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Venous Obstruction in Cardiac Rhythm Device Therapy

  • Joseph Donnelly
  • James Gabriels
  • Andrew Galmer
  • Jonathan Willner
  • Stuart Beldner
  • Laurence M. Epstein
  • Apoor Patel
Vascular Disease (M Weinberg, Section Editor)
  • 51 Downloads
Part of the following topical collections:
  1. Topical Collection on Vascular Disease

Abstract

Purpose of review

A variety of complex vascular pathologies arise following the implantation of electronic cardiac devices. Pacemaker and defibrillator lead insertion may cause proximal venous obstruction, resulting in symptomatic venous congestion and the compromise of potential future access sites for cardiac rhythm lead management.

Recent findings

Various innovative techniques to recanalize the vein and establish alternate venous access have been pioneered over the past few years.

Summary

A collaborative team of electrophysiologists and vascular specialists strategically integrate the patient’s vascular disease into the planning of electrophysiology procedures. When vascular complications occur after device implantation, the same team effectively manages both the resulting vascular sequelae and related cardiac rhythm device challenges. This review will outline the various vascular challenges related to device therapy and offer an effective strategy for their management.

Keywords

Vascular disease Electronic cardiac devices Proximal venous obstruction Lead insertion 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Greenspon AJ, Patel JD, Lau E, et al. Trends in permanent pacemaker implantation in the United States from 1993 to 2009: increasing complexity of patients and procedures. J Am Coll Cardiol. 2012;60:1540–5.CrossRefPubMedGoogle Scholar
  2. 2.
    van Veldhuisen DJ, Maass AH, Priori SG, et al. Implementation of device therapy (cardiac resynchronization therapy and implantable cardioverter defibrillator) for patients with heart failure in Europe: changes from 2004 to 2008. Eur J Heart Fail. 2009;11:1143–51.CrossRefPubMedGoogle Scholar
  3. 3.
    Robboy SJ, Harthorne JW, Leinbach RC, Sanders CA, Austen WG. Autopsy findings with permanent pervenous pacemakers. Circulation. 1969;39:495–501.CrossRefPubMedGoogle Scholar
  4. 4.
    Korkeila P, Nyman K, Ylitalo A, et al. Venous obstruction after pacemaker implantation. Pacing Clin Electrophysiol. 2007;30:199–206.CrossRefPubMedGoogle Scholar
  5. 5.
    Oginosawa Y, Abe H, Nakashima Y. The incidence and risk factors for venous obstruction after implantation of transvenous pacing leads. Pacing Clin Electrophysiol. 2002;25:1605–11.CrossRefPubMedGoogle Scholar
  6. 6.
    Lickfett L, Bitzen A, Arepally A, et al. Incidence of venous obstruction following insertion of an implantable cardioverter defibrillator. A study of systematic contrast venography on patients presenting for their first elective ICD generator replacement. Europace. 2004;6:25–31.CrossRefPubMedGoogle Scholar
  7. 7.
    Luedorff G, Grove R, Kranig W, Thale J. Different venous angioplasty manoeuvres for successful implantation of CRT devices. Clin Res Cardiol. 2009;98:159–64.CrossRefPubMedGoogle Scholar
  8. 8.
    Sticherling C, Chough SP, Baker RL, et al. Prevalence of central venous occlusion in patients with chronic defibrillator leads. Am Heart J. 2001;141:813–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Pauletti M, Pingitore R, Contini C. Superior vena cava stenosis at site of intersection of two pacing electrodes. Br Heart J. 1979;42:487–9.Google Scholar
  10. 10.
    Da Costa SS, Scalabrini Neto A, Costa R, Caldas JG, Martinelli Filho M. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study. Pacing Clin Electrophysiol. 2002;25:1301–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Melzer C, Lembcke A, Ziemer S, et al. Pacemaker-induced superior vena cava syndrome: clinical evaluation of long-term follow-up. Pacing Clin Electrophysiol. 2006;29:1346–51.CrossRefPubMedGoogle Scholar
  12. 12.
    Goudevenos JA, Reid PG, Adams PC, Holden MP, Williams DO. Pacemaker-induced superior vena cava syndrome: report of four cases and review of the literature. Pacing Clin Electrophysiol. 1989;12:1890–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Riley RF, Petersen SE, Ferguson JD, Bashir Y. Managing superior vena cava syndrome as a complication of pacemaker implantation: a pooled analysis of clinical practice. Pacing Clin Electrophysiol. 2010;33:420–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Lindsay HS, Chennells PM, Perrins EJ. Successful treatment by balloon venoplasty and stent insertion of obstruction of the superior vena cava by an endocardial pacemaker lead. Br Heart J. 1994;71:363–5.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Rozmus G, Daubert JP, Huang DT, Rosero S, Hall B, Francis C. Venous thrombosis and stenosis after implantation of pacemakers and defibrillators. J Interv Card Electrophysiol. 2005;13:9–19.CrossRefPubMedGoogle Scholar
  16. 16.
    Park HW, Kim W, Cho JG, Kang JC. Multiple pacing lead-induced superior vena cava syndrome: successful treatment by balloon angioplasty. J Cardiovasc Electrophysiol. 2005;16:221–3.CrossRefPubMedGoogle Scholar
  17. 17.
    Bracke FA, Meijer A, van Gelder LM. Symptomatic occlusion of the access vein after pacemaker or ICD lead extraction. Heart. 2003;89:1348–9.Google Scholar
  18. 18.
    Spittell PC, Hayes DL. Venous complications after insertion of a transvenous pacemaker. Mayo Clin Proc. 1992;67:258–65.CrossRefPubMedGoogle Scholar
  19. 19.
    Kim H, Chung JW, Park JH, et al. Role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction. Korean J Radiol. 2003;4:146–52.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Lin LJ, Lin JL, Tsai WC, Teng JK, Tsai LM, Chen JH. Venous access thrombosis detected by transcutaneous vascular ultrasound in patients with single-polyurethane-lead permanent pacemaker. Pacing Clin Electrophysiol. 1998;21:396–400.CrossRefPubMedGoogle Scholar
  21. 21.
    Seeger W, Scherer K. Asymptomatic pulmonary embolism following pacemaker implantation. Pacing Clin Electrophysiol. 1986;9:196–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Martínez-Sellés M, Bueno H, Almendral J, Díaz-Castro O. Pulmonary embolism after pacemaker implantation. Tex Heart Inst J. 2001;28:318–9.Google Scholar
  23. 23.
    Novak M, Dvorak P, Kamaryt P, Slana B, Lipoldova J. Autopsy and clinical context in deceased patients with implanted pacemakers and defibrillators: intracardiac findings near their leads and electrodes. Europace. 2009;11:1510–6.CrossRefPubMedGoogle Scholar
  24. 24.
    D’Aloia A, Bonadei I, Vizzardi E, Curnis A. Right giant atrial thrombosis and pulmonary embolism complicating pacemaker leads. BMJ Case Rep. 2013;2013.Google Scholar
  25. 25.
    Barreiro B, Bueso A, Manresa F. Pulmonary thromboembolism associated with superior vena cava thrombosis following permanent transvenous endocardial cardiac pacing. Monaldi Arch Chest Dis. 1994;49:112–4.PubMedGoogle Scholar
  26. 26.
    Monreal M, Hospital de Badalona Germans Trias i Pujol B, Spain, Lafoz E, et al. Upper-extremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest. 1991;99:280–3.CrossRefPubMedGoogle Scholar
  27. 27.
    Chuang CL, Tarng DC, Yang WC, Huang TP. An occult cause of arteriovenous access failure: central vein stenosis from permanent pacemaker wire. Report of three cases and review of the literature. Am J Nephrol. 2001;21:406–9.CrossRefPubMedGoogle Scholar
  28. 28.
    Biria M, Gupta R, Lakkireddy D, Gupta K. Recurrent positional syncope as the primary presentation of superior vena cava syndrome after pacemaker implantation. Heart Rhythm. 2009;6:144–5.CrossRefPubMedGoogle Scholar
  29. 29.
    Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med. 1994;331:1735–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Stokes K, From Medtronic I, Minneapolis, Minnesota, U.S.A, Anderson J, et al. The encapsulation of polyurethane-insulated transvenous cardiac pacemaker leads. Cardiovasc Pathol. 1995;4:163–71.CrossRefPubMedGoogle Scholar
  31. 31.
    Palatianos GM, Dewanjee MK, Panoutsopoulos G, Kapadvanjwala M, Novak S, Sfakianakis GN. Comparative thrombogenicity of pacemaker leads. Pacing Clin Electrophysiol. 1994;17:141–5.CrossRefPubMedGoogle Scholar
  32. 32.
    Goto Y, Abe T, Sekine S, Sakurada T. Long-term thrombosis after transvenous permanent pacemaker implantation. Pacing Clin Electrophysiol. 1998;21:1192–5.CrossRefPubMedGoogle Scholar
  33. 33.
    van Rooden CJ, Molhoek SG, Rosendaal FR, Schalij MJ, Meinders AE, Huisman MV. Incidence and risk factors of early venous thrombosis associated with permanent pacemaker leads. J Cardiovasc Electrophysiol. 2004;15:1258–62.CrossRefPubMedGoogle Scholar
  34. 34.
    Costa R, Da Silva KR, Rached R, et al. Prevention of venous thrombosis by warfarin after permanent transvenous leads implantation in high-risk patients. Pacing Clin Electrophysiol. 2009;32(Suppl 1):S247–51.CrossRefPubMedGoogle Scholar
  35. 35.
    Haghjoo M, Nikoo MH, Fazelifar AF, Alizadeh A, Emkanjoo Z, Sadr-Ameli MA. Predictors of venous obstruction following pacemaker or implantable cardioverter-defibrillator implantation: a contrast venographic study on 100 patients admitted for generator change, lead revision, or device upgrade. Europace. 2007;9:328–32.CrossRefPubMedGoogle Scholar
  36. 36.•
    Worley SJ, Gohn DC, Pulliam RW, Raifsnider MA, Ebersole BI, Tuzi J. Subclavian venoplasty by the implanting physicians in 373 patients over 11 years. Heart Rhythm. 2011;8:526–33. This seminal article highlights the various approaches to venoplasty, as well as outcomes over 11 years.Google Scholar
  37. 37.
    Kalman PG, Lindsay TF, Clarke K, Sniderman KW, Vanderburgh L. Management of upper extremity central venous obstruction using interventional radiology. Ann Vasc Surg. 1998;12:202–6.CrossRefPubMedGoogle Scholar
  38. 38.
    Spittell PC, Vlietstra RE, Hayes DL, Higano ST. Venous obstruction due to permanent transvenous pacemaker electrodes: treatment with percutaneous transluminal balloon venoplasty. Pacing Clin Electrophysiol. 1990;13:271–4.CrossRefPubMedGoogle Scholar
  39. 39.
    McCotter CJ, Angle JF, Prudente LA, et al. Placement of transvenous pacemaker and ICD leads across total chronic occlusions. Pacing Clin Electrophysiol. 2005;28:921–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Gula Lorne J, Ames A, Woodburn A, et al. Central venous occlusion is not an obstacle to device upgrade with the assistance of laser extraction. Pacing Clin Electrophysiol. 2005;28:661–6.Google Scholar
  41. 41.
    Sohal M, Williams S, Akhtar M, et al. Laser lead extraction to facilitate cardiac implantable electronic device upgrade and revision in the presence of central venous obstruction. Europace. 2014;16:81–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Wilkoff BL, Byrd CL, Love CJ, et al. Pacemaker lead extraction with the laser sheath: results of the pacing lead extraction with the excimer sheath (PLEXES) trials. J Am Coll Cardiol. 1999;33:1671–6.Google Scholar
  43. 43.
    Wazni O, Epstein LM, Carrillo RG, et al. Lead extraction in the contemporary setting: the LExICon study: an observational retrospective study of consecutive laser lead extractions. J Am Coll Cardiol. 2010;55:579–86.CrossRefPubMedGoogle Scholar
  44. 44.•
    Bordachar P, Defaye P, Peyrouse E, et al. Extraction of old pacemaker or cardioverter-defibrillator leads by laser sheath versus femoral approach. Circ Arrhythm Electrophysiol. 2010;3:319–23. This article highlights the role of lead extraction in the management of venous occlusion.Google Scholar
  45. 45.
    Rogers DP, Lambiase PD, Chow AW. Successful coronary sinus lead replacement despite total venous occlusion using femoral pull through, two operator counter-traction and subclavian venoplasty. J Interv Card Electrophysiol. 2007;19:69–71.CrossRefPubMedGoogle Scholar
  46. 46.
    Worley SJ, Gohn DC, Pulliam RW. Over the wire lead extraction and focused force venoplasty to regain venous access in a totally occluded subclavian vein. J Interv Card Electrophysiol. 2008;23:135–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Baerlocher MO, Asch MR, Myers A. Successful recanalization of a longstanding complete left subclavian vein occlusion by radiofrequency perforation with use of a radiofrequency guide wire. J Vasc Interv Radiol. 2006;17:1703–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Worley SJ, Gohn DC, Smith TL. Micro-dissection to open totally occluded subclavian veins. Heart Rhythm. 2005;2:S161.Google Scholar
  49. 49.
    Worley SJ, Gohn DC, Pulliam RW. Needle directed re-entry to cross a subclavian occlusion following failed microdissection. Pacing Clin Electrophysiol. 2007;30:1562–5.CrossRefPubMedGoogle Scholar
  50. 50.
    Antonelli D, Freedberg NA, Turgeman Y. Supraclavicular vein approach to overcoming ipsilateral chronic subclavian vein obstruction during pacemaker-ICD lead revision or upgrading. Europace. 2010;12:1596–9.CrossRefPubMedGoogle Scholar
  51. 51.
    Ovadia M, Cooper RS, Parnell VA, Dicapua D, Vatsia SK, Vlay SC. Transvenous pacemaker insertion ipsilateral to chronic subclavian vein obstruction: an operative technique for children and adults. Pacing Clin Electrophysiol. 2000;23:1585–93.CrossRefPubMedGoogle Scholar
  52. 52.
    Bosa-Ojeda F, Bethencourt-Munoz M, Vargas-Torres M, Lara-Paoron A, Rodriguez-Gonzalez A, Marrero-Rodriguez F. Upgrade of a pacemaker defibrillator to a biventricular device: the internal jugular vein approach in a case of bilateral subclavian veins occlusion. J Interv Card Electrophysiol. 2007;19:209–11.CrossRefPubMedGoogle Scholar
  53. 53.
    Pires LA, Hassan SA, Johnson KM. Coronary sinus lead placement via the internal jugular vein in patients with advanced heart failure: a simplified percutaneous approach. J Interv Card Electrophysiol. 2005;12:157–62.CrossRefPubMedGoogle Scholar
  54. 54.
    Sadarmin PP, Chelliah RK, Timperley J. Contralateral transvenous left ventricular lead placement of implantable devices with pre-sternal tunnelling in chronically obstructed subclavian veins. Indian Pacing Electrophysiol J. 2015;15:113–7.Google Scholar
  55. 55.
    Aleksic I, Kottenberg-Assenmacher E, Kienbaum P, et al. The innominate vein as alternative venous access for complicated implantable cardioverter defibrillator revisions. Pacing Clin Electrophysiol. 2007;30:957–60.CrossRefPubMedGoogle Scholar
  56. 56.
    Fox DJ, Petkar S, Davidson NC, Fitzpatrick AP. Upgrading patients with chronic defibrillator leads to a biventricular system and reducing patient risk: contralateral LV lead placement. Pacing Clin Electrophysiol. 2006;29:1025–7.CrossRefPubMedGoogle Scholar
  57. 57.
    Ellestad MH, Caso R, Greenberg PS. Permanent pacemaker implantation using the femoral vein: a preliminary report. Pacing Clin Electrophysiol. 1980;3:418–23.CrossRefPubMedGoogle Scholar
  58. 58.
    Erdogan O, Augostini R, Saliba W, Juratli N, Wilkoff BL. Transiliac permanent pacemaker implantation after extraction of infected pectoral pacemaker systems. Am J Cardiol. 1999;84:474–5. a9-10Google Scholar
  59. 59.
    Mathur G, Stables RH, Heaven D, Ingram A, Sutton R. Permanent pacemaker implantation via the femoral vein: an alternative in cases with contraindications to the pectoral approach. Europace. 2001;3:56–9.CrossRefPubMedGoogle Scholar
  60. 60.
    Allred JD, McElderry HT, Doppalapudi H, Yamada T, Kay GN. Biventricular ICD implantation using the iliofemoral approach: providing CRT to patients with occluded superior venous access. Pacing Clin Electrophysiol. 2008;31:1351–4.CrossRefPubMedGoogle Scholar
  61. 61.
    Yadav R, Chandra S, Naik N, Nagesh C, Kothari S. Unusual site of permanent pacing: a case report. Indian Pacing Electrophysiol J. 2009;9:108–11.Google Scholar
  62. 62.
    Cannon BC, Friedman RA, Fenrich AL, Fraser CD, McKenzie ED, Kertesz NJ. Innovative techniques for placement of implantable cardioverter-defibrillator leads in patients with limited venous access to the heart. Pacing Clin Electrophysiol. 2006;29:181–7.CrossRefPubMedGoogle Scholar
  63. 63.
    Luthje L, Zabel M, Seegers J, Zenker D, Vollmann D. Acute and long-term feasibility of contralateral transvenous lead placement with subcutaneous, pre-sternal tunnelling in patients with chronically implanted rhythm devices. Europace. 2011;13:1004–8.CrossRefPubMedGoogle Scholar
  64. 64.
    Bradley DJ, Bradley EA, Baughman KL, et al. Cardiac resynchronization and death from progressive heart failure: a meta-analysis of randomized controlled trials. JAMA. 2003;289:730–40.CrossRefPubMedGoogle Scholar
  65. 65.
    Wertheimer M, Hughes RK, Castle CH. Superior vena cava syndrome. Complication of permanent transvenous endocardial cardiac pacing. JAMA. 1973;224:1172–3.CrossRefPubMedGoogle Scholar
  66. 66.
    Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al. HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14:e503–e51.CrossRefPubMedGoogle Scholar
  67. 67.
    Murakami Y, Matsuno Y, Izumi S, et al. Superior vena cava syndrome as a complication of DDD pacemaker implantation. Clin Cardiol. 1990;13:298–300.CrossRefPubMedGoogle Scholar
  68. 68.
    Kee ST, Kinoshita L, Razavi MK, Nyman UR, Semba CP, Dake MD. Superior vena cava syndrome: treatment with catheter-directed thrombolysis and endovascular stent placement. Radiology. 1998;206:187–93.CrossRefPubMedGoogle Scholar
  69. 69.
    Williams DR, Demos NJ. Thrombosis of superior vena cava caused by pacemaker wire and managed with streptokinase. J Thorac Cardiovasc Surg. 1974;68:134–7.PubMedGoogle Scholar
  70. 70.
    Sunder SK, Ekong EA, Sivalingam K, Kumar A. Superior vena cava thrombosis due to pacing electrodes: successful treatment with combined thrombolysis and angioplasty. Am Heart J. 1992;123:790–2.CrossRefPubMedGoogle Scholar
  71. 71.
    Francis CM, Starkey IR, Errington ML, Gillespie IN. Venous stenting as treatment for pacemaker-induced superior vena cava syndrome. Am Heart J. 1995;129:836–7.CrossRefPubMedGoogle Scholar
  72. 72.
    De Raet JM, Vos JA, Morshuis WJ, van Boven WJP. Surgical management of superior vena cava syndrome after failed endovascular stenting. Interact Cardiovasc Thorac Surg. 2012;15:915–7.Google Scholar
  73. 73.
    Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149:315–52.CrossRefPubMedPubMedCentralGoogle Scholar
  74. 74.
    Youngson GG, McKenzie FN, Nichol PM. Superior vena cava syndrome: case report. A complication of permanent transvenous endocardial cardiac pacing requiring surgical correction. Am Heart J. 1980;99:503–5.CrossRefPubMedGoogle Scholar
  75. 75.
    Montgomery JH, D'Souza VJ, Dyer RB, Formanek AG, Prabhu SH. Nonsurgical treatment of the superior vena cava syndrome. Am J Cardiol. 1985;56:829–30.CrossRefPubMedGoogle Scholar
  76. 76.
    Klop B, Scheffer MG, McFadden E, Bracke F, van Gelder B. Treatment of pacemaker-induced superior vena cava syndrome by balloon angioplasty and stenting. Neth Hear J. 2011;19:41–6.Google Scholar
  77. 77.
    Slonim SM, Semba CP, Sze DY, Dake MD. Placement of SVC stents over pacemaker wires for the treatment of SVC syndrome. J Vasc Interv Radiol. 2000;11:215–9.CrossRefPubMedGoogle Scholar
  78. 78.
    Teo N, Sabharwal T, Rowland E, Curry P, Adam A. Treatment of superior vena cava obstruction secondary to pacemaker wires with balloon venoplasty and insertion of metallic stents. Eur Heart J. 2002;23:1465–70.CrossRefPubMedGoogle Scholar
  79. 79.
    Lanciego C, Rodriguez M, Rodriguez A, Carbonell MA, Garcia LG. Permanent pacemaker-induced superior vena cava syndrome: successful treatment by endovascular stent. Cardiovasc Intervent Radiol. 2003;26:576–9.CrossRefPubMedGoogle Scholar
  80. 80.
    Chan AW, Bhatt DL, Wilkoff BL, et al. Percutaneous treatment for pacemaker-associated superior vena cava syndrome. Pacing Clin Electrophysiol. 2002;25:1628–33.CrossRefPubMedGoogle Scholar
  81. 81.
    Garlitski AC, Swingle JD, Aizer A, Holmes DS, Bernstein NE, Chinitz LA. Percutaneous treatment of the superior vena cava syndrome via an excimer laser sheath in a patient with a single chamber atrial pacemaker. J Interv Card Electrophysiol. 2006;16:203–6.CrossRefPubMedGoogle Scholar
  82. 82.
    Jacob S, Mohamad T. Pacemaker lead malfunction following superior vena cava stenting. EP Europace. 2018;11:1266.CrossRefGoogle Scholar
  83. 83.
    Alimi YS, Gloviczki P, Vrtiska TJ, et al. Reconstruction of the superior vena cava: benefits of postoperative surveillance and secondary endovascular interventions. J Vasc Surg. 1998;27:287–99. 300–1Google Scholar
  84. 84.
    Kalra M, Gloviczki P, Andrews JC, et al. Open surgical and endovascular treatment of superior vena cava syndrome caused by nonmalignant disease. J Vasc Surg. 2003;38:215–23.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Joseph Donnelly
    • 1
  • James Gabriels
    • 1
  • Andrew Galmer
    • 1
  • Jonathan Willner
    • 1
  • Stuart Beldner
    • 1
  • Laurence M. Epstein
    • 1
  • Apoor Patel
    • 1
  1. 1.Department of CardiologyNorth Shore University HospitalManhassetUSA

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