Papers by Alessandro Verzini
Interactive Cardiovascular and Thoracic Surgery, Jul 1, 2009
To evaluate the clinical results of aortic valve replacement performed with a miniaturized closed... more To evaluate the clinical results of aortic valve replacement performed with a miniaturized closed circuit extracorporeal circulation (MECC) system and to compare it to standard cardiopulmonary bypass (CPB). One hundred and twenty consecutive patients undergoing isolated aortic valve replacement were randomly assigned to either a miniaturized closed circuit CPB with the maquet-cardiopulmonary MECC System᭧ (study group, ns60) or to a standard CPB (control group, ns60). Demographic characteristic and operative data were similar in the two groups. No hospital death occurred in either group and no difference in intensive care unit (ICU) stay and in-hospital stay was observed. Patients in the study group showed lower chest tube drainage (212"62 ml vs. 420"219 ml, P-0.05) and lower need for blood products (6.1% vs. 40.4%, P-0.05) than patients in the control group. Platelet count at ICU arrival was significantly higher in the study group (139"40=10 yl vs. 164"75=10 yl, Ps0.05). Peak postoperative troponin I release was significantly lower in the MECC group 9 9 (3.81"2.7 ngydl vs. 6.6"6.8 ngydl, P-0.05). In this randomized study the MECC system has demonstrated best postoperative clinical results in terms of need for transfusion, platelets consumption and myocardial damage as compared to standard CPB.
Journal of Heart Valve Disease, May 1, 2004
ABSTRACT Thromboembolism remains one of the most impor- tant and still unsolved problems in patie... more ABSTRACT Thromboembolism remains one of the most impor- tant and still unsolved problems in patients undergo- ing mitral valve replacement (MVR). Since the 1950s, more than 90 models of prosthetic heart device have been proposed, yet despite a continuing improvement both in materials and design, a non-thrombogenic, blood-compatible device is not yet available and thromboembolism remains a major concern when either a mechanical or a biological (tissue) prosthesis is used in valve replacement surgery. Moreover, a num- ber of patient-related local and systemic factors can increase the thromboembolic risk, irrespective of the choice of device. The risk-benefit ratio when choosing the correct anti- thrombotic strategy after MVR should take into account both the type of prosthesis implanted and the specific patient's characteristics. In addition, there is a growing interest in tailoring the surgical approach toward individual patients in order to address all the patient-related local risk factors that can be corrected concomitantly at the time of valve surgery.
European Journal of Cardio-Thoracic Surgery, May 31, 2021
OBJECTIVES The appropriateness of moderate aortic regurgitation treatment during mitral valve (... more OBJECTIVES The appropriateness of moderate aortic regurgitation treatment during mitral valve (MV) surgery remains unclear. The goal of this study was to evaluate the immediate and long-term outcomes of patients with moderate aortic regurgitation at the time of MV surgery. METHODS We included 183 patients admitted to our institution for elective treatment of MV disease between 2004 and 2018, in whom moderate aortic regurgitation was diagnosed during preoperative evaluation. One hundred and twenty-two patients underwent isolated MV surgery (study group) whereas 61 patients underwent concomitant MV surgery and aortic valve replacement (control group). RESULTS One death (0.8%) occurred in the study group, and 3 deaths (4.8%) occurred in the control group (P = 0.52). The rate of the most common postoperative complication was similar between the 2 groups. At 12 years, the cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 4.7 ± 2.8% in the study group; no cardiac deaths were observed in the control group (P = 0.078). At 6 and 12 years, in the study group, the cumulative incidence function of aortic valve reintervention, with death as a competing risk, was 2.5 ± 1.85% and 19 ± 7.1%, respectively. CONCLUSIONS The appropriate management of moderate aortic regurgitation at the time of MV surgery deserves a careful evaluation by balancing the reintervention rate with the age, the operative risk and the life expectancy of the patient. Our findings suggest that a patient-tailored approach is the key to achieving the best clinical outcome for each individual patient.
PubMed, Jul 1, 2012
Background and aim of the study: The study aim was to assess if an undersized mitral annuloplasty... more Background and aim of the study: The study aim was to assess if an undersized mitral annuloplasty for functional mitral regurgitation (FMR) in dilated cardiomyopathy can determine a clinically relevant mitral stenosis during exercise. Methods: Both, rest and stress echocardiography were performed in 12 patients submitted to an undersized ring annuloplasty for FMR in dilated cardiomyopathy. The mean ring size was 27 +/- 1.3 mm. All patients were in NYHA functional classes I-II, were in stable sinus rhythm, and without significant residual mitral regurgitation (grade < or = 2/4). Results: At peak exercise (mean 81 +/- 12 W), the main cardiac performance indices were significantly improved, including systolic blood pressure (121 +/- 5.6 versus 169 +/- 14 mmHg, p < 0.001), stroke volume (63 +/- 15 versus 77 +/- 14 ml, p < 0.001), left ventricular ejection fraction (43 +/- 9% versus 47 +/- 9%, p = 0.001), and systolic right ventricular function (pulsed tissue Doppler index peak systolic velocity: 8.6 +/- 1.7 versus 11.1 +/- 3.2 cm/s, p = 0.004). A mild increase in planimetric mitral valve area was observed at peak exercise (2.12 +/- 0.4 versus 2.17 +/- 0.3 cm2, p = 0.05). Although the transmitral mean gradient was increased from 3.2 +/- 1.2 to 6.3 +/- 2.3 mmHg (p < 0.0001), the systolic pulmonary artery pressure did not change significantly (27 +/- 2.8 versus 30.1 +/- 6.4 mmHg, p = 0.3), thus revealing a preserved cardiac adaptation to exercise. Conclusion: In these preliminary data, postoperative clinically relevant mitral stenosis was not observed in patients submitted to mitral repair for FMR. Stress echocardiography represents a valuable tool to assess an appropriate cardiac response to exercise and to detect a significant exercise-induced pulmonary hypertension after undersized annuloplasty ring surgery.
The Journal of Thoracic and Cardiovascular Surgery, Aug 1, 2012
PubMed, Jun 1, 2004
The prevalence of ischemic dilated cardiomyopathy in western countries is increasing despite impr... more The prevalence of ischemic dilated cardiomyopathy in western countries is increasing despite improvements in prevention, diagnosis, and treatment of cardiovascular disease. The management of patients with coronary artery disease and severe left ventricular dysfunction continues to be challenging and the mortality rate with medical therapy alone in this setting remains very high. Since heart transplantation represents a realistic option just for a very small number of patients, in recent years a variety of classic surgical interventions have been improved or optimized to address the complex and multifactorial pathophysiology of the ischemic heart failure picture. Myocardial revascularization, left ventricular restoration, mitral valve repair, passive containment device implantation, and surgical ablation of atrial fibrillation represent some of the "conventional" procedures which are currently in use or under development for the surgical treatment of ischemic cardiomyopathy. For several of them, the exact indications and results are not yet established and significant changes and improvements should reasonably be waited over the next few years. As techniques are refined and more data become available, the optimum surgical strategy for patients with advanced ischemic heart failure is likely to become clearer and more effective.
PubMed, Dec 1, 2007
Aortic valve pathology is the most common acquired valvular heart disease in the adults of wester... more Aortic valve pathology is the most common acquired valvular heart disease in the adults of western countries, and mitral regurgitation (MR) is often clinically present in patients with degenerative aortic stenosis or insufficiency. Many studies report an incidence of MR between 65-75% in patients evaluated for aortic valve replacement. Severe aortic valve disease may be associated with functional mitral regurgitation (FMR) defined as the failure of mitral valve to prevent systolic backward flow in the absence of any significant structural or intrinsic valvular disease. Increased afterload and left ventricular remodeling have been implicated to explain FMR in patients with aortic valve disease. Moreover, organic mitral valve disease can be associated with aortic stenosis and can be rheumatic or degenerative. We have examined the data of the literature to understand the evolution of MR, the impact of mitral regurgitation on the outcome of patients undergoing aortic valve replacement, and to determine clinical predictors of prognosis in patients with concomitant MR at the time of aortic valve replacement.
European Journal of Cardio-Thoracic Surgery, Apr 1, 2004
The Annals of Thoracic Surgery, Nov 1, 2019
Background. To evaluate the outcomes of frozen elephant trunk (FET) procedures performed with a c... more Background. To evaluate the outcomes of frozen elephant trunk (FET) procedures performed with a customized graft that allows debranch-first technique with continuous antegrade cerebral perfusion and early distal aortic and myocardial reperfusion. Methods. Between 2016 and 2018 34 patients (30 men; median age, 59.7 years) were enrolled in an ambispective single-center study called FET Optimization (clinicaltrials. gov: NCT03600077). The patients underwent FET procedure using a novel modified E-Vita graft (JOTEC GmbH, Hechingen, Germany) plus graft with 2 dedicated reperfusion branches with debranch-first technique. Mortality and morbidity were primary endpoints. Secondary endpoints were overall duration of cardiopulmonary bypass, debranching, limb ischemia, cardiac ischemia, cerebral perfusion, and amount of aortic coverage. Results. No deaths at 30 days were recorded, and the major adverse event (grade ‡ 2) rate was 33% (11 patients) including 1 (3%) nondisabling stroke and 1 (2.9%) permanent spinal cord ischemic event. Proximal FET collar anastomosis were in zone 0 (68%) or zone 1 (32%). Median cardiopulmonary bypass duration was 165 minutes (range, 144-185), distal aortic ischemic time 38 minutes (range, 32-45), and cardiac ischemic time 74 minutes (range, 62-94). The time of distal aortic ischemia was shorter in nonobese patients (27 vs 49 minutes, P [ .043) and in zone 0 (23 cases) vs zone 1 (11 cases) anastomosis (34 vs 42 minutes, P [ .043). Conclusions. The FET procedure with debranch-first technique is safe and feasible and resulted in low mortality and morbidity rates. Further investigation is needed to compare it with standard techniques.
European Journal of Cardio-Thoracic Surgery, Mar 23, 2012
OBJECTIVES: While the results of mitral repair in ischaemic mitral regurgitation have been repeat... more OBJECTIVES: While the results of mitral repair in ischaemic mitral regurgitation have been repeatedly reported, less data are available about the outcome of surgical repair of functional mitral regurgitation (FMR) in idiopathic dilated cardiomyopathy (iDCM) which represents the topic of this study. METHODS: Fifty-four iDCM patients (mean age 63 ± 10.5 years) underwent mitral valve repair for severe FMR. Coronary angiography confirmed the absence of coronary disease in all patients. Most of the patients (77.7%) were in New York Heart Association (NYHA) class III-IV. Pre-operative ejection fraction (EF) was 30.4 ± 8.5%, left ventricle end-diastolic diameter (LVEDD) 67.5 ± 7.8 mm, left ventricle end-systolic diameter (LVESD) diameter 53.9 ± 8.3 mm. Concomitant procedures were atrial fibrillation (AF) ablation (19 patients) and tricuspid repair (17 patients). Follow-up was 100% complete (mean 4.2 ± 2.5 years, median 4.2 years, range 3.3 months-11.1 years). RESULTS: In-hospital mortality was 5.6%. Actuarial survival at 6.5 years was 69 ± 8.8%. Patients submitted to successful AF ablation and/ or cardiac resynchronization therapy (CRT) had a significantly better survival (91 ± 7.9 vs 67 ± 9.5%, P = 0.01). Freedom from MR≥3+/4+ was 89.1 ± 5.7% at 6.5 years. Follow-up echocardiography showed a reduction in LVEDD (P < 0.0001) and LVESD (P = 0.0003). Mean EF increased to 38.7 ± 12.4% (P < 0.0001). Multivariate analysis identified successful ablation of AF and/or CRT (P = 0.01) and higher preoperative EF (0.03) as predictors of overall survival. Successful ablation of AF and/or CRT (P = 0.02) and lower preoperative systolic pulmonary artery pressure (0.04) were identified as independent predictors of reverse LV remodelling at follow-up. At last follow-up, 86.2% of the patients were in NYHA II or less. CONCLUSIONS: Mitral repair for FMR in well-selected iDCM patients is associated with low hospital mortality and significant clinical benefit at late follow-up. Concomitant successful AF ablation and/or CRT provide a major symptomatic and prognostic advantage and should be associated to mitral surgery whenever indicated.
The Annals of Thoracic Surgery, Jul 1, 2012
Background. This was a study to compare the results of mitral valve (MV) repair and MV replacemen... more Background. This was a study to compare the results of mitral valve (MV) repair and MV replacement for the treatment of functional mitral regurgitation (MR) in advanced dilated and ischemic cardiomyopathy (DCM). Methods. One-hundred and thirty-two patients with severe functional MR and systolic dysfunction (mean ejection fraction 0.32 ؎ 0.078) underwent mitral surgery in the same time frame. The decision to replace rather than repair the MV was taken when 1 or more echocardiographic predictors of repair failure were identified at the preoperative echocardiogram. Eighty-five patients (64.4%) received MV repair and 47 patients (35.6%) received MV replacement. Preoperative characteristics were comparable between the 2 groups. Only ejection fraction was significantly lower in the MV repair group (0.308 ؎ 0.077 vs 0.336 ؎ 0.076, p ؍ 0.04). Results. Hospital mortality was 2.3% for MV repair and 12.5% for MV replacement (p ؍ 0.03). Actuarial survival at 2.5 years was 92 ؎ 3.2% for MV repair and 73 ؎ 7.9% for MV replacement (p ؍ 0.02). At a mean follow-up of 2.3 years (median, 1.6 years), in the MV repair group LVEF significantly increased (from 0.308 ؎ 0.077 to 0.382 ؎ 0.095, p < 0.0001) and LV dimensions significantly decreased (p ؍ 0.0001). On the other hand, in the MV replacement group LVEF did not significantly change (from 0.336 ؎ 0.076 to 0.31 ؎ 0.11, p ؍ 0.56) and the reduction of LV dimensions was not significant. Mitral valve replacement was identified as the only predictor of hospital (odds ratio, 6; 95% confidence interval, 1.1 to 31; p ؍ 0.03) and overall mortality (hazard ratio, 3.1; 95% confidence interval, 1.1 to 8.9; p ؍ 0.02). Conclusions. In patients with advanced dilated and ischemic cardiomyopathy and severe functional MR, MV replacement is associated with higher in-hospital and late mortality compared with MV repair. Therefore, mitral repair should be preferred whenever possible in this clinical setting.
European Journal of Cardio-Thoracic Surgery, Jun 1, 2010
This study assesses the results of the 'clover technique' (suturing together the middle point of ... more This study assesses the results of the 'clover technique' (suturing together the middle point of the free edges of the tricuspid leaflets) for the treatment of tricuspid regurgitation (TR) due to severe prolapse or tethering. Methods: From 2001, 66 patients with severe TR due to prolapsing or tethered leaflets underwent 'clover repair'. Annuloplasty was associated in 64 patients (97%). The aetiology of TR was degenerative in 52 cases (79%), post-traumatic in eight (12%) and secondary to dilated cardiomyopathy (DCM) in six (9%). The main mechanism of TR was prolapse/flail of one leaflet in 15 patients (23%), of two leaflets in 31 (47%) and of all three leaflets in 14 (21%). The remaining six patients (9%) presented with severe leaflets' tethering. Results: Four deaths (6%) occurred during hospitalisation and one patient died 3.6 years after surgery. Survival was 91 AE 4.1% at 5 years. Follow-up of the 62 hospital survivors was 100% complete (mean length 3.5 AE 1.6 years, range 13 months-7.1 years). At the last echocardiogram, no or mild TR was detected in 55 (88.7%) patients, moderate (2+/4+) in six (9.6%) and severe (4+/ 4+) in one patient (1.6%). Mean tricuspid valve area and gradient were 4.3 AE 0.6 cm 2 and 2.8 AE 1.4 mmHg. In six patients, stress echocardiography was performed and no signs of tricuspid stenosis were detected. At the multivariable analysis, the degree of TR at hospital discharge was identified as the only predictor of TR !2+ at follow-up. Conclusions: Midterm clinical and echocardiographic results confirm the role of the 'clover technique' in the surgical treatment of TR due to lesions, which are unlikely to be effectively treatable by annuloplasty alone.
The Annals of Thoracic Surgery, Feb 1, 2007
Background. The purpose of this study was to evaluate the safety and clinical results of aortic v... more Background. The purpose of this study was to evaluate the safety and clinical results of aortic valve replacement performed with minimally invasive closed circuit extracorporeal circulation technique (MECC system) versus standard cardiopulmonary bypass. Methods. Forty consecutive patients undergoing isolated aortic valve replacement at a single institution were randomly assigned to either miniaturized closed circuit cardiopulmonary bypass with the Maquet-Cardiopulmonary (Rastatt, Germany) minimal extracorporeal circulation (MECC) system (study group B, n ؍ 17) or standard cardiopulmonary bypass (control group A, n ؍ 23). The MECC system is a low priming circuit without blood-air interface. Technical feasibility, in particular the potential entry of air in the circuit, and clinical results were prospectively evaluated. Results. Demographic characteristics and surgical data were similar in both groups. Patients in the study group showed reduced chest tube drainage (217 ؎ 62 mL vs 420 ؎ 219 mL, p < 0.05) and blood transfusion requirements (5.1% vs 43.4%, p < 0.02) compared with patients in the control group. Moreover, the study group showed significantly higher time course of hematocrit at all time points during the operation and longer hospital stay (p < 0.02) than the control group; similarly, in the study group patients' platelet count in intensive care unit admission was significantly higher than the control group (140 ؎ 29 ؋ 10 9 /L vs 119 ؎ 37 ؋ 10 9 /L, p < 0.05). Peak postoperative troponin C release was significantly lower in the study group (4.74 ؎ 2.82 vs 8.43 ؎ 6.25 ng/dL, p < 0.033). One patient undergoing the MECC system operation showed a major neurologic event on postoperative day four, which was probably secondary to severe aortic calcification. Conclusions. The MECC system is suitable for aortic valve replacement and provides better clinical results than standard cardiopulmonary bypass as regards blood transfusion requirements, platelets consumption, and myocardial damage.
European Journal of Cardio-Thoracic Surgery, Apr 15, 2022
OBJECTIVES With the expanding use of cardiac implantable electronic devices (CIEDs), lead interfe... more OBJECTIVES With the expanding use of cardiac implantable electronic devices (CIEDs), lead interference with the tricuspid valve (TV) causing significant tricuspid regurgitation (TR) has gained increasing recognition. However, current knowledge about the long-term results of the surgical treatment of TR in this setting is scanty. Therefore, increasing this information was the goal of this study. METHODS A retrospective review of our institutional database was carried out to select all patients with previously implanted CIEDs who underwent tricuspid valve repair and replacement from 2000 through 2019. Kaplan–Meier methods were used to analyse long-term survival. To describe the time course of TR, we performed a longitudinal analysis using generalized estimating equations. RESULTS A total of 151 patients were identified. Mechanical interference with leaflet mobility and coaptation was detected in 103 patients (68%) (CIED-induced group); in the remaining 48 patients (32%), the lead was associated with TR without being the cause of it (CIED-associated group). A total of 105 patients underwent TV repair; in the remaining 46, a TV replacement was necessary. In patients who underwent TV repair, no significant difference in moderate TR recurrence rate was highlighted between CIED-induced and CIED-associated TR. CONCLUSIONS In patients with CIEDs and surgically treated tricuspid regurgitation, TR is CIED-induced in about two-thirds of the cases and CIED-associated in one-third of them. In our experience, TV repair was still possible in 63% of the cases, with good long-term results and no significant durability difference between CIED-induced and CIED-associated TR.
Asian Cardiovascular and Thoracic Annals, May 20, 2021
Background Several papers already reported better outcomes of tricuspid valve repair with ring an... more Background Several papers already reported better outcomes of tricuspid valve repair with ring annuloplasty compared to suture techniques. However, the follow-up is usually limited to 10 years. With this study, we aim to analyze the results of tricuspid valve repair according to the technique employed when the follow-up is extended to more than 15 years. Materials and methods A retrospective review of our institutional database was carried on to find all patients who underwent tricuspid valve repair between January 1998 and December 2004. Kaplan–Meier method was employed to estimate survival and log-rank test was used to make intergroup comparison. Cox regression was employed to identify risk factor for mortality. Cumulative incidence function using death as competitive outcome was used to estimate cardiac death. To describe the time course of tricuspid regurgitation, a longitudinal analysis using generalized estimating equations with random intercept for correlated data was performed. Results One hundred forty-six patients were identified: 89 in the suture group and 57 in the ring group. No difference in term of long-term survival and cardiac death was evident between the two groups. A significant higher rate of tricuspid regurgitation ≥2+ and ≥3+ recurrence was evident in the suture group during the whole follow-up (p &lt; 0.001). Conclusion Our results corroborate the better results of tricuspid valve repair by means of ring implantation compared to suture techniques also when the follow-up is extended up to 18 years. Ring annuloplasty should be considered the first option for tricuspid valve repair due to a better durability.
Annals of cardiothoracic surgery, May 1, 2020
Journal of Cardiac Surgery, Oct 15, 2019
Acute aortic arch dissections represent life-threatening conditions with a high rate of mortality... more Acute aortic arch dissections represent life-threatening conditions with a high rate of mortality and neurological complications. Past longer techniques included an "en bloc" replacement of epiaortic vessels or the frozen elephant trunk (FET) procedure with conventional grafts for chronic dilatation. In this report, we described a case of an acute aortic dissection in a patient with aberrant right subclavian artery and challenging sovra-aortic vessel anatomy, treated with the new custom-made E-Vita Open Plus FET graft.
The Annals of Thoracic Surgery, Mar 1, 2009
We report the case of a woman affected by severe functional mitral regurgitation secondary to idi... more We report the case of a woman affected by severe functional mitral regurgitation secondary to idiopathic dilated cardiomyopathy, who underwent reductive mitral annuloplasty and implantation of CorCap cardiac support device (Acorn Cardiovascular Inc, St. Paul, MN). Despite the recurrence of severe mitral regurgitation early after surgery, a progressive reverse remodeling of the left ventricle has been echocardiographically demonstrated at a long-term follow-up due to the passive containment effect of the CorCap.
The Annals of Thoracic Surgery, Mar 1, 2008
Background. The aim of this study was to assess the occurrence of reverse left ventricular (LV) r... more Background. The aim of this study was to assess the occurrence of reverse left ventricular (LV) remodeling after effective mitral valve repair in advanced dilated cardiomyopathy and its impact on clinical outcome and repair durability. Methods. Of 111 patients undergoing mitral valve repair in ischemic or idiopathic dilated cardiomyopathy, 79 patients with no or trivial residual mitral regurgitation (MR) at discharge and with a follow-up length of at least 6 months were included in this study. Preoperatively they had 3 to 4؉ functional MR, an ejection fraction of 0.28 ؎ 0.055, an indexed LV end-diastolic volume of 113 ؎ 33.0 mL/m 2 , an indexed LV end-systolic volume of 80.8 ؎ 26.3 mL/m 2 , a tenting area of 2.7 ؎ 0.9 cm 2 , and a coaptation depth of 1.1 ؎ 0.3 cm. Sixty-three patients (79.8%) were in New York Heart Association class III or IV. A complete, rigid or semirigid undersized ring annuloplasty (with or without "edge-to-edge") was used. Concomitant procedures were coronary artery bypass grafting (49 of 79 patients, 62%), tricuspid valve repair (11 of 79 patients, 13.9%), and ablation of permanent atrial fibrillation (13 of 79 patients, 16.4%). Results. At a mean follow-up of 2 ؎ 1.3 years (median, 1.8 years), LV reverse remodeling was documented in 41 patients (51.8%), whereas in 38 patients (48.1%) LV dimensions remained unchanged or increased compared with preoperative values. The persistence or progression of LV remodeling paralleled the recurrence of MR and worsening of symptoms. Recurrence of MR of 3؉ or greater was 0% in the "reverse remodeling" group and 18.4% in the "no reverse remodeling" one (p ؍ 0.008). At 3 years, freedom from recurrence of MR of 2؉ or greater was 74% ؎ 11.7% and 62% ؎ 9.2% (p ؍ 0.004) and New York Heart Association class was 1.5 ؎ 0.61 and 2 ؎ 0.72 (p < 0.0001), respectively. Predictors of reverse remodeling were ischemic etiology (p ؍ 0.04), concomitant coronary artery bypass grafting (p ؍ 0.02), successful ablation of atrial fibrillation (p ؍ 0.05), and shorter history of congestive heart failure (p ؍ 0.06). The use of the edgeto-edge showed a trend toward favoring reverse remodeling compared with isolated annuloplasty (p ؍ 0.08). Conclusions. In patients with functional MR undergoing effective repair, the occurrence of reverse LV remodeling is associated with longer repair durability and a better clinical outcome compared with those with persistence or progression of the remodeling process.
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Papers by Alessandro Verzini