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Green O, Shenberg G, Baruch R, Argaman L, Levin T, Michelson I, Hadary R, Isakovich B, Golos M, Schwartz R, MacLoughlin R, Adi N, Arber N, Shapira S. Inhaled Exosomes Genetically Manipulated to Overexpress CD24 (EXO-CD24) as a Compassionate Use in Severe ARDS Patients. Biomedicines 2023; 11:2523. [PMID: 37760963 PMCID: PMC10525844 DOI: 10.3390/biomedicines11092523] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/01/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
RATIONALE Acute respiratory distress syndrome (ARDS) is a major global health concern with a significant unmet need. EXO-CD24 is delivered via inhalation-reduced cytokines and chemokine secretion and lung injury in ARDS and improved survival in mice models of ARDS, influenza, and sepsis. OBJECTIVES This clinical paper aims to evaluate the potential of EXO-CD24, a novel immunomodulatory treatment, in the compassionate care of critically ill, intubated patients with post-infection-induced acute respiratory distress syndrome (ARDS). METHODS Eleven critically ill patients diagnosed with post-infection ARDS (10 with COVID-19 and one with an adenovirus-associated infection) were administered EXO-CD24 in four medical centers across Israel. The patients had multiple co-morbidities, including cancer, hypertension, diabetes, and ischemic heart disease, and met the criteria for severe ARDS according to the Berlin classification. EXO-CD24 was administered via inhalation, and adverse events related to its use were carefully monitored. MEASUREMENTS AND MAIN RESULTS The administration of EXO-CD24 did not result in any recorded adverse events. The median hospitalization duration was 11.5 days, and the overall mortality rate was 36%. Notably, patients treated at the Tel Aviv Medical Center (TASMC) showed a lower mortality rate of 12.5%. The WBC and CRP levels decreased in comparison to baseline levels at hospitalization, and rapid responses occurred even in patients with kidney transplants who were off the ventilator within a few days and discharged shortly thereafter. The production of cytokines and chemokines was significantly suppressed in all patients, including those who died. Among the patients at TASMC, four had kidney transplants and were on immunosuppressive drugs, and all of them fully recovered and were discharged from the hospital. CONCLUSIONS EXO-CD24 holds promise as a potential therapeutic agent for all stages of ARDS, even in severe intubated cases. Importantly, EXO-CD24 demonstrated a favorable safety profile without any apparent side effects with promising efficacy. Furthermore, the potential of EXO-CD24 as a platform for addressing hyper-inflammatory states warrants exploration. Further research and larger-scale clinical trials are warranted to validate these preliminary findings.
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Affiliation(s)
- Orr Green
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
| | - Gil Shenberg
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
| | - Roni Baruch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
- Department of Kidney Transplantation, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Lihi Argaman
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
| | - Talya Levin
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
| | - Ian Michelson
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
| | - Ruthy Hadary
- Department of Internal Medicine C, Meir Medical Center, Kefar-Saba 4428164, Israel;
| | - Boris Isakovich
- Intensive Care Unit, Hillel Yaffe Medical Center, Hadera 3820302, Israel;
| | - Miri Golos
- Carmel Medical Center, Haifa 3436212, Israel;
| | - Reut Schwartz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
- Anesthesia and Intensive Care Unit, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Ronan MacLoughlin
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, D02 YN77 Dublin, Ireland;
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
| | - Nimrod Adi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
- Anesthesia and Intensive Care Unit, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Nadir Arber
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
| | - Shiran Shapira
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
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Bernstein E, Lev-Ari S, Shapira S, Leshno A, Sommer U, Al-Shamsi H, Shaked M, Segal O, Galazan L, Hay-Levy M, Sror M, Harlap-Gat A, Peer M, Moshkowitz M, Wolf I, Liberman E, Shenberg G, Gur E, Elran H, Melinger G, Mashiah J, Isakov O, Zrifin E, Gluck N, Dekel R, Kleinman S, Aviram G, Blachar A, Kessler A, Golan O, Geva R, Yossepowitch O, Neugut AI, Arber N. Data From a One-Stop-Shop Comprehensive Cancer Screening Center. J Clin Oncol 2023; 41:2503-2510. [PMID: 36669135 DOI: 10.1200/jco.22.00938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Cancer is the second leading cause of death globally. However, by implementing evidence-based prevention strategies, 30%-50% of cancers can be detected early with improved outcomes. At the integrated cancer prevention center (ICPC), we aimed to increase early detection by screening for multiple cancers during one visit. METHODS Self-referred asymptomatic individuals, age 20-80 years, were included prospectively. Clinical, laboratory, and epidemiological data were obtained by multiple specialists, and further testing was obtained based on symptoms, family history, individual risk factors, and abnormalities identified during the visit. Follow-up recommendations and diagnoses were given as appropriate. RESULTS Between January 1, 2006, and December 31, 2019, 8,618 men and 8,486 women, average age 47.11 ± 11.71 years, were screened. Of 259 cancers detected through the ICPC, 49 (19.8%) were stage 0, 113 (45.6%) stage I, 30 (12.1%) stage II, 25 (10.1%) stage III, and 31(12.5%) stage IV. Seventeen cancers were missed, six of which were within the scope of the ICPC. Compared with the Israeli registry, at the ICPC, less cancers were diagnosed at a metastatic stage for breast (none v 3.7%), lung (6.7% v 11.4%), colon (20.0% v 46.2%), prostate (5.6% v 10.5%), and cervical/uterine (none v 8.5%) cancers. When compared with the average stage of detection in the United States, detection was earlier for breast, lung, prostate, and female reproductive cancers. Patient satisfaction rate was 8.35 ± 1.85 (scale 1-10). CONCLUSION We present a proof of concept study for a one-stop-shop approach to cancer screening in a multidisciplinary outpatient clinic. We successfully detected cancers at an early stage, which has the potential to reduce morbidity and mortality as well as offer substantial cost savings.
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Affiliation(s)
- Ezra Bernstein
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,NYU Langone Medical Center, New York, NY
| | - Shahar Lev-Ari
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shiran Shapira
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ari Leshno
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Udi Sommer
- Tel Aviv University Faculty of Social Sciences, School of Political Science, Government and International Relations, Tel Aviv, Israel
| | - Humaid Al-Shamsi
- Burjeel Cancer Institute, University of Sharjah, Sharjah, United Arab Emirates
| | - Meital Shaked
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Ori Segal
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Lior Galazan
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Mori Hay-Levy
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Miri Sror
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Amira Harlap-Gat
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Michael Peer
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Menachem Moshkowitz
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Wolf
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Oncology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Eliezer Liberman
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Shenberg
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Eyal Gur
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Plastic and Reconstructive Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Hanoch Elran
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Gustavo Melinger
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,The Gynecological and Obstetric Ultrasound Unit, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Jacob Mashiah
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Dermatology and Venerology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Ofer Isakov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Gastrointestinal and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Elad Zrifin
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Oral and Maxillofacial Surgery Unit, Otolaryngology-Head and Neck Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Nathan Gluck
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Gastrointestinal and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Roy Dekel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Gastrointestinal and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Shlomi Kleinman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Oral and Maxillofacial Surgery Unit, Otolaryngology-Head and Neck Surgery, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Galit Aviram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Arye Blachar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Ada Kessler
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Orit Golan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Ravit Geva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Oncology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Ofer Yossepowitch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Alfred I Neugut
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Nadir Arber
- Health Promotion and Integrated Cancer Prevention Center, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Gastrointestinal and Liver Diseases, Tel Aviv Medical Center, Tel Aviv, Israel
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Shapira S, Shimon MB, Hay-Levi M, Shenberg G, Choshen G, Bannon L, Tepper M, Kazanov D, Seni J, Lev-Ari S, Peer M, Boubas D, Stebbing J, Tsiodras S, Arber N. A novel platform for attenuating immune hyperactivity using EXO-CD24 in Covid-19 and beyond. EMBO Mol Med 2022; 14:e15997. [PMID: 35776000 PMCID: PMC9349550 DOI: 10.15252/emmm.202215997] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 11/09/2022] Open
Abstract
A small but significant proportion of Covid19 patients develop life-threatening cytokine storm. We have developed a new anti-inflammatory drug, EXO-CD24, a combination of an immune checkpoint (CD24) and a delivery platform (exosomes). CD24 inhibits the NF-kB pathway and the production of cytokines/chemokines. EXO-CD24 discriminates Damage- from Pathogen-Associated Molecular Patterns (DAMPs and PAMPs) therefore does not interfere with viral clearance. EXO-CD24 was produced and purified from CD24-expressing 293-TREx™ cells. Exosomes displaying murine CD24 (mCD24) were also created. EXO-CD24/mCD24 were characterized and examined, for safety and efficacy, in vitro and in vivo. In a phase Ib/IIa study, 35 patients with moderate-high severity COVID-19 were recruited and given escalating doses, 108 -1010 , of EXO-CD24 by inhalation, QD, for five days. No adverse events related to the drug were observed up to 443-575 days. EXO-CD24 effectively reduced inflammatory markers and cytokine/chemokine, though randomized studies are required. EXO CD24 may be a treatment strategy to suppress the hyper-inflammatory response in the lungs of Covid-19 patients and further serve as a therapeutic platform for other pulmonary and systemic diseases characterized by cytokine storm.
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Affiliation(s)
- Shiran Shapira
- The Health Promotion Center and Integrated Cancer Prevention Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marina Ben Shimon
- The Health Promotion Center and Integrated Cancer Prevention Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mori Hay-Levi
- The Health Promotion Center and Integrated Cancer Prevention Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Shenberg
- The Health Promotion Center and Integrated Cancer Prevention Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy Choshen
- Department of Internal Medicine H, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Lian Bannon
- Department of 4Internal Medicine F, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Michael Tepper
- The Health Promotion Center and Integrated Cancer Prevention Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dina Kazanov
- The Health Promotion Center and Integrated Cancer Prevention Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Seni
- The Health Promotion Center and Integrated Cancer Prevention Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shahar Lev-Ari
- The Health Promotion Center and Integrated Cancer Prevention Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Peer
- Thoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Dimitrios Boubas
- 4th Dept of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, 12462, Athens, Greece
| | - Justin Stebbing
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Sotirios Tsiodras
- 4th Dept of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, 12462, Athens, Greece
| | - Nadir Arber
- The Health Promotion Center and Integrated Cancer Prevention Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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4
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Zahler D, Merdler I, Rozenfeld KL, Shenberg G, Milwidsky A, Berliner S, Banai S, Arbel Y, Shacham Y. C-Reactive Protein Velocity and the Risk of New Onset Atrial Fibrillation among ST Elevation Myocardial Infarction Patients. Isr Med Assoc J 2021; 23:169-173. [PMID: 33734630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Elevated C-reactive protein (CRP) was shown to be associated with an increased risk for new-onset atrial fibrillation (AF) in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI); however, the optimal time frame to measure CRP for risk stratification is not known. OBJECTIVES To evaluate the relation between the change in CRP over time (CRP velocity [CRPv]) and new-onset AF among STEMI patients treated with primary PCI. METHODS We included 801 STEMI patients who underwent PCI between 2007 and 2017 and had their CRP measured with a wide range assay (wr-CRP) at least twice during the 24 hours after admission. CRPv was defined as the change in wr-CRP concentration (mg/l) divided by the change in time (in hours) between the two measurements. Patient medical records were reviewed for occurrence of new-onset AF. RESULTS New onset AF occurred in 45 patients (6%). Patients with new onset AF had significantly higher median CRPv (1.27 vs. 0.43 mg/l/h, P = 0.002). New-onset AF during hospitalization occurred in 3.4%, 4.5 %, and 9.1% of patients in the first, second and third CRPv tertiles, respectively (P for trend = 0.006). In a multivariable logistic regression, adjusting for clinical variables the odds ratios for new onset AF was 1.93 (95% confidence interval 1.0-3.59, P = 0.04) for patients in the third CRPv tertile. CONCLUSIONS CRPv might be an independent and rapidly measurable biomarker for new-onset AF following primary PCI in STEMI patients.
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Affiliation(s)
- David Zahler
- Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Merdler
- Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren-Lee Rozenfeld
- Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gil Shenberg
- Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, IsraelDepartment of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assi Milwidsky
- Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Berliner
- Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shmuel Banai
- Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaron Arbel
- Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yacov Shacham
- Department of Cardiology, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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