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Giannino G, Braia V, Griffith Brookles C, Giacobbe F, D'Ascenzo F, Angelini F, Saglietto A, De Ferrari GM, Dusi V. The Intrinsic Cardiac Nervous System: From Pathophysiology to Therapeutic Implications. BIOLOGY 2024; 13:105. [PMID: 38392323 PMCID: PMC10887082 DOI: 10.3390/biology13020105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024]
Abstract
The cardiac autonomic nervous system (CANS) plays a pivotal role in cardiac homeostasis as well as in cardiac pathology. The first level of cardiac autonomic control, the intrinsic cardiac nervous system (ICNS), is located within the epicardial fat pads and is physically organized in ganglionated plexi (GPs). The ICNS system does not only contain parasympathetic cardiac efferent neurons, as long believed, but also afferent neurons and local circuit neurons. Thanks to its high degree of connectivity, combined with neuronal plasticity and memory capacity, the ICNS allows for a beat-to-beat control of all cardiac functions and responses as well as integration with extracardiac and higher centers for longer-term cardiovascular reflexes. The present review provides a detailed overview of the current knowledge of the bidirectional connection between the ICNS and the most studied cardiac pathologies/conditions (myocardial infarction, heart failure, arrhythmias and heart transplant) and the potential therapeutic implications. Indeed, GP modulation with efferent activity inhibition, differently achieved, has been studied for atrial fibrillation and functional bradyarrhythmias, while GP modulation with efferent activity stimulation has been evaluated for myocardial infarction, heart failure and ventricular arrhythmias. Electrical therapy has the unique potential to allow for both kinds of ICNS modulation while preserving the anatomical integrity of the system.
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Affiliation(s)
- Giuseppe Giannino
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Valentina Braia
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Carola Griffith Brookles
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Federico Giacobbe
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Fabrizio D'Ascenzo
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Gaetano Maria De Ferrari
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
| | - Veronica Dusi
- Cardiology, Department of Medical Sciences, University of Turin, 10124 Torino, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, 10126 Torino, Italy
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Chung WH, Masuyama K, Challita R, Hayase J, Mori S, Cha S, Bradfield JS, Ardell JL, Shivkumar K, Ajijola OA. Ischemia-induced ventricular proarrhythmia and cardiovascular autonomic dysreflexia after cardioneuroablation. Heart Rhythm 2023; 20:1534-1545. [PMID: 37562487 DOI: 10.1016/j.hrthm.2023.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Cardioneuroablation (CNA) is an attractive treatment of vasovagal syncope. Its long-term efficacy and safety remain unknown. OBJECTIVE The purpose of this study was to develop a chronic porcine model of CNA to examine the susceptibility to ventricular tachyarrhythmia (ventricular tachycardia/ventricular fibrillation [VT/VF]) and cardiac autonomic function after CNA. METHODS A percutaneous CNA model was developed by ablation of left- and right-sided ganglionated plexi (n = 5), confirmed by histology. Reproducible bilateral vagal denervation was confirmed after CNA by extracardiac vagal nerve stimulation (VNS) and histology. Chronic studies included 16 pigs randomized to CNA (n = 8) and sham ablation (n = 8, Control). After 6 weeks, animals underwent hemodynamic studies, assessment of cardiac sympathetic and parasympathetic function using sympathetic chain stimulation and direct VNS, respectively, and proarrhythmic potential after left anterior descending (LAD) coronary artery ligation. RESULTS After CNA, extracardiac VNS responses remained abolished for 6 weeks despite ganglia remaining in ablated ganglionated plexi. In the CNA group, direct VNS resulted in paradoxical increases in blood pressure, but not in sham-ablated animals (CNA group vs sham group: 8.36% ± 7.0% vs -4.83% ± 8.7%, respectively; P = .009). Left sympathetic chain stimulation (8 Hz) induced significant corrected QT interval prolongation in the CNA group vs the sham group (11.23% ± 4.0% vs 1.49% ± 4.0%, respectively; P < .001). VT/VF after LAD ligation was more prevalent and occurred earlier in the CNA group than in the control group (61.44 ± 73.7 seconds vs 245.11 ± 104.0 seconds, respectively; P = .002). CONCLUSION Cardiac vagal denervation is maintained long-term after CNA in a porcine model. However, chronic CNA was associated with cardiovascular dysreflexia, diminished cardioprotective effects of cardiac vagal tone, and increased susceptibility to VT/VF in ischemia. These potential long-term negative effects of CNA suggest the need for rigorous clinical studies on CNA.
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Affiliation(s)
- Wei-Hsin Chung
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California; China Medical University Hospital, Taichung, Taiwan
| | - Kiyoshi Masuyama
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Ronald Challita
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Steven Cha
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jeffery L Ardell
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California.
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Hayase J, Bradfield JS. Adjunctive Therapies for Ventricular Arrhythmia Management: Autonomic Neuromodulation-Established and Emerging Therapies. Card Electrophysiol Clin 2022; 14:769-778. [PMID: 36396192 DOI: 10.1016/j.ccep.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The autonomic nervous system plays an integral role in the pathophysiology of ventricular arrhythmias. In the modern era, several therapeutic interventions are available to the clinician for bedside and procedural/surgical management, and there are many ways in which modulation of the autonomic nervous system can provide life-saving benefit. This review discusses some of the current treatment options, the supporting evidence, and also introduce some of the emerging therapies in this expanding field of electrophysiology.
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Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA, USA.
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Nguyen DD, Akoum N, Hourmozdi J, Prutkin JM, Robinson M, Tregoning DM, Saour BM, Chatterjee NA, Sridhar AR. Catheter ablation of atrial fibrillation results in significant QTc prolongation in the postoperative period. Heart Rhythm O2 2021; 2:500-510. [PMID: 34667966 PMCID: PMC8505209 DOI: 10.1016/j.hroo.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The corrected QT interval (QTc) is a measure of ventricular repolarization time, and a prolonged QTc increases risk for malignant ventricular arrhythmias. Pulmonary vein isolation (PVI) may increase QTc but its effects have not been well studied. Objective Determine the incidence, risk factors, and outcomes of patients presenting for PVI in sinus and atrial fibrillation with postoperative QTc prolongation in a large cohort. Methods We performed a single-center retrospective study of consecutive atrial fibrillation ablations. QTc durations using Bazett correction were obtained from electrocardiograms at different postoperative intervals and compared to preoperative QTc. We studied clinical outcomes including clinically significant ventricular arrhythmia and death. A multivariable model was used to identify factors associated with clinically significant QTc prolongation, defined as ΔQTc ≥60 ms or new QTc duration ≥500 ms. Results A total of 352 PVIs were included in this study. We observed a statistically significant increase in mean QTc compared to baseline (446.3 ± 37.8 ms) on postoperative day (POD)0 (471.7 ± 38.2 ms, P < .001) and at POD1 (456.5 ± 35.0 ms, P < .001). There was no significant difference at 1 month (452.4 ± 33.5 ms, P = .39) and 3 months (447.3 ± 40.0 ms, P = .78). Sixty-six patients (19.2%) developed ΔQTc ≥60 ms or QTc ≥500 ms on POD0, with 4.1% persisting past 90 days. Female sex (odds ratio [OR] = 1.82, 95% confidence interval [CI] =1.01–3.29, P = .047) and history of coronary artery disease (OR = 2.16, 95% CI = 1.03–4.55, P = .042) were independently predictive of QTc prolongation ≥500 ms or ΔQTc ≥60 ms. There were no episodes of clinically significant ventricular arrhythmia or death attributable to arrhythmia. Conclusion QTc duration increased significantly immediately post-PVI and returned to baseline by 1 month. PVI did not provoke significant ventricular arrhythmias in our cohort.
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Affiliation(s)
- Dan D Nguyen
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Nazem Akoum
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Jonathan Hourmozdi
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Jordan M Prutkin
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Melissa Robinson
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Deanna M Tregoning
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Basil M Saour
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Neal A Chatterjee
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
| | - Arun R Sridhar
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington
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Hermans BJM, Zink MD, van Rosmalen F, Crijns HJGM, Vernooy K, Postema P, Pison L, Schotten U, Delhaas T. Pulmonary vein isolation in a real-world population does not influence QTc interval. Europace 2021; 23:i48-i54. [PMID: 33751076 PMCID: PMC7943360 DOI: 10.1093/europace/euaa390] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/18/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS We aimed to examine whether routine pulmonary vein isolation (PVI) induces significant ventricular repolarization changes as suggested earlier. METHODS AND RESULTS Five-minute electrocardiograms were recorded at hospital's admission (T-1d), 1 day after the PVI-procedure (T+1d) and at 3 months post-procedure (T+3m) from a registry of consecutive atrial fibrillation (AF) patients scheduled for routine PVI with different PVI modalities (radiofrequency, cryo-ablation, and hybrid). Only patients who were in sinus rhythm at all three recordings (n = 117) were included. QT-intervals and QT-dispersion were evaluated with custom-made software and QTc was calculated using Bazett's, Fridericia's, Framingham's, and Hodges' formulas. Both QT- and RR-intervals were significantly shorter at T+1d (399 ± 37 and 870 ± 141 ms) and T+3m (407 ± 36 and 950 ± 140 ms) compared with baseline (417 ± 36 and 1025 ± 164 ms). There was no statistically significant within-subject difference in QTc Fridericia (T-1d 416 ± 28 ms, T+1d 419 ± 33 ms, and T+3m 414 ± 25 ms) and QT-dispersion (T-1d 18 ± 12 ms, T+1d 21 ± 19 ms, and T+3m 17 ± 12 ms) between the recordings. A multiple linear regression model with age, sex, AF type, ablation technique, first/re-do ablation, and AF recurrence to predict the change in QTc at T+3m with respect to QTc at T-1d did not reach significance which indicates that the change in QTc does not differ between all subgroups (age, sex, AF type, ablation technique, first/re-do ablation, and AF recurrence). CONCLUSION Based on our data a routine PVI does not result in a prolongation of QTc in a real-world population. These findings, therefore, suggest that there is no need to intensify post-PVI QT-interval monitoring.
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Affiliation(s)
- Ben J M Hermans
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Matthias D Zink
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Frank van Rosmalen
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center Maastricht, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center Maastricht, Maastricht, The Netherlands
| | - Pieter Postema
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, The Netherlands
| | - Laurent Pison
- Department of Cardiology, Ziekenhuis Oost, Limburg, Genk, Belgium
| | - Ulrich Schotten
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
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Chikata A, Kato T, Usuda K, Fujita S, Maruyama M, Otowa K, Usuda K, Niwa S, Tsuda T, Hayashi K, Takamura M. Prolongation of QT interval after pulmonary vein isolation for paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2020; 31:2371-2379. [DOI: 10.1111/jce.14625] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Akio Chikata
- Department of Internal Medicine, Division of Cardiology Toyama Prefectural Central Hospital Toyama Japan
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Science Kanazawa Japan
| | - Takeshi Kato
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Science Kanazawa Japan
| | - Kazuo Usuda
- Department of Internal Medicine, Division of Cardiology Toyama Prefectural Central Hospital Toyama Japan
| | - Shuhei Fujita
- Department of Pediatrics Toyama Prefectural Central Hospital Toyama Japan
| | - Michiro Maruyama
- Department of Internal Medicine, Division of Cardiology Toyama Prefectural Central Hospital Toyama Japan
| | - Kan‐ichi Otowa
- Department of Internal Medicine, Division of Cardiology Toyama Prefectural Central Hospital Toyama Japan
| | - Keisuke Usuda
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Science Kanazawa Japan
| | - Satoru Niwa
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Science Kanazawa Japan
| | - Toyonobu Tsuda
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Science Kanazawa Japan
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Science Kanazawa Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine Kanazawa University Graduate School of Medical Science Kanazawa Japan
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Abdulhai F, Refaat MM. Pulmonary vein isolation and QT prolongation in paroxysmal atrial fibrillation: What have we learned? J Cardiovasc Electrophysiol 2020; 31:2380-2381. [PMID: 32557959 DOI: 10.1111/jce.14622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Farah Abdulhai
- Department of Internal Medicine, Cardiovascular Medicine/Cardiac Electrophysiology, American University of Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
| | - Marwan M Refaat
- Department of Internal Medicine, Cardiovascular Medicine/Cardiac Electrophysiology, American University of Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
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Boles U, Refila B, Gul EE, Szeplaki G, Keaney J, Galvin J, Keelan E. Ventricular Tachycardia Storm After Standard Radiofrequency Pulmonary Vein Isolation. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1536-1539. [PMID: 31628298 PMCID: PMC6818642 DOI: 10.12659/ajcr.918432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Patient: Male, 69 Final Diagnosis: Ventricular tachycardia storm post PVI ablation Symptoms: Recurrent premature ventricular contractions at 180–200 bpm rate that progressed into a VT storm Medication: — Clinical Procedure: Radiofrequency PVI ablation Specialty: Cardiology
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Affiliation(s)
- Usama Boles
- Heart and Vascular Center, Mater Private Hospital, Dublin, Ireland
| | - Beshoy Refila
- Heart and Vascular Center, Mater Private Hospital, Dublin, Ireland
| | - Enes E Gul
- Cardiology Department, Medina Cardiac Center, Medina, Saudi Arabia
| | - Gabor Szeplaki
- Heart and Vascular Center, Mater Private Hospital, Dublin, Ireland
| | - John Keaney
- Heart and Vascular Center, Mater Private Hospital, Dublin, Ireland
| | - Joseph Galvin
- Heart and Vascular Center, Mater Private Hospital, Dublin, Ireland
| | - Edward Keelan
- Heart and Vascular Center, Mater Private Hospital, Dublin, Ireland
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Leung LWM, Gallagher MM, Evranos B, Bolten J, Madden BP, Wright S, Kaba RA. Cardiac arrest following protamine administration: a case series. Europace 2019; 21:886-892. [DOI: 10.1093/europace/euy288] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 11/07/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Lisa W M Leung
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Mark M Gallagher
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Banu Evranos
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Jens Bolten
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Brendan P Madden
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Susan Wright
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
| | - Riyaz A Kaba
- Cardiology Clinical Academic Group, St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, London, UK
- Ashford and St Peter’s NHS Foundation Trust, Guildford Road, Chertsey, UK
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