhythmogenic substrate of Brugada syndrome: Current evidence and future perspectives.

Trends Cardiovasc Med 2020 Jun 15. Epub 2020 Jun 15.

Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Vrije Universiteit Brussel, Belgium. Electronic address:

Brugada syndrome is responsible for about 20% of sudden cardiac deaths in patients with apparently normal hearts. Basic and clinical research has elucidated some of the mechanisms that are responsible for life-threatening ventricular arrhythmias in this syndrome. Delays in activation and repolarization over the right ventricular outflow tract are the most likely cause of the ECG typical pattern and arrhythmogenesis. Invasive epicardial and endocardial mapping has identified the epicardium as the principal region of interest for these anomalies, and areas of fragmented potentials at invasive mapping are a target for epicardial ablation. Noninvasive mapping systems have been developed to study the epicardial depolarization and repolarization and may be particularly useful in assessing the epicardial arrhythmogenic substrate of Brugada syndrome for both clinical and research purpose. This review focuses on recent advances in this field.
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http://dx.doi.org/10.1016/j.tcm.2020.06.004DOI Listing
June 2020

Standardized Quantification of Vagal Denervation by Extracardiac Vagal Stimulation during Second Generation Cryoballoon ablation: a Vein per Vein Analysis.

J Atr Fibrillation 2019 Oct-Nov;12(3):2223. Epub 2019 Oct 31.

Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium.

Aims: The purpose of this study was to evaluate the contribution in the acute loss in vagal innervation after ablation with the second generation cryoballoon (CB-A) in each distinct pulmonary vein (PV) by means of external cardiac vagal stimulation (ECVS) by positioning a catheter in the internal jugular vein in a cohort of 60 patients.

Methods: Sixty patients, 50 starting from the left superior pulmonary vein (LSPV) and 10 from the right superior pulmonary vein with symptomatic paroxysmal atrial fibrillation (PAF), having undergone ECVS before the first and after each PV ablation by means of CB-A ablation, were included.

Results: The ECVS performed pre-ablation provoked cardioinhibitory responses in all cases with mean pause duration of 10251.83 ms ± 2826.23 ms. At the end of the procedure, the vagal reactions (VR) were significantly diminished. Specifically, compared against the initial pause, responses were 8957.06 ± 2711.66 ms (p < 0.01) after left superior PV, 10017.36 ± 9127.0 ms (p = 0.88) after left inferior PV, 6020.16 ± 3780.709 ms (p < 0.001) after right inferior PV and 1687.5 ± 2183.7 ms (p < 0.001) after right superior PV. Noteworthy, if starting with ablation in the RSPV, VR was immediately reduced by 90.34%, 990.7 ± 379.78 ms (p < 0.001) as compared to baseline response.

Conclusion: Although not directly targeting the ganglion plexuses, AF ablation with the CB-A causes a significant acute loss in parasympathetic innervation. The RSPV showed to be associated with the most significant reduction of acute loss in parasympathetic innervation.
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http://dx.doi.org/10.4022/jafib.2223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237095PMC
October 2019

The MB score: a new risk stratification index to predict the need for advanced tools in lead extraction procedures.

Europace 2020 04;22(4):613-621

Arrhythmology Unit, San Raffaele Hospital, Milan, Italy.

Aims: A validated risk stratification schema for transvenous lead extraction (TLE) could improve the management of these procedures. We aimed to derive and validate a scoring system to efficiently predict the need for advanced tools to achieve TLE success.

Methods And Results: Between November 2013 and March 2018, 1960 leads were extracted in 973 consecutive TLE procedures in two national referral sites using a stepwise approach. A procedure was defined as advanced extraction if required the use of powered sheaths and/or snares. The study population was a posteriori 1:1 randomized in derivation and validation cohorts. In the derivation cohort, presence of more than two targeted leads (odds ratio [OR] 1.76, P = 0.049), 3-year-old (OR 3.04, P = 0.001), 5-year-old (OR 3.48, P < 0.001), 10-year-old (OR 3.58, P = 0.008) oldest lead, implantable cardioverter-defibrillator (OR 3.84, P < 0.001), and passive fixation lead (OR 1.91, P = 0.032) were selected by a stepwise procedure and constituted the MB score showing a C-statistics of 0.82. In the validation group, the MB score was significantly associated with the risk of advanced extraction (OR 2.40, 95% confidence interval 2.02-2.86, P < 0.001) and showed an increase in event rate with increasing score. A low value (threshold = 1) ensured 100% sensibility and 100% negative predictive value, while a high value (threshold = 5) allowed a specificity of 92.8% and a positive predictive value of 91.9%.

Conclusion: In this study, we developed and tested a simple point-based scoring system able to efficiently identify patients at low and high risk of needing advanced tools during TLE procedures.
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http://dx.doi.org/10.1093/europace/euaa027DOI Listing
April 2020

Correction to: Two-year follow-up of one-stage left unilateral thoracoscopic epicardial and transcatheter endocardial ablation for persistent and long-standing persistent atrial fibrillation.

J Interv Card Electrophysiol 2020 09;58(3):345-346

Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium.

Owing to a type error during final correction and proof data submission to the journal, there were mistakes introduced into the legends of Fig. 3 and Fig. 4 as well as into the Y-axis title of the plot of Fig. 4.
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http://dx.doi.org/10.1007/s10840-020-00702-4DOI Listing
September 2020

Radiofrequency versus cryoballoon ablation for atrial fibrillation in the setting of left common pulmonary veins.

Pacing Clin Electrophysiol 2019 11 10;42(11):1456-1462. Epub 2019 Oct 10.

Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium.

Background: A left common pulmonary vein (LCPV) accounts as the most frequent pulmonary vein (PV) variation. Our aim was to compare the performance of radiofrequency (RF) versus second-generation cryoballoon (CB-A) ablation in patients with atrial fibrillation (AF) and LCPVs.

Methods: In a total cohort of 716 patients undergoing PV isolation with preprocedural CT-scanning, LCPV+ patients were selected with measurement of PV ostial area and trunk distance. All LCPV+ patients were matched between RF and CB-A group in a 1:1 ratio based on propensity scores, and compared for outcome.

Results: Left common pulmonary veins were found in 31% (88/283) RF versus 34% (146/433) CB-A patients, respectively, (P = .44). In the matched population of 83 LCPV+ patients in each group, electrical isolation could be achieved in all left-sided PVs. No significant difference was noted for the rate of AF/left atrial tachyarrhythmia (LAT) recurrence between RF and CB-A group (30% vs 28%, P = .86), with similar AF/LAT-free survival (log rank, P = .71). There were 48 patients with AF/LAT recurrence (29%) during the follow-up. Recurrence rate between paroxysmal versus persistent AF was 27/120 (22.5%) versus 21/46 (46%), P = .004. Cox proportional regression analysis withheld LA volume and persistent AF as independent variables to predict AF/LAT recurrence. No increased hazard for AF/LAT recurrence was observed for patients with a long (>15 mm) vs short (5-15 mm) LCPV trunk (OR 1.14, 95% CI 0.6-2.2, P = .7).

Conclusions: In our study, equal efficacy and outcome was noted in LCPV+ patients between RF and CB-A technology.
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http://dx.doi.org/10.1111/pace.13810DOI Listing
November 2019

Two-year follow-up of one-stage left unilateral thoracoscopic epicardial and transcatheter endocardial ablation for persistent and long-standing persistent atrial fibrillation.

J Interv Card Electrophysiol 2020 Sep 13;58(3):333-343. Epub 2019 Sep 13.

Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels, Belgium.

Purpose: The purpose of this study was to analyze the efficacy and complication rates of a one-stage left unilateral thoracoscopic hybrid procedure in a series of patients with persistent and long-standing persistent atrial fibrillation (AF) in a 2-year follow-up.

Methods: Fifty-one consecutive patients (34 males, 65.7 ± 8 years) having undergone hybrid isolation of pulmonary veins (PVs) and posterior wall of left atrium (LA) by means of left unilateral hybrid thoracoscopic ablation for symptomatic persistent (n = 22, 43%) and long-standing persistent atrial fibrillation (AF) (n = 29, 57%) were analyzed.

Results: At a mean follow-up of 24.9 ± 11.8 months (median 24), the success rate without antiarrhythmic therapy was achieved in 68.6% of patients. Procedure-related major complications were observed in 2 patients (4%) including diaphragmatic perforation and late pericardial tamponade requiring mini left-sided thoracotomy and pericardial drainage, respectively. The success rate did not significantly differ between persistent and long-standing persistent AF (respectively, 68.2 and 69%; P = 0.89). Patients with AF relapse during the blanking period were 3.8 times more likely to have AF recurrence after 3 months from the ablation procedure.

Conclusion: The hybrid one-stage left unilateral thoracoscopic procedure exhibits encouraging results in the setting of both persistent and long-standing persistent AF after a 2-year follow-up, at a low rate of adverse events.
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http://dx.doi.org/10.1007/s10840-019-00616-wDOI Listing
September 2020

Mid-term outcome following second-generation cryoballoon ablation for atrial fibrillation in heart failure patients: effectiveness of single 3-min freeze cryoablation performed in a cohort of patients with reduced left ventricular systolic function.

J Cardiovasc Med (Hagerstown) 2019 Oct;20(10):667-675

Heart Rhythm Management Center, UZ Brussel-VUB, Laarbeeklaan 101, 1090, Brussels, Belgium Electrophysiology Unit, Villa Maria Cecilia, Via Corriera, 1, 48033 Cotignola RA, Italy.

Purpose: Currently, information on the mid-term outcome of cryoballoon ablation (CB-A) for drug-resistant atrial fibrillation in patients with reduced left ventricular systolic function is limited.

Methods: Thirty-eight consecutive patients with paroxysmal or persistent atrial fibrillation (84.2% male), with median left ventricular ejection fraction of 37.3% were included in our study. All patients underwent the procedure with the 28-mm cryoballoon advance.

Results: There were no mayor complications related to the CB-A procedure. Median follow-up was 26.5 ± 13.7 months. The freedom from atrial fibrillation after a blanking period of 3 months was 42.9% in our cohort of patients. During the follow-up period, 13 patients underwent at least a new electrophysiological procedure. After a single procedure, the univariate predictors of clinical recurrence after the blanking period were age and persistent atrial fibrillation.

Conclusion: Second-generation CB-A of atrial fibrillation seems feasible and safe in patients with heart failure with reduced ejection fraction and heart failure with mid-range ejection fraction, in terms of complications rate and number of applications per vein. All pulmonary veins could be isolated with the 28-mm cryoballoon advance only.
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http://dx.doi.org/10.2459/JCM.0000000000000845DOI Listing
October 2019

Acute and one year outcome of premature ventricular contraction ablation guided by contact force and automated pacemapping software.

J Arrhythm 2019 Jun 14;35(3):542-549. Epub 2019 May 14.

Heart Rhythm Management Centre Universitair Ziekenhuis Brussel Postgraduate Program in Cardiac Electrophysiology and Pacing Vrije Universiteit Brussel Brussels Belgium.

Background: Radiofrequency (RF) ablation is a well-established approach to treat premature ventricular contractions (PVC) and is associated with good outcomes.

Aim: The present study sought to analyze the acute efficacy and 1-year outcomes of PVC ablation using RF technology with an approach based on automated pace-mapping and contact force (CF) information.

Methods: Sixty-one consecutive patients (52.4% males, age 45.9 ± 12.5) underwent catheter ablation for symptomatic monomorphic PVC. All procedures were guided by a 3-dimensional mapping system; site of ablation was selected based on PASO aided pace-mapping; RF was started on the selected location when stable catheter position with >10 g of CF were obtained.The procedure was defined as acutely effective if the PVC was eliminated and it did not recur during within 30 minutes. Long-term efficacy was defined as a decrease by more than 95% at 1 year of the initial PVC burden at ECG Holter monitoring.

Results: The PVC ablation was performed in the right ventricular outflow tract in 37 patients (60.7%), left ventricle in 15 patients (24.6%), coronary cusps in 6 patients (9.8%), right ventricle in 3 patients (4.9%); PVC ablation was acutely successful in 59 of patients (96.7%). At 1-year efficacy was obtained in 57 patients (93.4%). No major complications occurred. Mean procedural and fluoroscopy time were 94.5 ± 20.9 and 4.3 ± 2.5 minutes respectively.

Conclusion: Premature ventricular contraction RF ablation mainly guided by PASO and CF showed high success rate in both acute and 1-year follow-up (96.7% and 93.4% respectively). The best efficacy cut-off for RF ablation of PVCs has been identified in presence of both PASO ≥95% and CF >10 g.
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http://dx.doi.org/10.1002/joa3.12194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595285PMC
June 2019

Predictors of long-term outcome in patients undergoing a first repeat ablation consisting solely of re-isolation of reconnected pulmonary veins.

J Atr Fibrillation 2019 Feb-Mar;11(5):2114. Epub 2019 Feb 28.

Electrophysiology Unit, ZNA Middelheim, Lindendreef 1, 2020 Antwerp, Belgium.

Aims: To define predictors of long-term outcome of a first repeat ablation solely consisting of re-isolation of reconnected pulmonary veins (PVs).

Methods: Three hundred seven patients (age 59 ± 9%, 77% males, non-paroxysmal AF 43%) with recurrent AF after first PVI were studied. Re-isolation of reconnected PVs was guided by a circular mapping catheter and 3D mapping system using RF ablations. A PV was defined as "triggering" in case of spontaneous ectopy or AF paroxysms originating from the PV.

Results: After a mean follow-up of 5.05 ± 2.21 years, 194 (63.2%) patients (73.0% in PAF vs 50.4% in non-PAF, log Rank <0.001) were free from AF. A "triggering" PV was present in 48 (15.6%) during the first PVI and in 52 (16.9%) at repeat. Independent predictors of recurrence were a non-PAF type (HR: 1.814, 95%CI: 1.090 - 3.018, p=0.022) and early recurrence (≤ 3 months) after first PVI (HR: 1.632, 95%CI: 1.091 - 2.443, p=0.017) while a "triggering" PV at first or repeat was a predictor of good outcome (HR: 0.574; 95%CI: 0.344 - 0.959; p=0.034) in the multivariable analysis.

Conclusions: A repeat ablation solely consisting of re-isolation of reconnected PVs results in a high degree of long-term AF freedom, especially in PAF and in case of a PV trigger at index or repeat. Patients with non-PAF or experiencing early AF recurrence after first PVI are less responsive.
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http://dx.doi.org/10.4022/jafib.2114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6533818PMC
February 2019

Over-the-needle trans-septal access using the cryoballoon delivery sheath and dilator in atrial fibrillation ablation.

Pacing Clin Electrophysiol 2019 07 13;42(7):868-873. Epub 2019 May 13.

Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium.

Background: In the setting of second-generation cryoballoon (CB2) ablation, left atrial (LA) access is generally achieved using a standard sheath (SS) that is exchanged for the 15Fr cryoballoon delivery sheath (CBS) and dilator over a long wire (CBS over-the-wire technique, CBS-W). Our objective was to evaluate the direct use of the CBS to gain LA access, by advancing the latter over the trans-septal needle (CBS over-the-needle technique, CBS-N), under transesophageal echocardiographic (TEE) guidance.

Methods: Consecutive patients who underwent CB2 ablation with the CBS-N technique were evaluated for feasibility of gaining LA access using TEE guidance and fluoroscopy views. Complications related to the LA access were compared with a matched CBS-W control group. Subanalysis (30 CBS-W vs 30 CBS-N patients) evaluated time-to-LA of the CBS: time from superior vena cava (with SS vs CBS) to LA insertion of the CBS, after exchange or directly, respectively.

Results: LA access could be achieved in all 505 patients of the CBS-N group, without technique modification or additional equipment. Challenging interatrial septa were noted in 13% of these patients: previous atrial septal defect repair (1%), hypermobile (10%), aneurysmal (1%), and abnormally thickened/fibrotic (1%). Incidence of complications was similar to the CBS-W group. Subanalysis showed a shorter time-to-LA in the CBS-N versus CBS-W group, 72 ± 46 seconds versus 293 ± 180 seconds, P < .001.

Conclusions: Our study showed that the CBS-N technique is feasible and safe under echocardiographic guidance. Without sheath exchange, it simplifies the CB2 procedure, is less costly, time sparing, and might reduce the risk of air embolism.
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http://dx.doi.org/10.1111/pace.13709DOI Listing
July 2019

Posterior box isolation as an adjunctive ablation strategy during repeat ablation with the second-generation cryoballoon for recurrence of persistent atrial fibrillation: 1-year follow-up.

J Interv Card Electrophysiol 2019 Oct 27;56(1):1-7. Epub 2019 Apr 27.

Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit, Brussels, Belgium.

Background: The creation of a posterior box isolation of the left atrium (LAPWI) in addition to pulmonary vein isolation (PVI) with the second-generation cryoballoon (CB-A) seems to offer promising clinical outcome in patients affected by persistent atrial fibrillation (PersAF).

Aim: This work aims to study the clinical outcome of an ablation strategy based on the creation of a LAPWI during repeat procedures for recurrent AF after an index CB-A procedure for PersAF.

Methods And Results: A total of 33 patients having undergone a repeat procedure consisting in redo PVI plus LAPWI for recurrent PersAF with the CB-A after an index PVI ablation were retrospective included in our study. Electrical reconnection could be documented in 18 veins (13%). The LAPW was successfully isolated solely by CB-A ablation in 30 out of 33 (91%) patients; in the remaining 3 patients, isolation of the LAPW was completed by focal tip-irrigated RF ablation. The mean number of CB-A applications required for the superior portion of the LAPW and the inferior portion of the LAPW creation were 5.4 ± 0.9 and 4 ± 0.6, respectively. After a mean follow-up of 11.8 ± 3 months, 28 patients (85%) did not experience recurrence of any atrial arrhythmias during follow-up, without the need of further ablation or class I or III AADs.

Conclusion: Left posterior wall isolation with the CB-A is feasible and safe during repeat ablation procedures for recurrent PersAF. In our study, the 12-month freedom from any arrhythmia was 85% following this ablation strategy.
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http://dx.doi.org/10.1007/s10840-019-00551-wDOI Listing
October 2019

Evaluation of the luminal esophageal temperature behavior during left atrium posterior wall ablation by means of second-generation cryoballoon.

J Interv Card Electrophysiol 2019 Aug 7;55(2):191-196. Epub 2019 Feb 7.

Heart Rhythm Management Center, Postgraduate program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, Brussels, Belgium.

Purpose: The purpose of this study was to clarify the behavior of the luminal esophageal temperature (LET) in a cohort of patients undergoing second-generation cryoballoon (CB-A) for pulmonary vein isolation (PVI) and additional left atrium posterior wall (LAPW) ablation by means of CB-A.

Methods: Thirty patients with symptomatic persistent AF (PersAF), having undergone PVI + LAPW cryoballoon ablation with LET monitoring.

Results: Interruption of the application due to a LET below 15 °C occurred in 5 patients (16.6%), 2 at the LIPV and 3 in the LAPW. The 5 patients underwent gastroscopy the day after ablation. In all individuals, esophageal thermal lesion (ETL) was absent.

Conclusion: The evaluation of LET might be an additional tool in helping to prevent damage to the esophagus during the LAPW ablation with the CB-A by stopping the freeze application when temperature reaches values of < 15 °C.
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http://dx.doi.org/10.1007/s10840-019-00523-0DOI Listing
August 2019

Quantification of acute parasympathetic denervation during cryoballoon ablation by using extracardiac vagal stimulation.

J Cardiovasc Med (Hagerstown) 2019 Mar;20(3):107-113

Heart Rhythm Management Centre, Postgraduate Course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium.

Aims: The purpose of this study was to systematically quantify the level of acute parasympathetic denervation in a stepwise fashion by means of extracardiac vagal stimulation (ECVS) by positioning a quadripolar catheter in the internal jugular vein, in a cohort of patients undergoing second-generation cryoballoon ablation for paroxysmal atrial fibrillation.

Methods: Fifty patients with symptomatic paroxysmal atrial fibrillation, having undergone extracardiac vagal stimulation before and after ablation by means of second-generation cryoballoon second-generation cryoballoon ablation, were included.

Results: The extracardiac vagal stimulation performed preablation provoked cardioinhibitory responses in all patients with mean pause duration of 10130.6 ± 3280.0 ms. At the end of the procedure, the VRs were significantly diminished with mean pause of 1687.5 ms ± 2183.7 ms (P = 0.00 compared with the pause before the procedure).

Conclusion: The ECVS proved to be a reproducible, feasible and reliable method to quantify the degree of parasympathetic denervation during CB-A. In all patients, significant cardiac parasympathetic denervation could be observed at the end of the procedure. Responses to ECVS were more specific to quantify the vagal denervation than the increase in the heart rate. However larger studies are needed to confirm this observation.
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http://dx.doi.org/10.2459/JCM.0000000000000760DOI Listing
March 2019

Hybrid thoracoscopic epicardial ablation of right ventricular outflow tract in patients with Brugada syndrome.

Heart Rhythm 2019 06 27;16(6):879-887. Epub 2018 Dec 27.

Cardiac Surgery Department, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Brussels, Belgium.

Background: Abnormal delayed electrograms (EGMs) from the anterior wall of the right ventricular outflow tract (RVOT) epicardium have become the ablation target in Brugada syndrome (BrS).

Objective: The aim of this study was to analyze the safety, feasibility, and efficacy of a novel hybrid thoracoscopic approach to perform epicardial RVOT radiofrequency ablation in BrS.

Methods: Thirty-six patients with BrS (26 men (72.2%); mean age 36.6±15.8 years; range 3-63 years) who underwent hybrid thoracoscopic epicardial ablation of RVOT from January 2016 to April 2018 were included in this study. Two expert electrophysiologists analyzed the EGMs during ajmaline challenge and guided the surgeon to perform ablation. Ajmaline challenge was repeated after 1 month to assess the absence of the BrS electrocardiographic pattern. Patients were followed by remote monitoring and outpatient visits every 6 months.

Results: The elimination of all abnormal EGMs was achieved in 94.4% of patients. After a mean follow-up of 16 ± 8 months (range 6-30 months), freedom from ventricular arrhythmias was obtained in 7 (77.8%) patients in secondary prevention 9/36 (25%) and in 24 (100%) patients in primary prevention 24/36 (75%). Major complications were observed in 1 patient (2.8%), who experienced late cardiac tamponade.

Conclusion: Hybrid thoracoscopic epicardial RVOT ablation in BrS is a safe and feasible approach, allowing direct visualization of ablation during radiofrequency delivery. Because of ventricular arrhythmia recurrences, implantable cardioverter-defibrillator implantation is still mandatory in patients treated in secondary prevention and with high risk.
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http://dx.doi.org/10.1016/j.hrthm.2018.12.026DOI Listing
June 2019

Management of a leadless pacemaker recall via extraction in a patient with a history of multiple previous device implants.

J Electrocardiol 2019 Mar - Apr;53:5-7. Epub 2018 Dec 12.

Chair and Unit of Cardiology, University of Brescia, Spedali Civili Hospital, Brescia, Italy. Electronic address:

We describe a management strategy of a leadless pacemaker recall (LP) via extraction in a pacemaker-dependent patient with a history of multiple previous device implants. We performed a two-step procedure. First, we implanted a second LP in the right ventricle. Then, 3 days later for concerns about the stability of the newly-implanted device, we retrieved the first LP, 3 years after its original implant. The patient was hemodynamically stable throughout the two procedures and no adverse event occurred in the 3 days of coexistence of the two LPs. Although the limitation of a single case experience, this approach may be taken into consideration when facing similar high-risk cases.
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http://dx.doi.org/10.1016/j.jelectrocard.2018.12.009DOI Listing
July 2020

Second-Generation Cryoballoon Ablation for Atrial Fibrillation - A Detailed Analysis of the Impact of Left Atrial Volume Index on Clinical Outcome.

Circ J 2018 12 14;83(1):84-90. Epub 2018 Nov 14.

Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel.

Background: Pulmonary vein isolation (PVI) by means of cryoballoon is increasingly being used for the treatment of atrial fibrillation (AF). This study assessed whether the left atrial volume index (LAVI) predicts AF recurrence following PVI by means of 2nd-generation cryoballoon (Cryoballoon Advance; CB-A) when comparing persistent AF (PeAF) and paroxysmal AF (PAF). Methods and Results: Patients with drug-resistant AF and undergoing preprocedural computed tomography (CT) and PVI with CB-A were included. LAV was estimated from 3D CT images. A total of 417 patients with AF were included (95 PeAF, 322 PAF patients). After a mean of 22.1±9.4 months follow-up, 45/95 (47%) PeAF patients and 254/322 (79%) PAF patients had no recurrence. LAVI was an independent predictor for AF recurrence in PeAF patients (hazard ratio 1.042 per 1 mL/m; 95% confidence interval 1.006-1.080, P=0.02), but not in PAF patients. In PeAF patients with LAVI ≤61 mL/m, the freedom from recurrence was 78.5% vs. 22.2% in those with LAVI >61 mL/m (hazard ratio 5.771, 95% confidence interval 2.434-13.682, P<0.001), and the mid-term success rate was comparable with PAF patients.

Conclusions: LAVI predicted AF recurrence after PVI using CB-A in PeAF patients but not in PAF patients. If LAVI was ≤61 mL/m, the mid-term efficacy among PeAF patients was equivalent to that for PAF patients.
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http://dx.doi.org/10.1253/circj.CJ-18-0650DOI Listing
December 2018

Continuous monitoring after second-generation cryoballoon ablation for paroxysmal atrial fibrillation in patients with cardiac implantable electronic devices.

Heart Rhythm 2019 02 18;16(2):187-196. Epub 2018 Aug 18.

Heart Rhythm Management Center, Postgraduate Course in Clinical EP and Pacing, Vrije Universiteit Brussel, Brussels, Belgium. Electronic address:

Background: The second-generation cryoballoon (CB) is effective in achieving pulmonary vein isolation. Continuous monitoring would eliminate any over- or underestimated freedom from atrial fibrillation (AF) postablation.

Objective: The purpose of this study was to differentiate between arrhythmias occurring after cryoballoon ablation (CBA), detecting true AF in symptomatic patients and detecting silent subclinical AF.

Methods: Between June 2012 and January 2015, 54 patients with a preexisting cardiac implantable electronic device (CIED) who had undergone CBA for paroxysmal atrial fibrillation (PAF) were included in our retrospective study. Regular CIED controls, physical examination, and ECG recordings were performed by an experienced cardiologist blinded to the ablation procedure. Data on any hospitalization during follow-up were gathered. Patients were encouraged to note all clinical symptoms during follow-up.

Results: Continuous monitoring showed a success rate of 83.3% after 1 year and 75.93% after 3 years of follow-up. During the first year, 68% of episodes of palpitations after ablation were due to sinus tachycardia, nonsustained ventricular tachycardia, or supraventricular tachycardia. AF recurrence was detected in 15.6% of asymptomatic patients during follow-up. Total AF burden post-CBA had decreased to 0.64% ± 4.34% (P <.001) during long-term follow-up of 3.3 years.

Conclusion: Although this is a selected group of patients with a preexisting CIED, continuous monitoring showed freedom from AF in 83.3% of patients post-CBA after 1 year and 75.93% after 3 years of follow-up.
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http://dx.doi.org/10.1016/j.hrthm.2018.08.015DOI Listing
February 2019

Real-Time Recordings in Cryoballoon Pulmonary Veins Isolation: Comparison Between the 25mm and the 20mm Achieve Catheters.

J Atr Fibrillation 2018 Apr 30;10(6):1855. Epub 2018 Apr 30.

Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel- Laarbeeklaan 101, 1090 Brussels, Belgium.

Aims: Real Time Recordings (RTR) of pulmonary vein (PV) activity provide important information in the setting of the 2nd generation Cryoballoon (CB-A), as a funcion of time to isolation. Visualization of RTR with the standard inner lumen mapping catheter (ILMC) 20mm Achieve (AC) is possible in roughly 50% of PVs. A novel 25mm-Achieve Advance (AC-A) has been developed with the aim of increasing the detection of RTR. The purpose of this study is to compare the AC-A with the AC, to feasibility and improvement of RTR.

Methods: We assigned 50 patients with paroxysmal or persistent atrial fibrillation to CB-A PVI, using the AC-A as ILMC. We compared this group with 50 patients, matched for age and left atrial volume, who previously underwent the CB-A PVI using the AC.

Results: RTR were more frequently observed with the AC-A than with the AC (74% vs 49%; p= 0.02). RTR in the left superior PVs was similar in both groups (74% vs 72%, p= 0.8). RTR with the AC-A were equally appreciated in left or right sided, superior or inferior PVs. No significant differences were found in terms of feasibility, procedure fluoroscopy and freezing times, nadir temperatures, and acute PVI.

Conclusions: CB-A PVI with the AC-A is feasible and safe in all PVs. The AC-A has proven significantly superior in visualising RTR if compared to the AC, affording RTR in 74% of PVs.
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http://dx.doi.org/10.4022/jafib.1855DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6009793PMC
April 2018

Single 3-min freeze per vein ablation strategy with the second-generation cryoballoon for atrial fibrillation in a large cohort of patients: long term outcome after a single procedure.

J Interv Card Electrophysiol 2018 Oct 13;53(1):81-89. Epub 2018 Jun 13.

Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Laarbeeklaan 101, Brussels, Belgium.

Purpose: The purpose of the present study was to assess the long-term success rate of a single 3-min freeze per vein ablation strategy in the setting of pulmonary vein isolation (PVI) by means of second-generation cryoballoon (CB-A; Arctic Front Advance, Medtronic, Minneapolis, MN, USA) in a large cohort of patients.

Methods: Three hundred and one patients with drug resistant atrial fibrillation (AF) having undergone PVI by means of CB-A using a single 3-min freeze per vein ablation strategy were included in the analysis.

Results: Paroxysmal AF (PAF) was documented in 70.8% of the patients, while 29.2% presented with persistent AF (PersAF). The mean number of CB applications was 1.09 ± 0.3 in the left superior pulmonary vein (LSPV), 1.04 ± 0.2 in the left inferior pulmonary vein (LIPV), 1.12 ± 0.3 in the right superior pulmonary vein (RSPV), and 1.12 ± 0.3 in the right inferior pulmonary vein (RIPV). All PVs were successfully isolated with a 28-mm CB-A only. After a mean follow-up of 38.1 ± 7.5 months, 207 (68.8%) patients were free of atrial tachyarrhythmia (ATa) recurrences following a single procedure. Specifically, 72.8% of patients presenting with PAF and 59.1% of individuals with PersAF did not experience a recurrence.

Conclusions: A single 3-min freeze per vein strategy is effective in treating AF on a long term follow-up of 38 months. Specifically, it can afford freedom from ATa recurrences in 72.8% of patients affected by PAF and 59.1% of patients initially presenting with PersAF after a single CB-A procedure.
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http://dx.doi.org/10.1007/s10840-018-0393-4DOI Listing
October 2018

Impact of an additional right pulmonary vein on second-generation cryoballoon ablation for atrial fibrillation: a propensity matched score study.

J Interv Card Electrophysiol 2019 Jan 21;54(1):1-8. Epub 2018 Apr 21.

Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, 101 Laarbeeklaan, 1090, Brussels, Belgium.

Purpose: Cryoballoon (CB) technology in the context of anatomical pulmonary vein (PV) variants might hypothetically hamper successful PV isolation (PVI). Our aim was to assess the impact of a right middle PV (RMPV) in the setting of second-generation cryoballoon (CB advance-CB-A), on procedural parameters and on mid-term follow-up.

Methods: Consecutive patients with AF presenting RMPV (RMPV+) at the pre-procedural computed tomography who underwent PVI by CB-A were enrolled. Comparison with propensity score-matched patients without RMPV (RMPV-) was performed. Acute procedural parameters and clinical follow-up were assessed.

Results: A total of 240 patients (80 RMPV+) were included in the analysis. Twelve of 80 (15%) RMPV+ patients underwent a direct cryo-application in this variant and accomplished the isolation without phrenic nerve palsy, whereas in 25 of 80 (31%) RMPV+ patients, the RMPVs were not targeted directly nor indirectly (by co-occlusion during application at a major PV). At a median follow-up of 17.3 [interquartile range 11.3-26.5] months, there was no significant difference in AF-free survival between RMPV+ and RMPV- patients (78.8 vs 78.1%, P = 1.00), and the recurrence of atrial arrhythmias among patients with versus without an intentional or indirect cryo-application to the RMPV was not different (22 vs 20%, P = 1.00).

Conclusions: Mid-term outcome after CB-A ablation did not differ between RMPV+ and RMPV- patients. Within RMPV+ patients, outcome was similar between those with versus without a cryo-application (either direct or indirect) to the additional vein.
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http://dx.doi.org/10.1007/s10840-018-0373-8DOI Listing
January 2019

Anatomical and procedural predictors of pulmonary vein stenosis in the setting of second-generation cryoballoon ablation.

J Cardiovasc Med (Hagerstown) 2018 Jun;19(6):290-296

Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium.

Aims: Pulmonary vein stenosis (PVS) is a well recognized complication as a consequence of pulmonary vein isolation. In the current study, we sought to analyze potential anatomical and intraprocedural predictors of PVS during second-generation cryoballoon ablation, particularly focusing on the impact of freeze duration and number of cryoapplications.

Methods: Fifty-four patients who underwent cryoballoon ablation for atrial fibrillation were included retrospectively in this study. All patients underwent cardiac-enhanced multidetector computed tomography both before and after the ablation. The exclusion criteria were any contraindications for the procedure, including the presence of an intracavitary thrombus, uncontrolled heart failure and contraindications to general anesthesia.

Results: Mild (25-50%) PVS was only detected in one vein (0.4%) and neither moderate (50-75%) nor severe (>75%) PVS were found. Twenty-five pulmonary veins (12%) exhibited slight narrowing of the diameter (less than 25%). In the univariate analysis, a longer duration of cryoapplication and a larger pulmonary vein ostium preprocedure diameter and area were independently associated with pulmonary vein narrowing [odds ratio (OR): 1.004; confidence interval (CI): 1.001-1.008, P = 0.016; OR: 1.250, CI: 1.090-1.434, P = 0.001 and OR: 1.006; CI: 1.002-1.011, P = 0.006] respectively.

Conclusion: Longer duration of cryoablation, an increased number of applications per vein and larger pulmonary vein ostia are associated with a higher risk of pulmonary vein diameter and area reduction. These findings might suggest to lower the dosing to a single and shorter application if isolation is attained, to reduce the possibility of future pulmonary vein narrowing.
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http://dx.doi.org/10.2459/JCM.0000000000000646DOI Listing
June 2018