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Rapid right ventricular pacing for balloon aortic valvuloplasty: expanding its routine use in neonates and infants. Cardiol Young 2020; 30:1890-1895. [PMID: 33021192 DOI: 10.1017/s1047951120003133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Rapid right ventricular pacing during balloon aortic valvuloplasty is commonly used to achieve balloon stability in children and adults. There is no consensus for the use of the technique in neonates and infants. We sought to review our institutional experience with rapid right ventricular pacing-assisted balloon aortic valvuloplasty across all age groups and evaluate the safety and effectiveness of the technique in the sub-group of neonates and infants <12months. METHODS Retrospective study between February, 2011 and February, 2020. RESULTS A total of 37 patients (Group I: 21 neonates/infants <12months and Group II: 16 children 12 months-16 years) were analysed. Catheter-measured left ventricular to aortic gradient reduced from median of 66 mmHg (with a range from 30 to 125 mmHg) to 14 mmHg (with a range from 5 to 44 mmHg) in Group I and 44 mmHg (with a range from 28 to 93 mmHg) to 18 mmHg (with a range from 2 to 65 mmHg) in Group II (p < 0.001). Procedure and fluoroscopy times were identical in the two groups. Balloon:annulus ratio was 0.94 and 0.88 in Groups I and II, respectively. Freedom from reintervention was 100% for Group I at a median time of 3.2 years and 81% at 2.7 years for Group II. Reinterventions in Group II (3/16 pts) were performed predominantly for complex left ventricular outflow tract stenosis. At follow-up echocardiogram, 45% of patients in Group I had no aortic regurgitation, 30% trace-mild, 20% mild-moderate, and 5% moderate aortic regurgitation, whereas in Group II, 50% of patients had no aortic regurgitation, 32% had mild aortic regurgitation, and 18% mild-moderate aortic regurgitation. Unicuspid valves were only encountered in Group 1 (2/21 pts, 10%) and they were predictive of mild-aortic regurgitation during follow-up (p = 0.003). Ventricular fibrillation occurred in three neonates with suspicion of myocardial ischemia on the pre-procedure echocardiogram. All were successfully defibrillated. CONCLUSIONS Rapid right ventricular pacing can be expanded in neonates and infants to potentially decrease the incidence of aortic regurgitation and reintervention rates, hence avoiding high-risk surgical bail-out procedures for severe aortic regurgitation in the first year of life. Myocardial ischemia may predispose to ventricular dysrhythmias during rapid right ventricular pacing.
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Mylonas KS, Ziogas IA, Mylona CS, Avgerinos DV, Bakoyiannis C, Mitropoulos F, Tzifa A. Rapid right ventricular pacing for balloon valvuloplasty in congenital aortic stenosis: A systematic review. World J Cardiol 2020; 12:540-549. [PMID: 33312439 PMCID: PMC7701905 DOI: 10.4330/wjc.v12.i11.540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/22/2020] [Accepted: 10/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Balloon aortic valvuloplasty (BAV) is a well-established treatment modality for congenital aortic valve stenosis.
AIM To evaluate the role of rapid right ventricular pacing (RRVP) in balloon stabilization during BAV on aortic regurgitation (AR) in pediatric patients.
METHODS A systematic review of the MEDLINE, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines (end-of-search date: July 8, 2020). The National Heart, Lung, and Blood Institute and Newcastle-Ottawa scales was utilized for quality assessment.
RESULTS Five studies reporting on 72 patients were included. The studies investigated the use of RRVP-assisted BAV in infants (> 1 mo) and older children, but not in neonates. Ten (13.9%) patients had a history of some type of aortic valve surgical or catheterization procedure. Before BAV, 58 (84.0%), 7 (10.1%), 4 (5.9%) patients had AR grade 0 (none), 1 (trivial), 2 (mild), respectively. After BAV, 34 (49.3%), 6 (8.7%), 26 (37.7%), 3 (4.3%), patients had AR grade 0, 1, 2, and 3 (moderate), respectively. No patient developed severe AR after RRVP. One (1.4%) developed ventricular fibrillation and was defibrillated successfully. No additional arrhythmias or complications occurred during RRVP.
CONCLUSION RRVP can be safely used to achieve balloon stability during pediatric BAV, which could potentially decrease AR rates.
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Affiliation(s)
- Konstantinos S Mylonas
- Department of Cardiothoracic Surgery, Yale New Haven Hospital, New Haven, CT 06510, United States
| | - Ioannis A Ziogas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Charitini S Mylona
- Department of Pediatrics, Trikala General Hospital, Trikala 42100, Greece
| | - Dimitrios V Avgerinos
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital, New York, NY 10065, United States
| | - Christos Bakoyiannis
- Division of Vascular Surgery, First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Fotios Mitropoulos
- Department of Pediatric Cardiac Surgery, Mitera Children’s Hospital, Athens 15123, Greece
| | - Aphrodite Tzifa
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, Mitera Children’s Hospital, Athens 15123, Greece
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Torres A, Vincent JA, Everett A, Lim S, Foerster SR, Marshall AC, Beekman RH, Murphy J, Trucco SM, Gauvreau K, Holzer R, Bergersen L, Porras D. Balloon valvuloplasty for congenital aortic stenosis: Multi-center safety and efficacy outcome assessment. Catheter Cardiovasc Interv 2015; 86:808-20. [DOI: 10.1002/ccd.25969] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/28/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Alejandro Torres
- Division of Pediatric Cardiology; Morgan Stanley Children's Hospital of New York Presbyterian; New York New York
| | - Julie A. Vincent
- Division of Pediatric Cardiology; Morgan Stanley Children's Hospital of New York Presbyterian; New York New York
| | - Allen Everett
- Division of Pediatric Cardiology; Johns Hopkins University; Baltimore Maryland
| | - Scott Lim
- Division of Pediatric Cardiology; University of Virginia; Charlottesville Virginia
| | - Susan R. Foerster
- Division of Pediatric Cardiology; Children's Hospital of Wisconsin; Milwaukee Wisconsin
| | - Audrey C. Marshall
- Department of Cardiology; Boston Children's Hospital, Boston Massachusetts, Children's Hospital Boston; Boston Massachusetts
| | - Robert H. Beekman
- Division of Pediatric Cardiology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Joshua Murphy
- Division of Pediatric Cardiology; Washington University in St. Louis; St. Louis Missouri
| | - Sara M. Trucco
- Division of Pediatric Cardiology; Children's Hospital of Pittsburgh; Pittsburgh Pennsylvania
| | - Kimberlee Gauvreau
- Department of Cardiology; Boston Children's Hospital, Boston Massachusetts, Children's Hospital Boston; Boston Massachusetts
| | - Ralf Holzer
- Division of Pediatric Cardiology; Nationwide Children's Hospital; Columbus Ohio
| | - Lisa Bergersen
- Department of Cardiology; Boston Children's Hospital, Boston Massachusetts, Children's Hospital Boston; Boston Massachusetts
| | - Diego Porras
- Department of Cardiology; Boston Children's Hospital, Boston Massachusetts, Children's Hospital Boston; Boston Massachusetts
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Porras D, Bergersen L. Standardizing care in congenital heart disease: approaches in the catheterization laboratory. Interv Cardiol 2014. [DOI: 10.2217/ica.13.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Porras D, Brown DW, Rathod R, Friedman K, Gauvreau K, Lock JE, Esch JJ, Bergersen L, Marshall AC. Acute outcomes after introduction of a standardized clinical assessment and management plan (SCAMP) for balloon aortic valvuloplasty in congenital aortic stenosis. CONGENIT HEART DIS 2013; 9:316-25. [PMID: 24127834 DOI: 10.1111/chd.12142] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Standardization of care can reduce practice variation, optimize resource utilization, and improve clinical outcomes. We have created a standardized clinical assessment and management plan (SCAMP) for patients having balloon aortic valvuloplasty (BAV) for congenital aortic stenosis (AS). This study compares acute outcomes of BAV at our institution before and after introduction of this SCAMP. METHODS In this retrospective matched cohort study, each SCAMP patient was matched to four historical controls. Outcomes were categorized based on the combination of residual AS and aortic regurgitation (AR) as: (1) Optimal: gradient ≤ 35 mm Hg and trivial or no AR; (2) Adequate: gradient ≤ 35 mm Hg and mild AR; (3) Inadequate: gradient > 35 mm Hg and/or moderate or severe AR. RESULTS All 23 SCAMP patients achieved a residual AS gradient ≤ 35 mm Hg; the median residual AS gradient for the SCAMP group was lower (25 [10-35] mm Hg) than in matched controls (30 [0-65] mm Hg; P = 0.005). The two groups did not differ with regard to degree of AR grade after BAV. Compared with controls, SCAMP patients were more likely to have an optimal result and less likely to have an inadequate result (52% vs. 34% and 17% vs. 45%, respectively; P = 0.02) CONCLUSIONS: A SCAMP for BAV resulted in optimal acute results in half of the initial 23 patients enrolled, and outcomes in this group were better than those of matched historical controls. Whether these improved acute outcomes translate into better long-term outcomes for this patient population remains to be seen.
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Affiliation(s)
- Diego Porras
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA; Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
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Al Marshafawy H, Al Sawah GA, Hafez M, Matter M, El Gamal A, Sheishaa AG, El Kair MA. Balloon Valvuloplasty of Aortic Valve Stenosis in Childhood: Midterm Results in a Children's Hospital, Mansoura University, Egypt. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2012; 6:57-64. [PMID: 22412302 PMCID: PMC3296496 DOI: 10.4137/cmc.s8602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Balloon valvuloplasty was established as an alternative to surgery for treatment of aortic valve stenosis in childhood. Acute complications after balloon dilatation including aortic insufficiency or early death were described. Aim of Work: To analyze early outcome and midterm results of balloon aortic valvuloplasty (BAV) in Children’s Hospital, Mansoura University, Egypt. Subjects and Methods: Between April 2005–June 2008, all consecutive patients of age <18 years treated for aortic valve stenosis (AVS) with BAV were analyzed retrospectively. The study included 21 patients; 17 males, and 4 females. Their age ranged from the neonatal period to 10 years (mean age 5.6 ± 3.7 years). Patients with gradient ≥50 mmHg and aortic valve insufficiency (AI) up to grade I were included. All patients had isolated aortic valve stenosis except 3 patients (14.3%) had associated aortic coarctation. Six patients (28.6%) had bicuspid aortic valve. All patients had normal myocardial function except one (4.8%) had FS 15%. The duration of follow up was (mean ± SD: 18.5 ± 11.7 months). Results: Femoral artery approach was used in 20 patients (95.2%) and carotid artery in one neonate (4.8%). Balloon/annulus ratio was 0.83 ± 0.04. Significant reduction in pressure gradient was achieved (mean 66.7 ± 9.8 mmHg to 20.65 ± 2.99 mmHg) (P < 0.001). Nine patients (42.8%) developed grade I AI, 2 patients (9.5%) developed grade II AI and 1 patient (4.8%) developed grade III AI. Two early deaths (9.5%); one died due to heart failure caused by grade IV AI and a neonate died because of severely compromised LV function. One patient (4.8%) had femoral artery occlusion necessitating anticoagulation. Patients remained free from re-intervention during follow up. Conclusion: Balloon valvuloplasty of aortic valve stenosis significantly reduces gradient with low morbidity and mortality in children.
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Brown DW, Dipilato AE, Chong EC, Lock JE, McElhinney DB. Aortic valve reinterventions after balloon aortic valvuloplasty for congenital aortic stenosis intermediate and late follow-up. J Am Coll Cardiol 2011; 56:1740-9. [PMID: 21070926 DOI: 10.1016/j.jacc.2010.06.040] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 05/27/2010] [Accepted: 06/16/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVES the aim of this study was to evaluate the long-term results of transcatheter balloon aortic valvuloplasty, the preferred treatment for congenital aortic stenosis (AS). BACKGROUND aortic valve function and reintervention late after this procedure are not well characterized. METHODS from 1985 to 2008, 563 patients underwent balloon dilation for congenital AS. After excluding those converted to univentricular circulation and/or died ≤ 30 days after the procedure, 509 patients constituted the study cohort. RESULTS The median follow-up period was 9.3 years (range 0.1 to 23.6 years); cumulative follow-up was 5,003 patient-years. The median age was 2.4 years (range 1 day to 40.5 years), and most patients (73%) had isolated native AS. Peak AS gradients decreased significantly after dilation (median decrease, 35 mm Hg), and acute post-dilation aortic regurgitation was moderate or greater in 70 patients (14%). Older patients more often had post-dilation aortic regurgitation (p < 0.001). During follow-up, 225 patients (44%) underwent aortic valve reintervention: repeat balloon dilation in 115 (23%), aortic valve repair in 65 (13%), and aortic valve replacement in 116 (23%). Survival free from any aortic valve reintervention was 89 ± 1% at 1 year, 72 ± 2% at 5 years, 54 ± 3% at 10 years, and 27 ± 3% at 20 years. Freedom from aortic valve replacement was 90 ± 2% at 5 years, 79 ± 3% at 10 years, and 53 ± 4% at 20 years. In multivariate analyses, lower post-dilation AS gradient and lower grade of post-dilation aortic regurgitation were associated with longer freedom from aortic valve replacement, but age, era, and pre-dilation AS severity were not. CONCLUSIONS although transcatheter aortic valvuloplasty is effective for relief of congenital AS, there are steady long-term hazards for surgical aortic valve reintervention and replacement that are independent of age at initial intervention or AS severity.
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Affiliation(s)
- David W Brown
- Department of Cardiology, Children’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Brown DW, Dipilato AE, Chong EC, Gauvreau K, McElhinney DB, Colan SD, Lock JE. Sudden Unexpected Death After Balloon Valvuloplasty for Congenital Aortic Stenosis. J Am Coll Cardiol 2010; 56:1939-46. [DOI: 10.1016/j.jacc.2010.06.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 06/18/2010] [Accepted: 06/21/2010] [Indexed: 10/18/2022]
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Ewert P, Bertram H, Breuer J, Dähnert I, Dittrich S, Eicken A, Emmel M, Fischer G, Gitter R, Gorenflo M, Haas N, Kitzmüller E, Koch A, Kretschmar O, Lindinger A, Michel-Behnke I, Nuernberg JH, Peuster M, Walter K, Zartner P, Uhlemann F. Balloon valvuloplasty in the treatment of congenital aortic valve stenosis--a retrospective multicenter survey of more than 1000 patients. Int J Cardiol 2010; 149:182-185. [PMID: 20153064 DOI: 10.1016/j.ijcard.2010.01.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2009] [Revised: 12/24/2009] [Accepted: 01/17/2010] [Indexed: 11/15/2022]
Abstract
BACKGROUND The value of balloon valvuloplasty of the aortic valve in childhood is still under debate. OBJECTIVE To evaluate the results of the procedure in a retrospective multicenter survey of a large cohort over a long time interval. METHODS Retrospective analysis of 1004 patients with balloon valvuloplasty of the aortic valve performed between 9/1985 and 10/2006 at 20 centers in Germany, Austria and Switzerland. Amongst others, the following parameters were evaluated before and after the procedure as well as at the end of follow-up or before surgery: clinical status, left ventricular function, transaortic pressure gradient, degree of aortic regurgitation, freedom from re-intervention or surgery. PATIENTS Patients from 1 day to 18 years of age with aortic valve stenosis were divided into four groups: 334 newborns (1-28 days); 249 infants (29-365 days); 211 children (1-10 years), and 210 adolescents (10-18 years). RESULTS Median follow-up was 32 months (0 days to 17.5 years). After dilatation the pressure gradient decreased from 65 (± 24)mm Hg to 26 (± 16)mm Hg and remained stable during follow-up. The newborns were the most affected patients. Approximately 60% of them had clinical symptoms and impaired left ventricular function before intervention. Complication rate was 15% in newborns, 11% in infants and 6% in older children. Independently of age, 50% of all patients were free from surgery 10 years after intervention. CONCLUSIONS In this retrospective multicenter study, balloon valvuloplasty of the aortic valve has effectively postponed the need for surgery in infants, children and adolescents up to 18 years of age.
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Affiliation(s)
- P Ewert
- Deutsches Herzzentrum Berlin, Germany.
| | - H Bertram
- Medizinische Hochschule Hannover, Germany
| | - J Breuer
- Universitätsklinik Bonn, Germany
| | | | | | - A Eicken
- Deutsches Herzzentrum München, Germany
| | - M Emmel
- Universitätsklinik Köln, Germany
| | | | - R Gitter
- Landes-Kinderklinik Linz, Germany
| | | | - N Haas
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Germany
| | | | - A Koch
- Universitätsklinik Erlangen, Germany
| | | | | | | | | | - M Peuster
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Germany
| | | | - P Zartner
- Deutsches Kinderherzzentrum St. Augustin, Germany
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Eicken A, Georgiev S, Balling G, Schreiber C, Hager A, Hess J. Neonatal balloon aortic valvuloplasty-predictive value of current risk score algorithms for treatment strategies. Catheter Cardiovasc Interv 2009; 76:404-10. [DOI: 10.1002/ccd.22363] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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David F, Sánchez A, Yánez L, Velásquez E, Jiménez S, Martínez A, Alva C. Cardiac pacing in balloon aortic valvuloplasty. Int J Cardiol 2006; 116:327-30. [PMID: 16889846 DOI: 10.1016/j.ijcard.2006.03.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2005] [Revised: 03/05/2006] [Accepted: 03/24/2006] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate the rapid ventricular pacing in balloon aortic valvuloplasty to achieve balloon stability. MATERIAL AND METHODS From September 2004 to July 2005, a prospective protocol was carried out: ten patients with aortic valve stenosis were treated with this method. Patient's age ranged from 3 to 16 years with mean age of 10.2+/-4.3 years. In all cases a bipolar pacing catheter was placed in the right ventricle. Rapid ventricular pacing was initiated at the rate of 150 per minute and was gradually increased to achieve a 50% drop in systemic pressure. The balloon was inflated only after the pacing rate was reached and the blood pressure dropped. Pacing was continued until the balloon was completely deflated. RESULTS The systolic gradients across the aortic valve before balloon dilatation ranged from 40 to 110 mm Hg, mean 68.5+/-20 mm Hg. The pacing rate required to drop the pressure by 50% ranged from 170 to 250 per minute, mean 209+/-25. Balloon stability at time of inflation was achieved in all cases with no balloon movement. The post ballooning gradients ranged from 5 to 28 mm Hg, mean 19.7+/-8.3 mm Hg (p<0.001). In all cases there was no change in aortograms, performed before and after balloon dilatation in aorta, except in one patient who developed grade I aortic regurgitation. CONCLUSIONS Rapid ventricular pacing appears to be an effective and a safe procedure to stabilize the balloon during balloon aortic valvuloplasty and is thought to decrease the incidence of aortic insufficiency.
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Affiliation(s)
- Felipe David
- Congenital Heart Diseases Department, Cardiology Hospital, National Medical Center Siglo XXI, Av. Cuauhtemoc 330, Col. Doctores, CP 06720, México City, Mexico
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Ettedgui J. Percutaneous aortic valvoplasty in congenital aortic valvar stenosis. Cardiol Young 2002; 12:316. [PMID: 12206551 DOI: 10.1017/s1047951100012889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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