(Circulation. 2001;103:2060.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Electroanatomic Mapping of Entrained and Exit Zones in Patients With Repaired Congenital Heart Disease and Intra-Atrial Reentrant Tachycardia
From the Department of Cardiology, Children’s Hospital, Boston, Mass.
Correspondence to John K. Triedman, MD, Department of Cardiology, Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail triedman{at}cardio1.tch.harvard.edu
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Abstract |
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Background—Characterization of reentrant circuits and targeting ablation sites remains difficult for intra-atrial reentrant tachycardias (IART) in congenital heart disease (CHD).
Methods and Results—Electroanatomic mapping and entrainment pacing were performed before successful ablation of 18 IART circuits in 15 patients with CHD. Principal features of IART circuits were atrial septal defect (4 patients), atriotomy (3 patients), other atrial scar (3 patients), crista terminalis (3 patients), and right atrioventricular valve (5 patients). A median of 176 sites (range, 96 to 317 sites) was mapped for activation and 13 sites (range, 9 to 28 sites) for entrainment response. Postpacing intervals within 20 ms of tachycardia cycle length and stimulus–to–P-wave intervals of 0 to 90 ms (exit zones) were mapped to atrial surfaces generated by electroanatomic mapping. Criteria for entrainment were met over a median of 21 cm2 of atrial surface (range, 2 to 75 cm2), 19% (range, 1% to 81%) of total area tested. Using integrated data, relations between activation sequence and protected corridor of conduction could be inferred for 16 of 17 IARTs. Successful ablation was achieved at a site distant from the putative protected corridor in 9 of 18 (50%) circuits.
Conclusions—The right atrium in CHD supports a variety of IART mechanisms. Fusion of activation and entrainment data provided insight into specific IART mechanisms relevant to ablation.
Key Words: atrial flutter • heart defects, congenital • catheter ablation
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Considerable knowledge has been developed regarding the causes of intra-atrial reentrant tachycardia (IART) in congenital heart disease (CHD). Awareness of the morbid significance of IART has prompted application of a variety of therapies, but none has proved highly effective for arrhythmia suppression. Catheter ablation has been used to target specific arrhythmia circuits. Although short-term ablation outcomes are satisfactory,1 2 3 long-term recurrence is common.4 Knowledge of recurrent IART patterns and underlying atrial features1 and application of new electrophysiological imaging technologies that are well referenced to the spatial geometry of the mapped atrial chamber may improve these outcomes. However, the complexity of the atrial substrate renders even these data ambiguous in many cases.
The current study investigates the application of data fusion techniques to characterize specific IART circuits, with particular reference to the location and geometry of protected conduction corridors that may be arrhythmogenic or vulnerable to ablation. Electroanatomic IART activation maps were combined with functional electrophysiological measurements, made at multiple sites, consisting of the response to entrainment pacing and identification of P-wave exit zones related to emergence of the IART wave front from protected conduction corridors.
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Methods |
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Patient Population
The study group consisted of patients with CHD referred to Children’s Hospital, Boston, Mass, before April 2000 for ablation of IART. This study includes patients in whom electroanatomic mapping and systematic entrainment pacing studies were performed, followed by successful short-term termination of IART by ablation. Informed consent was obtained in accordance with Hospital policies. Patients were studied under general anesthesia after hemodynamic evaluation.
Electroanatomic Mapping
IARTs were mapped using the CARTO system (Biosense
Webster). Validation of this technology and of its use in CHD has
been
reported.5 6 7 8
An interscapular location reference sensor was applied and an atrial
reference electrode placed to record left atrial activation, either
from the coronary sinus or transesophageally.
Activation mapping was performed by initial systematic sampling of the
entire atrial endocardial surface, followed by more detailed mapping of
areas of interest and entrainment pacing. Simultaneous
recordings of intracardiac electrograms and 12-lead surface ECG
were obtained (CardioLab, Prucka Engineering, Inc). Recordings
from the 2 systems were cross-referenced
manually.
Entrainment Pacing
Entrainment pacing was performed at a variable
number of sites in the right atrium. Each site was paced at a cycle
length 5 to 25 ms shorter than the tachycardia cycle
length. If capture was demonstrated by shortening of the paced
intervals, and the tachycardia cycle length, P-wave
morphology, and intracardiac activation sequence were identical, then
the postpacing interval was determined as the return cycle length at
the distal electrode of the pacing
catheter.9 If a return cycle
electrogram was not visible on the distal electrode, the proximal
electrode pair electrogram was used under the following conditions: (1)
a recording immediately before pacing demonstrated the temporal
relation between the distal and proximal electrograms, and (2) the
morphology of the proximal electrogram was unchanged with
pacing.10 If the difference
between the postpacing interval and the tachycardia cycle
length was 
20 ms, the point was deemed to lie within the entrained
zone comprising the primary tachycardia
circuit.
Determination of Exit Zones
An idealized model of the IART mechanism and its
relation to the measurements described below is presented in
Figure 1
. Stimulus–to–P-wave intervals were determined by
inspection of the P wave in 12 leads during tachycardia and
identification of the electrocardiographic signature of baseline
inflections. If an identical electrocardiographic pattern of P-wave
onset could be identified during an entrainment pacing sequence, the
duration from stimulus to P wave was recorded. The exit zone from a
protected conduction corridor was defined as the region of the atrium
with stimulus–to–P-wave intervals of 0 to 90
ms.
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Spatial Measurements
The density and homogeneity of sampling of the atrial
surface with entrainment pacing were estimated by point-to-point
measurements obtained using the CARTO system. Entrainment sampling
density (D) was calculated as
the mean proximity of each entrained point to its 3 nearest neighbors.
Each point was considered to sample a circular area
A, calculated as
A=
(D/2)2
cm2. Total coverage of the atrium by
entrainment study was calculated as the sum of areas covered by
entrainment.
Data Fusion
Activation sequence maps were overlaid with
electroanatomic maps of entrained and exit zones. These maps were
created by using the CARTO system to map binarized entrainment pacing
data onto the spatial framework that had been developed during
activation mapping
(Figure 2) and overlaid on activation sequences using
Photoshop (Adobe). For entrainment, points that were in the circuit
were mapped in red, whereas those out of the circuit were mapped in
purple. For identification of exit zones, points with a
stimulus–to–P-wave interval of 0 to 90 ms were mapped in red, whereas
other points were mapped in purple. Colors were linearly interpolated
between adjacent points.
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Statistics
Data are summarized as mean±SD or median
(range). Comparisons of means and medians are made using
t test and Wilcoxon
rank-sum test as appropriate, with
P<0.05 considered
significant.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Patient Population
Fifteen patients were studied (5 female; median age, 24 years; range, 3 to 50 years). Six patients had had biventricular surgical repairs for tetralogy of Fallot (2 patients), total anomalous pulmonary venous connection (1 patient), atrial septal defect (1 patient), pulmonary atresia with ventricular septal defect (1 patient), and corrected transposition of the great vessels with ventricular septal defect (1 patient). One patient had unrepaired biventricular anatomy (Ebstein’s anomaly variant with giant right atrium). Seven patients had had a Fontan procedure by creation of either a right atrial–pulmonary artery anastomosis or right atrial–right ventricular conduit: tricuspid atresia (4 patients) and single ventricle (3 patients). One patient with single right ventricle had had a bidirectional Glenn anastomosis.
Descriptions of Tachycardia
Circuits
Entrainment mapping was performed for 18 IART circuits.
One patient had 3 and another had 2 circuits mapped. Median
tachycardia cycle length was 313 ms (range, 177 to 384 ms).
A median of 176 sites per circuit (range, 96 to 317 sites per circuit)
was mapped for activation, and a median of 13 sites per circuit (range,
9 to 28 sites per circuit) was mapped for entrainment. Entrainment
pacing cycle lengths were chosen to be 10 to 20 ms shorter than
tachycardia cycle length; this resulted in observed
entrainment pacing cycle lengths with a mean prematurity of 15 ms
(5.3% of mean tachycardia cycle length) that ranged from
86% to 98% of the tachycardia cycle
length.
Dimensions, Locations, and Coverage of
Tachycardia Circuits
Linear dimensions and volumes of the atria studied are
presented in
Table 1. Indexed for body surface area, the volumes
of the atria of Fontan procedure patients were nearly twice those of
biventricular repair patients. Two hundred seventy
entrainment sites were evaluated, 103 of which met criteria for
entrainment. The mean interpoint distance measured for entrained points
was 2.2±1.0 cm, versus 2.8±1.2 cm for nonentrained points
(P<0.001). This difference
suggests an operator bias to sample areas of the heart demonstrated to
be in circuit more thoroughly than those not in circuit. A median of 89
cm2 of right atrial endocardial surface
(range, 19 to 178 cm2) was evaluated by
entrainment pacing
(Table 2). Although total atrial surface area is not
available by this technique, these values are of comparable magnitude
and somewhat smaller than the surface area of a sphere with a 7-cm
diameter (154 cm2). A median of 4.5 sites
per circuit mapped met entrainment criteria (range, 1 to 13 sites per
circuit), covering a median of 21 cm2
(range, 2 to 75 cm2) and accounting for 19%
of the total mapped right atrial surface area (range, 1% to
81%).
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Location of Entrained and Exit Zones in
Isthmus-Dependent Atrial Flutter
Five patients had isthmus-dependent atrial flutter
confirmed by activation mapping and response to ablation. In 4 cases,
the entrained zone completely or nearly encircled the
atrioventricular (AV) valve annulus, with variable
posterior extension of the zone to include portions of the septum,
right atrial free wall, and lateral right atrial wall. Exit zones were
observed at the medial isthmus and atrial septum. In 1 case, the
entrained zone failed to include the isthmus but did include the
superior aspect of the tricuspid annulus. An example of
isthmus-dependent atrial flutter from the present series is given
in Figure 3.
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Case Examples
Figure 4 demonstrates entrainment mapping of IART in a
patient who had had a Fontan procedure. The activation sequence had 2
conduction pathways, indicated by yellow arrows. Mapping of entrained
and exit zones demonstrated that the lower loop was primary, with a
presumed corridor extending anteriorly in this region from the crista
terminalis. Ablation at the site of the yellow star resulted in abrupt
slowing, with shift of the entrained zone to the upper limb of the
circuit. IART was terminated by cephalad extension of the
radiofrequency (RF) application.
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Figure 5 demonstrates complex activation in the lateral
right atrium of a patient who had had a Fontan procedure. White arrows
highlight an apparent corridor (left) where unsuccessful RF
applications were made. Mapping of entrainment revealed that only a
small area (
1% mapped atrial surface) met entrainment criteria. The
exit zone encompassed much of the anterior right atrial surface, which
activated rapidly. Successful RF applications were made in the
gap between entrained and exit zones.
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Relation of Successful Ablation Sites to
Entrained and Exit Zones
The location of successful ablation sites in relation
to entrained and exit zones is presented in
Figure 6. Entrained zones are diagrammed as outlined areas,
exit zones are vertically hatched, and an arrow represents the
direction of the activation wave front. These 3 features of the IART
circuit defined a path that included the successful ablation site in 17
of 18 circuits. In 13 circuits, the entrained and exit zones overlapped
(Figure 6B), and in 4 circuits a gap existed between the two
(Figure 6A). A single isthmus-based atrial flutter (see
above) had a site of successful ablation that was not clearly related
to the mapped circuit. When supported by data from activation mapping,
overlaps or gaps were considered likely to represent protected
conduction corridors, as per the schema presented in
Figure 1
. Eight of 18 circuits were successfully targeted in
this area, including 4 of 5 isthmus-dependent atrial flutters. Six
circuits were successfully targeted in the entrained zone at sites
distant from the presumed protected area. Three circuits were
successfully targeted in neither the entrained nor the exit zones but
in an area lying between the two, which was plausibly included in the
circuit by activation sequence mapping.
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Discussion |
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In this report, atrial reentrant tachycardias were mapped in patients with a broad spectrum of repaired CHD by superimposition of data describing the functional properties of the tachycardia circuit—response to entrainment pacing—onto activation sequence maps of those tachycardias. The validity of this approach was tested in 5 patients who had a right AV valve (4 tricuspid and 1 mitral). These patients had maps constructed of isthmus-dependent atrial flutter, ie, counterclockwise rotation of an activation wave front around the right AV valve annulus. In 4 of 5 cases, the entrained zones encircled (or nearly encircled) the right AV annulus, were bounded posteriorly by the inferred location of the crista terminalis, and demonstrated exit zones at the base of the atrial septum.
Extension of these observations to complex circuits anchored to central obstacles other than the AV valve annulus allowed distinction of bystander tissue from atrial tissue critical to the arrhythmia circuit. We were also able to infer the locations of protected conduction corridors and their relations to anatomic and presumed surgical lines of conduction block. Identification of these areas sometimes showed that sites that might have been deemed optimal for attempted RF ablation were not, in fact, those locations in which successful ablation lesions were placed. Mapping the atria in this manner also revealed that entrainable wave fronts in atrial reentrant tachycardias may in places be broad and that fractional right atrial surface area that is considered in circuit is sizable. This may explain why favorable entrainment responses during atrial reentrant tachycardias do not necessarily have a high positive predictive value,11 although unfavorable entrainment responses have a high negative predictive value for ablation success.2
Characterization of IART Circuits
A variety of anatomic substrates were characterized
underlying this relatively small sample of arrhythmias by
superposition of activation latency and multisite entrainment mapping
data. A complex and effective example of this is demonstrated in
Figure 7, which shows the use of entrainment mapping to
characterize a macroreentrant circuit using segments of the atrial
septum and the left atrium. Prior studies suggest diverse
arrhythmogenic substrates for IART. Central obstacles presumably
related to surgical and hemodynamic injury include
fixed lines of conduction block at atriotomy and cannulation
sites2 3 and areas
of electrically silent and presumably inexcitable tissue traversed by
channels of surviving atrial
myocardium.8
Isthmus-dependent atrial flutter circuits are often identified in
patients with CHD (particularly after biventricular
repairs) and are successfully ablated in the
tricuspid–inferior vena cava
isthmus.1 2 12 13
IART circuits have also been mapped to locations related to an atrial
septal defect14 or the left
atrium.15 A recent review of
88 patients with IART ablated using fluoroscopic techniques revealed
both the importance of underlying surgical anatomy in
determining the distribution of successful ablation sites and the
variation in the distribution of those
sites.1
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IARTs occurring in postoperative CHD patients have been
thought to be exclusively macroreentrant in mechanism, with the
smallest demonstrated circuits using an atrial septal defect
repair14 or the
inferior vena
cava16 as a central
obstacle. A novel observation from this study is the identification of
reentrant tachycardia on the right atrial free wall with
only small, focal areas of entrainment demonstrable
(Figure 6). This suggests that small reentrant circuits may
also rarely underlie chronic postoperative tachycardias, a
finding consistent with recent reports documenting ablation of
focal atrial fibrillation in the right
atrium.17
It was observed in this series of patients that successful termination of tachycardia by application of RF energy might occur at sites distinct from a protected corridor. By analogy to isthmus-dependent atrial flutter, such corridors have been assumed to represent a narrow, extended neck of conductive tissue bounded by anatomic or anisotropic obstacle and possibly possessing abnormal conduction properties.18 The existence of conduction channels traversing areas of scarring on the right atrial free wall in patients who have undergone atriotomies has been proposed by Nakagawa et al8 and suggested as a target for ablation. In the current study, we considered protected corridors to consist of the segment of the tachycardia circuit located immediately proximal to the onset of the surface P wave, when it was discernible and appeared to be orthodromic. Although isthmus-dependent flutters had successful termination in this area, nearly half of the ablated circuits were successfully terminated at other sites. Because we analyzed entrainment data retrospectively, it is not possible to say whether explicit targeting of areas proximal to exit sites might have been equally or more effective at terminating tachycardia. However, these observations substantiate the notion that creating a blocking lesion based on anatomic understanding of conduction boundaries will often be a successful ablative strategy.
Positive Predictive Value of Entrainment
Pacing
The size of measured entrained zones in these
macroreentrant circuits varied widely, signifying diverse right atrial
mechanisms. The fraction of atrial endocardial points meeting the
common entrainment criteria used in this study was generally large,
averaging 30%. Operator bias in favor of checking points likely to
meet entrainment criteria is a potential limitation of this study.
However, examination of the interpoint distances in entrained and
nonentrained areas indicates that this effect was minor, and the
fraction of the endocardial surface tested for entrainment that was in
circuit was still 20%. This suggests that targeting sites for
ablation solely by entrainment may have a low positive predictive value
for success.
Anatomic visualization of entrainment zones may thus have
practical value for our understanding of entrainment as a clinically
useful technique. No standard criterion for the difference between the
postpacing interval and the tachycardia cycle length
signifying in-circuit response to entrainment has been validated
experimentally. At any entrained site, this difference is a function of
both distance of the site from the tachycardia circuit and
conduction velocity between the site and the circuit. Mapping of
entrainment in the proposed manner allows the tradeoff between
sensitivity and positive predictive value of entrainment pacing to be
visualized anatomically. As the criterion for entrainment is
relaxed (eg, from 20
30 ms), the entrained area, channel width and,
hypothetically, the sensitivity of the technique will also increase. At
the same time, relaxation of the entrainment criterion will diminish
its positive predictive value and probably increase the need for
additional criteria for choice of ablation site, such as observation of
mid-diastolic
potentials.19 Conversely,
imposing a more stringent criterion for entrainment (eg, from 2010
ms) will have the opposite effects. In our experience, measurements of
entrainment made at a single site may vary by as much as 5 to 10 ms,
and our choice to designate entrainment as occurring with a threshold
of 20 ms in timing difference reflects both a balance between these 2
competing issues and concordance with the range of values used by other
investigators.19 20
Limitations
Entrainment maps were constructed after ablation, and
entrained sites were sampled in a sparse and inhomogeneous
distribution. This was because of the intermittent inability to capture
atrial tissue or to measure accurately low-amplitude, postentrainment
atrial signals. Mapping of 10 to 20 points may be insufficient to
completely define circuits by entrainment mapping. In this study,
anatomic understanding of these lower resolution maps was enhanced by
superposition of the data onto higher-resolution activation
maps.
There was an apparent bias to map entrainable sites more densely in areas considered by other criteria (eg, activation sequence and anatomic knowledge) to represent plausible target sites for ablation. A geometric correction based on the distance between each point and its nearest neighbors was made in an effort to correct for this, but there remains an unknown amount of error in the estimates of entrained and nonentrained surface area.
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Acknowledgments |
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Dr Alexander was supported in part by a grant from the National Heart, Lung, and Blood Institute (R01-HL62385); Dr Bevilacqua was supported by a grant from the Hood Foundation; and Dr Berul was supported by grants from the National Institutes of Health (K08-HL03607 and P50-HL61036).
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Footnotes |
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Dr. Triedman serves as a consultant to Biosense Webster, Inc, which manufactures the CARTO system.
Received November 7, 2000; revision received January 17, 2001; accepted January 26, 2001.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Committee Members, C. Blomstrom-Lundqvist, M. M. Scheinman, E. M. Aliot, J. S. Alpert, H. Calkins, A. J. Camm, W. B. Campbell, D. E. Haines, K. H. Kuck, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias --executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) Developed in Collaboration with NASPE-Heart Rhythm Society J. Am. Coll. Cardiol., October 15, 2003; 42(8): 1493 - 1531. [Full Text] [PDF]
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C. Blomstrom-Lundqvist, M. M. Scheinman, E. M. Aliot, J. S. Alpert, H. Calkins, A. J. Camm, W. B. Campbell, D. E. Haines, K. H. Kuck, B. B. Lerman, et al. ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias*--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias) Circulation, October 14, 2003; 108(15): 1871 - 1909. [Full Text] [PDF]
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 Committee Members, C. Blomstrom-Lundqvist, M. M Scheinman, E. M Aliot, J. S Alpert, H. Calkins, A.J. Camm, W.B. Campbell, D. E Haines, K. H Kuck, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary: A Report of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines(Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias)Developed in collaboration with NASPE-Heart Rhythm Society Eur. Heart J., October 2, 2003; 24(20): 1857 - 1897. [Full Text] [PDF]
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J. B. Morton, P. Sanders, V. Deen, J. K. Vohra, and J. M. Kalman Sensitivity and specificity of concealed entrainment for the identification of a critical isthmus in the atrium: relationship to rate, anatomic location and antidromic penetration J. Am. Coll. Cardiol., March 6, 2002; 39(5): 896 - 906. [Abstract] [Full Text] [PDF]
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F. Ouyang, S. Ernst, T. Vogtmann, M. Goya, M. Volkmer, A. Schaumann, D. Bansch, M. Antz, and K.-H. Kuck Characterization of Reentrant Circuits in Left Atrial Macroreentrant Tachycardia: Critical Isthmus Block Can Prevent Atrial Tachycardia Recurrence Circulation, April 23, 2002; 105(16): 1934 - 1942. [Abstract] [Full Text] [PDF]
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