BackgroundCombined interpretation of late diastolic mitral annulus velocity (A′) with left atrial... more BackgroundCombined interpretation of late diastolic mitral annulus velocity (A′) with left atrial volume index (LAVi) may have additional benefits in the assessment of diastolic dysfunction.HypothesisThe LAVi/A′ ratio may be useful in the identifying advanced diastolic dysfunction (ADD) and predicting clinical outcomes in patients with dyspnea.MethodsWe enrolled 395 consecutive patients hospitalized with dyspnea (New York Heart Association class II–IV) and performed transthoracic Doppler echocardiography and B‐type natriuretic peptide (BNP) measurement. LAVi/A′ values were evaluated in terms of diagnosing ADD and predicting clinical outcome.ResultsOn the receiver operation characteristic curve analysis for the determination of ADD, the area under the curves of LAVi/A′ in the entire population was comparable to those of BNP (0.94 vs 0.93, P = 0.845) and mitral E/E′ (0.94 vs 0.93, P = 0.614) and higher than that of LAVi (0.94 vs 0.87; P = 0.014). A LAVi/A′ of 4.0 was the best cut‐off ...
Catheterization and Cardiovascular Diagnosis, 1997
A new vascular sheath design (anesthesia infusion sleeve, or AIS) was developed to enable adminis... more A new vascular sheath design (anesthesia infusion sleeve, or AIS) was developed to enable administration of local anesthetics or other medications into the subcutaneous tissue around an arterial or venous insertion site without any additional needle sticks or manipulation. Design, animal testing, and an initial small single-site clinical study have previously been published. The current study was multicenter and randomized 80 patients to use of a standard sheath for vascular access or the AIS. Pain associated with sheath placement, postprocedure pain, and pain associated with sheath removal before and during manual compression was recorded. Baseline pain was identical in both the standard and AIS groups. Pain during infiltration and with initial femoral artery compression was significantly lower in the AIS group. A quality of life questionnaire indicated that the AIS sheath was associated with less discomfort and was preferred over a standard sheath in patients who had had a previous procedure performed. The AIS represents a simple addition to standard sheath design, offering superior pain control during removal compared to the standard technique, without the need for systemic analgesics or additional needle punctures.
Obesity is associated withright ventricular (RV) dysfunction, but its effect on RV remodeling in ... more Obesity is associated withright ventricular (RV) dysfunction, but its effect on RV remodeling in patients with pulmonary hypertension(PHTN) has not been studied. We evaluated the effect of obesity, and its interplay with diabetes, in patients with PHTN using RV echocardiographic strain imaging. 185 patients underwent echocardiographic imaging and pulmonary artery pressure was calculated using tricuspid regurgitation jet velocity. From focused RV apical-four-chamber view, global and mid peak systolic RV free wall longitudinal strain (FWLS) wascalculated using speckle-tracking software. Global and mid RV FWLS in patients with PHTN (n=84) was lower (-16.8+/-7 vs -18.9+/-6.3, P=0.035 & -11.2+/-12.8 vs -18.9+/-9.2, P=0.002 respectively) compared with patients without PHTN (n=101). Among patients without PHTN, obese patients (BMI >30) had lower global and mid RV FWLS (-17.2+/-6.2 vs -20.3+/-5.7, P=0.012 & -17.6+/-7.2 vs -21.9+/-7.3, P=0.004), even after excluding diabetic patients (Mid RV FWLS -18.2+/-6.8 vs -22.1+/-8, P=0.032). Among patients with PHTN, obese patients had similar RV FWLS compared with non-obese patients (P=0.46). However, on excluding diabetic patients from PHTN group, obese patients with PHTN had higher global and mid RV FWLS (-21.7+/-5.7 vs -16.1+/-8, P=0.017 & -23.8+/-4.8 vs -17+/-9.4, P=0.009 respectively) compared to non-obese patients which suggests a protective effect of obesity on RV function in patients with PHTN. Obesity is associated with subclinical RV dysfunction as assessed by RV strain imaging, but paradoxically it may confer a protective effect on RV function once the patient develops PHTN. Future studies should evaluate the clinical impact of this paradox.
Background: Cardiac sarcoidosis is clinically manifest in only about 5% of known sarcoid patients... more Background: Cardiac sarcoidosis is clinically manifest in only about 5% of known sarcoid patients and should be considered when an otherwise asymptomatic and young patient presents with unexplained heart block. Current guidelines require histological verification for diagnosis and recommend early imaging for identification of patients at risk and to aid in diagnosis. Case: A 53-year-old white male presented with complaints of dyspnea on exertion for 3 weeks. A 12 lead ECG showed sinus rhythm with bifascicular block and third degree heart block. The patient had a remote history of uveitis. Labs revealed markedly elevated ACE levels. A CT chest and Cardiac MRI were obtained, which revealed bilateral hilar and mediastinal lymphadenopathy, and enhanced T2 uptake in the basal septum with EF 46% without LGE, suggestive of sarcoidosis. Consults were placed with Pulmonology and Rheumatology about biopsy and steroid treatment. There was strong suspicion for sarcoidosis, but biopsy was deferred during the hospitalization. A dual chamber ICD was placed and the patient was started on Prednisone and was discharged home in stable condition. Decision-Making: With the patient having a history of uveitis, and his otherwise unexplained presentation with third degree heart block, there was strong suspicion of cardiac sarcoid. Therefore, a CT Chest and Cardiac MRI were ordered on admission, which had findings strongly suggestive of cardiac sarcoidosis. Biopsy was deferred during hospitalization after discussion with our consultants. With his third degree heart block and mildly reduced ejection fraction, a dual chamber ICD was placed. The patient was started on Prednisone 20 mg daily with plans to titrate to 1 mg/kg/day as an outpatient. Conclusions: Current guidelines suggest to obtain histological verification to make a diagnosis of cardiac sarcoid. However, with a strong clinical history, imaging studies suggestive of sarcoidosis, and otherwise unexplainable cardiac symptoms, histological evidence of cardiac or extra-cardiac sarcoidosis may not be needed to diagnose and begin prompt treatment for cardiac sarcoidosis.
Catheterization and Cardiovascular Diagnosis, Jun 1, 1995
This study was designed to compare a new investigational coronary perfusion balloon (Wave, Scimed... more This study was designed to compare a new investigational coronary perfusion balloon (Wave, Scimed Life Systems Inc.) with that of an approved, widely used, current generation device (Flowtrack 40, Advanced Cardiovascular Systems). Domestic swine were anesthetized with pentobarbital and instrumented using standard percutaneous technique. Left ventricular contractile function (dP/dt) was monitored using a micromanometer while intracoronary and surface ECGs were also recorded. Eight target vessels were studied (4 LAD and 4 Cx) in random order. The perfusion balloons were kept inflated for 10 min. Complete coronary occlusion with a standard angioplasty balloon produced marked decreases in mean aortic pressure, left ventricular developed pressure, peak + dP/dt, peak-dP/dt, and significant ST segment elevation in both intracoronary and surface ECG at 30 seconds. Neither the Wave or Flowtrack 40 produced any change in heart rate or mean aortic pressure. Both catheters caused a drop in left ventricular developed pressure immediately after balloon inflation. At 10 min, however, there was a small but significant decrease only with the Flowtrack 40. Similarly, peak +dP/dt was slightly depressed during Flowtrack 40 inflation at 10 min but not with the Wave catheter. Both catheters produced ST segment elevation on the surface and intracoronary electrocardiographic records. These changes were significantly greater with the Flowtrack 40 system. Thus, both the Flowtrack 40 and Wave perfusion balloons are effective in preventing ischemia during coronary occlusion in swine; however, the latter system may be more effective in this model. o 1995 Wiley-Liss, Inc.
Arteriosclerosis, Thrombosis, and Vascular Biology, 2017
Introduction: Drug-eluting Stent(DESs) have demonstrated improved patency and freedom from target... more Introduction: Drug-eluting Stent(DESs) have demonstrated improved patency and freedom from target lesion revascularization compared with Bare-Metal stents or Percutaneous Transluminal Angioplasty(PTA); however, the effect on clinical outcome parameters, such as limb salvage and wound healing, remains unidentified. We present a direct comparison of clinical outcomes in patients who underwent DES vs PTA. Methods: We collected data of patients who underwent infra-popliteal arterial interventions at our institution. Clinical end points analyzed were all cause mortality, target vessel revascularization, primary vessel patency, and target limb major and minor amputations. Differences between two groups were analyzed by chi square for categorical variables and t test for continuous variables. Statistical significance was considered for P values less than .05 in a 2-sided test. Results: Total of 83 cases, n=42 in DES group and n=41 in PTA group were analyzed. Mean age was 71.6 years (range ...
Journal of Community Hospital Internal Medicine Perspectives, 2021
ABSTRACT Gadodiamide is a gadolinium-based chemical element that is considered safe and well tole... more ABSTRACT Gadodiamide is a gadolinium-based chemical element that is considered safe and well tolerated in patients without renal dysfunction and is therefore routinely used as a contrast agent in magnetic resonance imaging. Although radio-opaque, it is not frequently used for coronary angiography due to its less than optimal image quality and prohibitive cost. Our center’s previous experience was less than satisfactory but the addition of a power injection system yielded good quality diagnostic images. We report a case of 63 years old male with a known history of severe, life-threatening anaphylactic reaction to previous iodinated dye presenting with persistent angina despite optimal medical therapy. Coronary and bypass graft angiography was performed using 24 cc of undiluted Gadodiamide (OMNISCAN) with a power injector (ACIST®) without any incidents or premedication with an interpretable angiogram.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
INTRODUCTION Brugada Syndrome typically presents with sudden nocturnal arrhythmias. Diagnosis may... more INTRODUCTION Brugada Syndrome typically presents with sudden nocturnal arrhythmias. Diagnosis may be challenging due to variable and transient electrocardiogram patterns and nondiagnostic provocation studies. Genetic testing can establish the etiology, but results may be inconclusive with variants of uncertain significance. CASE A 24-year-old male with family history of sudden cardiac death was found unresponsive due to seizure. He was hemodynamically stable. ECG showed saddle-back ST elevations in V1 and V2. Procainamide challenge was negative. We subsequently performed genetic testing, which demonstrated AKAP9 variant. DISCUSSION AKAP9 is a scaffolding protein that facilitates phosphorylation of delayed-rectifier potassium channels. The AKAP9 variant alters potassium current causing disordered repolarization and ventricular reentry. It has been previously linked to other channelopathies, but its pathogenicity is fully undetermined. CONCLUSION Genetic testing is a useful tool to determine the origin of channelopathy, but inconclusive results with variants of uncertain significance should be clinically correlated.
The purpose of this analysis was to evaluate the cardioprotective benefit of beta-blockers in pre... more The purpose of this analysis was to evaluate the cardioprotective benefit of beta-blockers in preventing anthracycline induced cardiotoxicity (AIC) in breast cancer patients. Anthracyclines are the cornerstone treatment for breast cancer. Yet, their use has declined in the last decade due to associated AIC. While beta blockers may protect left ventricular function, prior trials were underpowered with equivocal results. The authors systematically searched online databases through August 2018 for studies evaluating effectiveness of beta blockers in preventing AIC in breast cancer patients. We analyzed 9 studies including 771 patients. Data on ACEI, trastuzumab or other malignancies were excluded. The primary outcome was comparison of postchemotherapy LVEF between beta blocker and placebo. Secondary outcomes were changes in global longitudinal strain (GLS), left ventricular end-diastolic diameter (LVEDD) and diastolic function parameters, as assessed by 2D echocardiogram and MRI. The mean baseline left ventricular ejection fraction (LVEF) >60% in all studies. Our pooled analysis demonstrated significantly higher LVEF post-chemotherapy in the beta blocker group in comparison to placebo: mean difference-3.84 with 95% CI [-(6.19-1.48) p = 0.001]. The absolute change in EF also favored beta blockers: mean difference-3.66 with 95% CI [-(6.20-1.12) p = 0.005]. Diastolic function, GLS and LVEDD were also preserved by beta blockers, but only LVEDD reached statistical significance. In conclusion, this study suggests that beta blockers during anthracycline chemotherapy prevent may cardiotoxicity by preserving left ventricular function.
BackgroundCombined interpretation of late diastolic mitral annulus velocity (A′) with left atrial... more BackgroundCombined interpretation of late diastolic mitral annulus velocity (A′) with left atrial volume index (LAVi) may have additional benefits in the assessment of diastolic dysfunction.HypothesisThe LAVi/A′ ratio may be useful in the identifying advanced diastolic dysfunction (ADD) and predicting clinical outcomes in patients with dyspnea.MethodsWe enrolled 395 consecutive patients hospitalized with dyspnea (New York Heart Association class II–IV) and performed transthoracic Doppler echocardiography and B‐type natriuretic peptide (BNP) measurement. LAVi/A′ values were evaluated in terms of diagnosing ADD and predicting clinical outcome.ResultsOn the receiver operation characteristic curve analysis for the determination of ADD, the area under the curves of LAVi/A′ in the entire population was comparable to those of BNP (0.94 vs 0.93, P = 0.845) and mitral E/E′ (0.94 vs 0.93, P = 0.614) and higher than that of LAVi (0.94 vs 0.87; P = 0.014). A LAVi/A′ of 4.0 was the best cut‐off ...
Catheterization and Cardiovascular Diagnosis, 1997
A new vascular sheath design (anesthesia infusion sleeve, or AIS) was developed to enable adminis... more A new vascular sheath design (anesthesia infusion sleeve, or AIS) was developed to enable administration of local anesthetics or other medications into the subcutaneous tissue around an arterial or venous insertion site without any additional needle sticks or manipulation. Design, animal testing, and an initial small single-site clinical study have previously been published. The current study was multicenter and randomized 80 patients to use of a standard sheath for vascular access or the AIS. Pain associated with sheath placement, postprocedure pain, and pain associated with sheath removal before and during manual compression was recorded. Baseline pain was identical in both the standard and AIS groups. Pain during infiltration and with initial femoral artery compression was significantly lower in the AIS group. A quality of life questionnaire indicated that the AIS sheath was associated with less discomfort and was preferred over a standard sheath in patients who had had a previous procedure performed. The AIS represents a simple addition to standard sheath design, offering superior pain control during removal compared to the standard technique, without the need for systemic analgesics or additional needle punctures.
Obesity is associated withright ventricular (RV) dysfunction, but its effect on RV remodeling in ... more Obesity is associated withright ventricular (RV) dysfunction, but its effect on RV remodeling in patients with pulmonary hypertension(PHTN) has not been studied. We evaluated the effect of obesity, and its interplay with diabetes, in patients with PHTN using RV echocardiographic strain imaging. 185 patients underwent echocardiographic imaging and pulmonary artery pressure was calculated using tricuspid regurgitation jet velocity. From focused RV apical-four-chamber view, global and mid peak systolic RV free wall longitudinal strain (FWLS) wascalculated using speckle-tracking software. Global and mid RV FWLS in patients with PHTN (n=84) was lower (-16.8+/-7 vs -18.9+/-6.3, P=0.035 & -11.2+/-12.8 vs -18.9+/-9.2, P=0.002 respectively) compared with patients without PHTN (n=101). Among patients without PHTN, obese patients (BMI >30) had lower global and mid RV FWLS (-17.2+/-6.2 vs -20.3+/-5.7, P=0.012 & -17.6+/-7.2 vs -21.9+/-7.3, P=0.004), even after excluding diabetic patients (Mid RV FWLS -18.2+/-6.8 vs -22.1+/-8, P=0.032). Among patients with PHTN, obese patients had similar RV FWLS compared with non-obese patients (P=0.46). However, on excluding diabetic patients from PHTN group, obese patients with PHTN had higher global and mid RV FWLS (-21.7+/-5.7 vs -16.1+/-8, P=0.017 & -23.8+/-4.8 vs -17+/-9.4, P=0.009 respectively) compared to non-obese patients which suggests a protective effect of obesity on RV function in patients with PHTN. Obesity is associated with subclinical RV dysfunction as assessed by RV strain imaging, but paradoxically it may confer a protective effect on RV function once the patient develops PHTN. Future studies should evaluate the clinical impact of this paradox.
Background: Cardiac sarcoidosis is clinically manifest in only about 5% of known sarcoid patients... more Background: Cardiac sarcoidosis is clinically manifest in only about 5% of known sarcoid patients and should be considered when an otherwise asymptomatic and young patient presents with unexplained heart block. Current guidelines require histological verification for diagnosis and recommend early imaging for identification of patients at risk and to aid in diagnosis. Case: A 53-year-old white male presented with complaints of dyspnea on exertion for 3 weeks. A 12 lead ECG showed sinus rhythm with bifascicular block and third degree heart block. The patient had a remote history of uveitis. Labs revealed markedly elevated ACE levels. A CT chest and Cardiac MRI were obtained, which revealed bilateral hilar and mediastinal lymphadenopathy, and enhanced T2 uptake in the basal septum with EF 46% without LGE, suggestive of sarcoidosis. Consults were placed with Pulmonology and Rheumatology about biopsy and steroid treatment. There was strong suspicion for sarcoidosis, but biopsy was deferred during the hospitalization. A dual chamber ICD was placed and the patient was started on Prednisone and was discharged home in stable condition. Decision-Making: With the patient having a history of uveitis, and his otherwise unexplained presentation with third degree heart block, there was strong suspicion of cardiac sarcoid. Therefore, a CT Chest and Cardiac MRI were ordered on admission, which had findings strongly suggestive of cardiac sarcoidosis. Biopsy was deferred during hospitalization after discussion with our consultants. With his third degree heart block and mildly reduced ejection fraction, a dual chamber ICD was placed. The patient was started on Prednisone 20 mg daily with plans to titrate to 1 mg/kg/day as an outpatient. Conclusions: Current guidelines suggest to obtain histological verification to make a diagnosis of cardiac sarcoid. However, with a strong clinical history, imaging studies suggestive of sarcoidosis, and otherwise unexplainable cardiac symptoms, histological evidence of cardiac or extra-cardiac sarcoidosis may not be needed to diagnose and begin prompt treatment for cardiac sarcoidosis.
Catheterization and Cardiovascular Diagnosis, Jun 1, 1995
This study was designed to compare a new investigational coronary perfusion balloon (Wave, Scimed... more This study was designed to compare a new investigational coronary perfusion balloon (Wave, Scimed Life Systems Inc.) with that of an approved, widely used, current generation device (Flowtrack 40, Advanced Cardiovascular Systems). Domestic swine were anesthetized with pentobarbital and instrumented using standard percutaneous technique. Left ventricular contractile function (dP/dt) was monitored using a micromanometer while intracoronary and surface ECGs were also recorded. Eight target vessels were studied (4 LAD and 4 Cx) in random order. The perfusion balloons were kept inflated for 10 min. Complete coronary occlusion with a standard angioplasty balloon produced marked decreases in mean aortic pressure, left ventricular developed pressure, peak + dP/dt, peak-dP/dt, and significant ST segment elevation in both intracoronary and surface ECG at 30 seconds. Neither the Wave or Flowtrack 40 produced any change in heart rate or mean aortic pressure. Both catheters caused a drop in left ventricular developed pressure immediately after balloon inflation. At 10 min, however, there was a small but significant decrease only with the Flowtrack 40. Similarly, peak +dP/dt was slightly depressed during Flowtrack 40 inflation at 10 min but not with the Wave catheter. Both catheters produced ST segment elevation on the surface and intracoronary electrocardiographic records. These changes were significantly greater with the Flowtrack 40 system. Thus, both the Flowtrack 40 and Wave perfusion balloons are effective in preventing ischemia during coronary occlusion in swine; however, the latter system may be more effective in this model. o 1995 Wiley-Liss, Inc.
Arteriosclerosis, Thrombosis, and Vascular Biology, 2017
Introduction: Drug-eluting Stent(DESs) have demonstrated improved patency and freedom from target... more Introduction: Drug-eluting Stent(DESs) have demonstrated improved patency and freedom from target lesion revascularization compared with Bare-Metal stents or Percutaneous Transluminal Angioplasty(PTA); however, the effect on clinical outcome parameters, such as limb salvage and wound healing, remains unidentified. We present a direct comparison of clinical outcomes in patients who underwent DES vs PTA. Methods: We collected data of patients who underwent infra-popliteal arterial interventions at our institution. Clinical end points analyzed were all cause mortality, target vessel revascularization, primary vessel patency, and target limb major and minor amputations. Differences between two groups were analyzed by chi square for categorical variables and t test for continuous variables. Statistical significance was considered for P values less than .05 in a 2-sided test. Results: Total of 83 cases, n=42 in DES group and n=41 in PTA group were analyzed. Mean age was 71.6 years (range ...
Journal of Community Hospital Internal Medicine Perspectives, 2021
ABSTRACT Gadodiamide is a gadolinium-based chemical element that is considered safe and well tole... more ABSTRACT Gadodiamide is a gadolinium-based chemical element that is considered safe and well tolerated in patients without renal dysfunction and is therefore routinely used as a contrast agent in magnetic resonance imaging. Although radio-opaque, it is not frequently used for coronary angiography due to its less than optimal image quality and prohibitive cost. Our center’s previous experience was less than satisfactory but the addition of a power injection system yielded good quality diagnostic images. We report a case of 63 years old male with a known history of severe, life-threatening anaphylactic reaction to previous iodinated dye presenting with persistent angina despite optimal medical therapy. Coronary and bypass graft angiography was performed using 24 cc of undiluted Gadodiamide (OMNISCAN) with a power injector (ACIST®) without any incidents or premedication with an interpretable angiogram.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
INTRODUCTION Brugada Syndrome typically presents with sudden nocturnal arrhythmias. Diagnosis may... more INTRODUCTION Brugada Syndrome typically presents with sudden nocturnal arrhythmias. Diagnosis may be challenging due to variable and transient electrocardiogram patterns and nondiagnostic provocation studies. Genetic testing can establish the etiology, but results may be inconclusive with variants of uncertain significance. CASE A 24-year-old male with family history of sudden cardiac death was found unresponsive due to seizure. He was hemodynamically stable. ECG showed saddle-back ST elevations in V1 and V2. Procainamide challenge was negative. We subsequently performed genetic testing, which demonstrated AKAP9 variant. DISCUSSION AKAP9 is a scaffolding protein that facilitates phosphorylation of delayed-rectifier potassium channels. The AKAP9 variant alters potassium current causing disordered repolarization and ventricular reentry. It has been previously linked to other channelopathies, but its pathogenicity is fully undetermined. CONCLUSION Genetic testing is a useful tool to determine the origin of channelopathy, but inconclusive results with variants of uncertain significance should be clinically correlated.
The purpose of this analysis was to evaluate the cardioprotective benefit of beta-blockers in pre... more The purpose of this analysis was to evaluate the cardioprotective benefit of beta-blockers in preventing anthracycline induced cardiotoxicity (AIC) in breast cancer patients. Anthracyclines are the cornerstone treatment for breast cancer. Yet, their use has declined in the last decade due to associated AIC. While beta blockers may protect left ventricular function, prior trials were underpowered with equivocal results. The authors systematically searched online databases through August 2018 for studies evaluating effectiveness of beta blockers in preventing AIC in breast cancer patients. We analyzed 9 studies including 771 patients. Data on ACEI, trastuzumab or other malignancies were excluded. The primary outcome was comparison of postchemotherapy LVEF between beta blocker and placebo. Secondary outcomes were changes in global longitudinal strain (GLS), left ventricular end-diastolic diameter (LVEDD) and diastolic function parameters, as assessed by 2D echocardiogram and MRI. The mean baseline left ventricular ejection fraction (LVEF) >60% in all studies. Our pooled analysis demonstrated significantly higher LVEF post-chemotherapy in the beta blocker group in comparison to placebo: mean difference-3.84 with 95% CI [-(6.19-1.48) p = 0.001]. The absolute change in EF also favored beta blockers: mean difference-3.66 with 95% CI [-(6.20-1.12) p = 0.005]. Diastolic function, GLS and LVEDD were also preserved by beta blockers, but only LVEDD reached statistical significance. In conclusion, this study suggests that beta blockers during anthracycline chemotherapy prevent may cardiotoxicity by preserving left ventricular function.
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Papers by Mahesh Bikkina