Gigli Dott. Lorenzo
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Fighting Cardiac Thromboembolism during Transcatheter Procedures: An Update on the Use of Cerebral Protection Devices in Cath Labs and EP Labs.
Life (Basel)2023 Aug;13(9):. doi: 1819.
Preda Alberto, Montalto Claudio, Galasso Michele, Munafò Andrea, Garofani Ilaria, Baroni Matteo, Gigli Lorenzo, Vargiu Sara, Varrenti Marisa, Colombo Giulia, Carbonaro Marco, Della Rocca Domenico Giovanni, Oreglia Jacopo, Mazzone Patrizio, Guarracini Fabrizio
Abstract
Intraprocedural stroke is a well-documented and feared potential risk of cardiovascular transcatheter procedures (TPs). Moreover, subclinical neurological events or covert central nervous system infarctions are concerns related to the development of dementia, future stroke, cognitive decline, and increased risk of mortality. Cerebral protection devices (CPDs) were developed to mitigate the risk of cardioembolic embolism during TPs. They are mechanical barriers designed to cover the ostium of the supra-aortic branches in the aortic arch, but newer devices are able to protect the descending aorta. CPDs have been mainly designed and tested to provide cerebral protection during transcatheter aortic valve replacement (TAVR), but their use in both Catheterization and Electrophysiology laboratories is rapidly increasing. CPDs have allowed us to perform procedures that were previously contraindicated due to high thromboembolic risk, such as in cases of intracardiac thrombosis identified at preprocedural assessment. However, several concerns related to their employment have to be defined. The selection of patients at high risk of thromboembolism is still a subjective choice of each center. The aim of this review is to update the evidence on the use of CPDs in either Cath labs or EP labs, providing an overview of their structural characteristics. Future perspectives focusing on their possible future employment are also discussed.
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Subcutaneous Implantable Cardioverter Defibrillator: A Contemporary Overview.
Life (Basel)2023 Jul;13(8):. doi: 1652.
Guarracini Fabrizio, Preda Alberto, Bonvicini Eleonora, Coser Alessio, Martin Marta, Quintarelli Silvia, Gigli Lorenzo, Baroni Matteo, Vargiu Sara, Varrenti Marisa, Forleo Giovanni Battista, Mazzone Patrizio, Bonmassari Roberto, Marini Massimiliano, Droghetti Andrea
Abstract
The difference between subcutaneous implantable cardioverter defibrillators (S-ICDs) and transvenous ICDs (TV-ICDs) concerns a whole extra thoracic implantation, including a defibrillator coil and pulse generator, without endovascular components. The improved safety profile has allowed the S-ICD to be rapidly taken up, especially among younger patients. Reports of its role in different cardiac diseases at high risk of SCD such as hypertrophic and arrhythmic cardiomyopathies, as well as channelopathies, is increasing. S-ICDs show comparable efficacy, reliability, and safety outcomes compared to TV-ICD. However, some technical issues (i.e., the inability to perform anti-bradycardia pacing) strongly limit the employment of S-ICDs. Therefore, it still remains only an alternative to the traditional ICD thus far. This review aims to provide a contemporary overview of the role of S-ICDs compared to TV-ICDs in clinical practice, including technical aspects regarding device manufacture and implantation techniques. Newer outlooks and future perspectives of S-ICDs are also brought up to date.
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Electrocardiogram Changes in the Postictal Phase of Epileptic Seizure: Results from a Prospective Study.
J Clin Med2023 Jun;12(12):. doi: 4098.
Gigli Lorenzo, Sala Simone, Preda Alberto, Okubo Kenji, Peretto Giovanni, Frontera Antonio, Varrenti Marisa, Baroni Matteo, Carbonaro Marco, Vargiu Sara, Di Resta Chiara, Striano Pasquale, Mazzone Patrizio, Della Bella Paolo
Abstract
BACKGROUND:
The brain and heart are strictly linked and the electrical physiologies of these organs share common pathways and genes. Epilepsy patients have a higher prevalence of electrocardiogram (ECG) abnormalities compared to healthy people. Furthermore, the relationship between epilepsy, genetic arrhythmic diseases and sudden death is well known. The association between epilepsy and myocardial channelopathies, although already proposed, has not yet been fully demonstrated. The aim of this prospective observational study is to assess the role of the ECG after a seizure.
MATERIALS AND METHODS:
From September 2018 to August 2019, all patients admitted to the emergency department of San Raffaele Hospital with a seizure were enrolled in the study; for each patient, neurological, cardiological and ECG data were collected. The ECG was performed at the time of the admission (post-ictal ECG) and 48 h later (basal ECG) and analyzed by two blinded expert cardiologists looking for abnormalities known to indicate channelopathies or arrhythmic cardiomyopathies. In all patients with abnormal post-ictal ECG, next generation sequencing (NGS) analysis was performed.
RESULTS:
One hundred and seventeen patients were enrolled (females: 45, median age: 48 ± 12 years). There were 52 abnormal post-ictal ECGs and 28 abnormal basal ECGs. All patients with an abnormal basal ECG also had an abnormal post-ictal ECG. In abnormal post-ictal ECG, a Brugada ECG pattern (BEP) was found in eight patients (of which two had BEP type I) and confirmed in two basal ECGs (of which zero had BEP type I). An abnormal QTc interval was identified in 20 patients (17%), an early repolarization pattern was found in 4 patients (3%) and right precordial abnormalities were found in 5 patients (4%). Any kind modification of post-ictal ECG was significantly more pronounced in comparison with an ECG recorded far from the seizure ( = 0.003). A 10:1 higher prevalence of a BEP of any type (particularly in post-ictal ECG, = 0.04) was found in our population compared to general population. In three patients with post-ictal ECG alterations diagnostic for myocardial channelopathy (BrS and ERP), not confirmed at basal ECG, a pathogenic gene variant was identified (KCNJ8, PKP2 and TRMP4).
CONCLUSION:
The 12-lead ECG after an epileptic seizure may show disease-related alterations otherwise concealed in a population at a higher incidence of sudden death and channelopathies. Post-ictal BEP incidence was higher in cases of nocturnal seizure.
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Left Atrial Appendage Occlusion in Patients with Failure of Antithrombotic Therapy: Good Vibes from Early Studies.
J Clin Med2023 Jun;12(11):. doi: 3859.
Preda Alberto, Baroni Matteo, Varrenti Marisa, Vargiu Sara, Carbonaro Marco, Giordano Federica, Gigli Lorenzo, Mazzone Patrizio
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and predisposes patients to an increased risk of cardioembolic events (CE), such as ischemic stroke, TIA, or systemic embolism [...].
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Uric acid significantly correlates with the presence of low-voltage areas at the endocardial mapping in patients with non-valvular atrial fibrillation.
Nutr Metab Cardiovasc Dis2023 Jul;33(7):1323-1329. doi: 10.1016/j.numecd.2023.05.002.
Baroni Matteo, Fortuna Matteo, Maloberti Alessandro, Leidi Filippo, Ciampi Claudio Mario, Carbonaro Marco, Testoni Alessio, Vargiu Sara, Varrenti Marisa, Paolucci Marco, Gigli Lorenzo, Giannattasio Cristina, Mazzone Patrizio
Abstract
BACKGROUND AND AIMS:
Interest in the role of atrial substrate in maintaining Atrial Fibrillation (AF) is growing. Fibrosis is the culprit in the electrical derangement of the myocytes. Many cardiovascular risk factors are known to be linked to atrial scarring; among them Uric Acid (UA) is emerging. The purpose of our study is to find whether UA is associated with Left Atrium (LA) with pathological substrate.
METHODS AND RESULTS:
81 patients who underwent radiofrequency transcatheter ablation for nonvalvular AF at the cardiological department of the Niguarda Hospital were enrolled in an observational, cross-sectional, single-center study. UA levels were analysed before the procedure. High density electroanatomic mapping of the LA was performed and patients were divided according to the presence or not of areas of pathological substrate (bipolar voltage
CONCLUSIONS:
In a population of patients who underwent AF ablation, higher UA levels were significantly associated with pathological LA substrate at electro-anatomical mapping.
Copyright © 2023 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.
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Left Bundle Branch Area Pacing over His Bundle Pacing: How Far Have We Come?
J Clin Med2023 May;12(9):. doi: 3251.
Baroni Matteo, Preda Alberto, Varrenti Marisa, Vargiu Sara, Carbonaro Marco, Giordano Federica, Gigli Lorenzo, Mazzone Patrizio
Abstract
Implantable cardiac pacemakers have greatly evolved during the few past years, focusing on newer modalities of physiologic cardiac pacing [...].
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Direct anchoring technique for pacing and defibrillation leads inserted through cephalic vein: insight for a single high-volume center.
Minerva Cardiol Angiol2023 Jun;71(3):342-348. doi: 10.23736/S2724-5683.22.06147-6.
Baroni Matteo, Gigli Lorenzo, Posca Francesco, Carbonaro Marco, Leidi Filippo, Fortuna Matteo, Ciampi Claudio M, Proietti Riccardo
Abstract
BACKGROUND:
Direct anchoring of PM and ICD leads over cephalic vein body is officially discouraged by manufactures due to a supposed risk of conductor fracture or insulation failure, however careful tightening of anchoring knots can probably prevent lead damage. Direct anchoring (DA) technique is routinely used in our center for all leads inserted by cephalic vein while standard anchoring sleeves are used to secure subclavian leads only. Aim of the study is to assess short- and long-term safety of cephalic direct anchoring technique.
METHODS:
All patients undergoing PM and ICD implantation in our center from November 2014 to March 2016 were consecutively enrolled. Primary endpoints were acute lead fracture, lead dislodgement and chronic lead failure. Secondary endpoint was a composite of short-term surgical complications (pocket hematoma, pneumothorax, and pericardial effusion) plus device infections. Subclavian leads secured with sleeve anchoring (SA) were used as control.
RESULTS:
A total of 550 leads were implanted in 310 consecutive patients. DA involved 323 leads (59%) while SA was used for 227 (41%). Median follow-up was 50 months (IQR 24-62 months). 17 lead malfunctions (3.1%) were observed during follow-up. No difference was observed between groups (10 DA vs. 7 SP, P=ns). Survival analysis found no difference between groups. Secondary endpoints were not statistically different between groups (5 vs. 1, P=0.08).
CONCLUSIONS:
Direct anchoring technique of PM and ICD leads is a safe technique and does not increase lead malfunction risk.
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[Leadless pacemakers: results of a survey from implanter centers in the Lombardy region].
G Ital Cardiol (Rome)2022 Feb;23(2):120-127. doi: 10.1714/3735.37214.
Limite Luca Rosario, Baratto Francesca, Mantica Massimo, Sirico Giusy, Rovaris Giovanni, MOntemerlo Elisabetta, Pecora Domenico, Pagani Massimo, Fedele Luigi, Augello Giuseppe, Zuffada Francesca, Rordorf Roberto, Ambrosini Francesco, Gigli Lorenzo, De Filippo Paolo, Pani Antonio, Forleo Giovanni, Mitacchione Gianfranco, Della Bella Paolo, Mazzone Patrizio
Abstract
BACKGROUND:
Transvenous pacing is nowadays the cornerstone of interventional management of bradyarrhythmias. It is still associated, however, with significant complications, mostly related to indwelling transvenous leads or device pocket. In order to reduce these complications, leadless pacemakers have been recently introduced into clinical practice, but no guidelines are yet available to indicate who are those patients that might benefit the most and whether leadless pacing should be preferred in the old or young population. This survey aims to describe the use of leadless pacemaker devices in a real-world setting.
METHODS:
Eleven arrhythmia centers in the Lombardy region (out of a total of 17 participating centers) responded to the proposed questionnaire regarding patient characteristics and indications to leadless pacing.
RESULTS:
Out of a total of 411 patients undergoing leadless pacing during 4.2 ± 0.98 years, the median age was 77 years, with 0.18% of patients having less than 18 years, 29.9% 18-65 years, 34.3% 65-80 years and 35.6% >80 years. The most common indication was slow atrial fibrillation (49% of patients), followed by atrioventricular block and sinoatrial dysfunction. Two centers reported in-hospital complications.
CONCLUSIONS:
Leadless pacemakers proved to be a safe pacing strategy actually destined mostly to elderly patients.
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Clinical characteristics and outcomes of patients with ventricular arrhythmias after continuous-flow left ventricular assist device implant.
Artif Organs2022 Aug;46(8):1608-1615. doi: 10.1111/aor.14234.
Gulletta Simone, Scandroglio Anna Mara, Pannone Luigi, Falasconi Giulio, Melisurgo Giulio, Ajello Silvia, D'Angelo Giuseppe, Gigli Lorenzo, Lipartiti Felicia, Agricola Eustachio, Lapenna Elisabetta, Castiglioni Alessandro, De Bonis Michele, Landoni Giovanni, Bella Paolo Della, Zangrillo Alberto, Vergara Pasquale
Abstract
BACKGROUND:
Ventricular arrhythmias (VAs) are observed in 25%-50% of continuous-flow left ventricular assist device (CF-LVAD) recipients, but their role on mortality is debated.
METHODS:
Sixty-nine consecutive patients with a CF-LVAD were retrospectively analyzed. Study endpoints were death and occurrence of first episode of VAs post CF-LVAD implantation. Early VAs were defined as VAs in the first month after CF-LVAD implantation.
RESULTS:
During a median follow-up of 29.0 months, 19 patients (27.5%) died and 18 patients (26.1%) experienced VAs. Three patients experienced early VAs, and one of them died. Patients with cardiac resynchronization therapy (CRT-D) showed a trend toward more VAs (p = 0.076), compared to patients without CRT-D; no significant difference in mortality was found between patients with and without CRT-D (p = 0.63). Patients with biventricular (BiV) pacing ?98% experienced more frequently VAs (p = 0.046), with no difference in mortality (p = 0.56), compared to patients experiencing BiV pacing
CONCLUSIONS:
VAs in CF-LVAD are a common clinical problem, but they do not impact mortality. Timing of ICD implantation does not have a significant impact on patients' survival. Patients with BiV pacing ?98% experienced more frequently VAs.
© 2022 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.
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State-of-the-Art of Endomyocardial Biopsy on Acute Myocarditis and Chronic Inflammatory Cardiomyopathy.
Curr Cardiol Rep2022 May;24(5):597-609. doi: 10.1007/s11886-022-01680-x.
Ammirati Enrico, Buono Andrea, Moroni Francesco, Gigli Lorenzo, Power John R, Ciabatti Michele, Garascia Andrea, Adler Eric D, Pieroni Maurizio
Abstract
PURPOSE OF REVIEW:
Histologic evidence of myocardial inflammatory infiltrate not secondary to an ischemic injury is required by current diagnostic criteria to reach a definite diagnosis of myocarditis. Endomyocardial biopsy (EMB) is therefore often indicated for the diagnosis of myocarditis, although it may lack sufficient sensitivity considering the limited possibility of myocardial sampling. Improving the diagnostic yield and utility of EMB is of high priority in the fields of heart failure cardiology and myocarditis in particular. The aim of the present review is to highlight indications, strengths, and shortcomings of current EMB techniques, and discuss innovations currently being tested in ongoing clinical studies, especially in the setting of acute myocarditis and chronic inflammatory cardiomyopathy.
RECENT FINDINGS:
EMB provides unique diagnostic elements and prognostic information which can effectively guide the treatment of myocarditis. Issues affecting the diagnostic performance in the setting of acute myocarditis and chronic inflammatory cardiomyopathies will be discussed in this review in the light of recent expert consensus documents on the management of these conditions and on indication to EMB. Recent innovations using electroanatomic mapping (EAM)-guided EMB and fluoroscopic-guided EMB during temporary mechanical circulatory support have improved the utility of the procedure. EMB remains an important diagnostic test whose results need to be interpreted in the context of (1) clinical pre-test probability, (2) timing of sampling, (3) quality of sampling (4) site of sampling, (5) histologic type of myocarditis, and (6) analytic methods that are applied. Herein we will review these caveats as well as perspectives and innovations related to the use of this diagnostic tool.
© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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Atrial Flutter Mechanism Detection Using Directed Network Mapping.
Front Physiol2021 ;12():749635. doi: 749635.
Vila Muhamed, Rivolta Massimo Walter, Luongo Giorgio, Unger Laura Anna, Luik Armin, Gigli Lorenzo, Lombardi Federico, Loewe Axel, Sassi Roberto
Abstract
Atrial flutter (AFL) is a common atrial arrhythmia typically characterized by electrical activity propagating around specific anatomical regions. It is usually treated with catheter ablation. However, the identification of rotational activities is not straightforward, and requires an intense effort during the first phase of the electrophysiological (EP) study, i.e., the mapping phase, in which an anatomical 3D model is built and electrograms (EGMs) are recorded. In this study, we modeled the electrical propagation pattern of AFL (measured during mapping) using network theory (NT), a well-known field of research from the computer science domain. The main advantage of NT is the large number of available algorithms that can efficiently analyze the network. Using directed network mapping, we employed a cycle-finding algorithm to detect all cycles in the network, resembling the main propagation pattern of AFL. The method was tested on two subjects in sinus rhythm, six in an experimental model of simulations, and 10 subjects diagnosed with AFL who underwent a catheter ablation. The algorithm correctly detected the electrical propagation of both sinus rhythm cases and simulations. Regarding the AFL cases, arrhythmia mechanisms were either totally or partially identified in most of the cases (8 out of 10), i.e., cycles around the mitral valve, tricuspid valve and figure-of-eight reentries. The other two cases presented a poor mapping quality or a major complexity related to previous ablations, large areas of fibrotic tissue, etc. Directed network mapping represents an innovative tool that showed promising results in identifying AFL mechanisms in an automatic fashion. Further investigations are needed to assess the reliability of the method in different clinical scenarios.
Copyright © 2021 Vila, Rivolta, Luongo, Unger, Luik, Gigli, Lombardi, Loewe and Sassi.
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High-Density Characterization of the Ventricular Electrical Substrate During Sinus Rhythm in Post-Myocardial Infarction Patients.
JACC Clin Electrophysiol2020 Jul;6(7):799-811. doi: 10.1016/j.jacep.2020.04.008.
Frontera Antonio, Melillo Francesco, Baldetti Luca, Radinovic Andrea, Bisceglia Caterina, D'Angelo Giuseppe, Foppoli Luca, Gigli Lorenzo, Peretto Giovanni, Cireddu Manuela, Sala Simone, Mazzone Patrizio, Della Bella Paolo
Abstract
OBJECTIVES:
The aim of this study was to characterize, during sinus rhythm, the electric activation abnormalities in post-myocardial infarction patients undergoing ablation of ventricular tachycardia (VT) in order to identify specific signatures of those abnormal electrograms (EGMs).
BACKGROUND:
In the setting of VT ablation, substrate characterization hinges on the identification of local abnormal ventricular activity (LAVA) and late potentials (LPs) that are considered to be related to the VT circuit.
METHODS:
Patients scheduled for VT ablation underwent high-density ventricular substrate mapping. The substrate map during sinus rhythm was then compared with the activation maps of the clinical VT. Abnormal EGMs (LAVA and LPs) during sinus rhythm were characterized according to their configuration, duration, and amplitude and distinguished as belonging to bystander region or to the re-entrant circuit. Underlying electrophysiological mechanisms (wave-front collision, slow conduction) were identified on the activation maps and assigned to corresponding EGMs.
RESULTS:
Ten patients satisfied the criteria to be enrolled in the study. A mean of 5 ± 1 slow-conduction areas and 4 ± 2 wave-front collisions were identified. LAVA was due to slow conduction in 60.5%, followed by wave-front collision (17.5%). LPs were caused by slow conduction in 52% of cases and by wave-front collision in 43% of cases. During sinus rhythm, entrance and exit sites were characterized by LAVA, while at the VT isthmus, only LPs were identified. Cutoff values of duration
CONCLUSIONS:
In the setting of post-myocardial infarction cardiomyopathy, specific EGM signatures are expressions of distinct electrophysiological phenomena. LAVA and LPs may play a bystander or an active role in the VT circuit, but only LPs with low amplitude and short duration predicted the VT isthmus.
Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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Long-Term Outcome After Ventricular Tachycardia Ablation in Nonischemic Cardiomyopathy: Late Potential Abolition and VT Noninducibility.
Circ Arrhythm Electrophysiol2020 Aug;13(8):e008307. doi: 10.1161/CIRCEP.119.008307.
Okubo Kenji, Gigli Lorenzo, Trevisi Nicola, Foppoli Luca, Radinovic Andrea, Bisceglia Caterina, Frontera Antonio, D'Angelo Giuseppe, Cireddu Manuela, Paglino Gabriele, Mazzone Patrizio, Della Bella Paolo
Abstract
BACKGROUND:
In patients with an ischemic cardiomyopathy (ICM), the combination of late potential (LP) abolition and postprocedural ventricular tachycardia (VT) noninducibility is known to be the desirable end point for a successful long-term outcome after VT ablation. We investigated whether LP abolition and VT noninducibilty have a similar impact on the outcomes of patients with non-ICMs (NICM) undergoing VT ablation.
METHODS:
A total of 403 patients with NICM (523 procedures) who underwent a VT ablation from 2010 to 2016 were included. The procedure end points were the LP abolition (if the LPs were absent, other ablation strategies were undertaken) and the VT noninducibilty.
RESULTS:
The underlying structural heart disease consisted of dilated cardiomyopathy (DCM, 49%), arrhythmogenic right ventricular dysplasia (ARVD, 17%), postmyocarditis (14%), valvular heart disease (8%), congenital heart disease (2%), hypertrophic cardiomyopathy (2%), and others (5%). The epicardial access was performed in 57% of the patients. At baseline, the LPs were present in 60% of the patients and a VT was either inducible or sustained/incessant in 85% of the cases. At the end of the procedure, the LP abolition was achieved in 79% of the cases and VT noninducibility in 80%. After a multivariable analysis, the combination of LP abolition and VT noninducibilty was independently associated with free survival from VT (hazard ratio, 0.45 [95% CI, 0.29-0.69], =0.0002) and cardiac death (hazard ratio, 0.38 [95% CI, 0.18-0.74], =0.005). The benefit of the LP abolition on preventing the VT recurrence in patients with ARVD and postmyocarditis appeared superior to that observed for those with DCM.
CONCLUSIONS:
In patients with NICM undergoing VT ablation, the strategy of LP abolition and VT noninducibilty were associated with better outcomes in terms of long-term VT recurrences and cardiac survival. Graphic Abstract: A graphic abstract is available for this article.
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COVID-19 in lung transplant recipients: A case series from Milan, Italy.
Transpl Infect Dis2020 Dec;22(6):e13356. doi: 10.1111/tid.13356.
Morlacchi Letizia Corinna, Rossetti Valeria, Gigli Lorenzo, Amati Francesco, Rosso Lorenzo, Aliberti Stefano, Nosotti Mario, Blasi Francesco
Abstract
Limited data are currently available regarding the course of COVID-19 in lung and solid organ transplant recipients. We hereby present four cases of SARS-CoV-2 pneumonia in lung transplant recipients from our center, set in Milan, Italy. We reduced immunosuppressive regimen in all these patients, typically holding the antiproliferative agent and augmenting steroids; everybody received hydroxychloroquine, initial empiric antibiotic treatment with piperacillin/tazobactam, and high-dose low molecular weight heparin. Clinical course seemed favorable in three of our patients, but one of them deteriorated after 10 days of hospitalization, probably due to an acute form of graft dysfunction triggered both by COVID-19 and a nosocomial bacterial infection, and eventually died. Although short-term prognosis could be considered benign in the majority of our patients, we should carefully monitor these individuals in order to detect early sign of clinical deterioration and graft dysfunction in the next few months.
© 2020 Wiley Periodicals LLC.
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Septal Late Gadolinium Enhancement and Arrhythmic Risk in Genetic and Acquired Non-Ischaemic Cardiomyopathies.
Heart Lung Circ2020 Sep;29(9):1356-1365. doi: 10.1016/j.hlc.2019.08.018.
Peretto Giovanni, Sala Simone, Lazzeroni Davide, Palmisano Anna, Gigli Lorenzo, Esposito Antonio, De Cobelli Francesco, Camici Paolo G, Mazzone Patrizio, Basso Cristina, Della Bella Paolo
Abstract
BACKGROUND:
In many genetic and acquired non-ischaemic cardiomyopathies (NICM) there have been frequent reports of involvement of the interventricular septum (IVS) by late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR). However, no studies have investigated the relationship between septal LGE and arrhythmias in different NICM subtypes.
METHODS:
This study enrolled 103 patients with septal LGE at baseline CMR and different NICM: hypertrophic (n=29) or lamin A/C gene (LMNA)-associated (n=23) cardiomyopathy, and acute (n=30) or previous (n=21) myocarditis. During follow-up, the occurrences of malignant ventricular arrhythmias (MVA) and major bradyarrhythmias (BA) were evaluated.
RESULTS:
At 4.9±0.7 years of follow-up, the occurrence of MVA and major BA in genetic vs acquired NICM were 10 of 52 vs 12 of 51, and 10 of 52 vs 4 of 51, respectively (both p=n.s.). However, MVA occurred more frequently in LMNA-NICM (eight of 23 vs two of 29 hypertrophic, p=0.015) and in previous myocarditis (nine of 21 vs three of 30 acute, p=0.016), while major BAs were particularly common in LMNA-NICM patients only (nine of 23 vs one of 29 hypertrophic, p=0.003). Different patterns of septal LGE were consistently retrospectively identified at baseline CMR: junctional and limited to the base in 79.3% of uneventful hypertrophic NICM; extended and focally transmural in LMNA-NICM with follow-up arrhythmias (both p
CONCLUSION:
Septal LGE was significantly associated with MVA at the 5-year follow-up in LMNA-NICM or previous myocarditis, and with major BA in LMNA-NICM only. These differences correlated with heterogeneous patterns of IVS LGE in different NICM.
Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
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Cardiac and Neuromuscular Features of Patients With LMNA-Related Cardiomyopathy.
Ann Intern Med2019 Oct;171(7):458-463. doi: 10.7326/M18-2768.
Peretto Giovanni, Di Resta Chiara, Perversi Jacopo, Forleo Cinzia, Maggi Lorenzo, Politano Luisa, Barison Andrea, Previtali Stefano C, Carboni Nicola, Brun Francesca, Pegoraro Elena, D'Amico Adele, Rodolico Carmelo, Magri Francesca, Manzi Rosa C, Palladino Alberto, Isola Franco, Gigli Lorenzo, Mongini Tiziana E, Semplicini Claudio, Calore Chiara, Ricci Giulia, Comi Giacomo P, Ruggiero Lucia, Bertini Enrico, Bonomo Paolo, Nigro Gerardo, Resta Nicoletta, Emdin Michele, Favale Stefano, Siciliano Gabriele, Santoro Lucio, Sinagra Gianfranco, Limongelli Giuseppe, Ambrosi Alessandro, Ferrari Maurizio, Golzio Pier G, Bella Paolo Della, Benedetti Sara, Sala Simone,
Abstract
BACKGROUND:
Mutations in the LMNA (lamin A/C) gene have been associated with neuromuscular and cardiac manifestations, but the clinical implications of these signs are not well understood.
OBJECTIVE:
To learn more about the natural history of LMNA-related disease.
DESIGN:
Observational study.
SETTING:
13 clinical centers in Italy from 2000 through 2018.
PATIENTS:
164 carriers of an LMNA mutation.
MEASUREMENTS:
Detailed cardiologic and neurologic evaluation at study enrollment and for a median of 10 years of follow-up.
RESULTS:
The median age at enrollment was 38 years, and 51% of participants were female. Neuromuscular manifestations preceded cardiac signs by a median of 11 years, but by the end of follow-up, 90% of the patients had electrical heart disease followed by structural heart disease. Overall, 10 patients (6%) died, 14 (9%) received a heart transplant, and 32 (20%) had malignant ventricular arrhythmias. Fifteen patients had gait loss, and 6 had respiratory failure. Atrial fibrillation and second- and third-degree atrioventricular block were observed, respectively, in 56% and 51% of patients with combined cardiac and neuromuscular manifestations and 37% and 33% of those with heart disease only.
LIMITATIONS:
Some of the data were collected retrospectively. Neuromuscular manifestations were more frequent in this analysis than in previous studies.
CONCLUSION:
Many patients with an LMNA mutation have neurologic symptoms by their 30s and develop progressive cardiac manifestations during the next decade. A substantial proportion of these patients will have life-threatening neurologic or cardiologic conditions.
PRIMARY FUNDING SOURCE:
None.
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A novel homozygous mutation in the TRDN gene causes a severe form of pediatric malignant ventricular arrhythmia.
Heart Rhythm2020 Feb;17(2):296-304. doi: 10.1016/j.hrthm.2019.08.018.
Rossi Daniela, Gigli Lorenzo, Gamberucci Alessandra, Bordoni Roberta, Pietrelli Alessandro, Lorenzini Stefania, Pierantozzi Enrico, Peretto Giovanni, De Bellis Gianluca, Della Bella Paolo, Ferrari Maurizio, Sorrentino Vincenzo, Benedetti Sara, Sala Simone, Di Resta Chiara
Abstract
BACKGROUND:
Triadin is a protein expressed in cardiac and skeletal muscle that has an essential role in the structure and functional regulation of calcium release units and excitation-contraction coupling. Mutations in the triadin gene (TRDN) have been described in different forms of human arrhythmia syndromes with early onset and severe arrhythmogenic phenotype, including triadin knockout syndrome.
OBJECTIVE:
The purpose of this study was to characterize the pathogenetic mechanism underlying a case of severe pediatric malignant arrhythmia associated with a defect in the TRDN gene.
METHODS:
We used a trio whole exome sequencing approach to identify the genetic defect in a 2-year-old boy who had been resuscitated from sudden cardiac arrest and had frequent episodes of ventricular fibrillation and a family history positive for sudden death. We then performed in vitro functional analysis to investigate possible pathogenic mechanisms underlying this severe phenotype.
RESULTS:
We identified a novel homozygous missense variant (p.L56P) in the TRDN gene in the proband that was inherited from the heterozygous unaffected parents. Expression of a green fluorescent protein (GFP)-tagged mutant human cardiac triadin isoform (TRISK32-L56P-GFP) in heterologous systems revealed that the mutation alters protein dynamics. Furthermore, when co-expressed with the type 2 ryanodine receptor, caffeine-induced calcium release from TRISK32-L56P-GFP was relatively lower compared to that observed with the wild-type construct.
CONCLUSION:
The results of this study allowed us to hypothesize a pathogenic mechanism underlying this rare arrhythmogenic recessive form, suggesting that the mutant protein potentially can trigger arrhythmias by altering calcium homeostasis.
Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
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Phrenic Nerve Limitation During Epicardial Catheter Ablation of Ventricular Tachycardia.
JACC Clin Electrophysiol2019 Jan;5(1):81-90. doi: 10.1016/j.jacep.2018.08.011.
Okubo Kenji, Trevisi Nicola, Foppoli Luca, Bisceglia Caterina, Baratto Francesca, Gigli Lorenzo, D'Angelo Giuseppe, Radinovic Andrea, Cireddu Manuela, Paglino Gabriele, Mazzone Patrizio, Della Bella Paolo
Abstract
OBJECTIVES:
This study sought to investigate the incidence of phrenic nerve (PN) limitation and the utility of displacing the PN with a balloon.
BACKGROUND:
The PN can limit the epicardial ablation of ventricular tachycardia (VT).
METHODS:
From 2010 to 2017, 363 patients undergoing VT epicardial ablation at a single center were studied. Before the ablation, we used high output (20-mA) pacing maneuvers to verify the course of the PN. When we observed its capture, we used 1 of 3 different approaches to protect it: 1) non-balloon strategy (nerve-sparing ablation); 2) PN displacement with a small balloon (6 mm × 20 mm); or 3) PN displacement with a large balloon (20 mm × 45 mm).
RESULTS:
PN capture occurred in 25 patients (7%) at the target ablation site. The most common cause was myocarditis (12 patients [48%]), and the incidence of the PN limitation was significantly higher in myocarditis than in other causes (19% vs. 4%, respectively; p = 0.0002). PN displacement was attempted in 7 patients by using large balloons and in 6 patients with small balloons, resulting in successful PN displacements and complete late potential (LP) abolition in 6 patients (86%) and 3 patients (50%), respectively. Among the 12 patients in whom the non-balloon strategy was used, only 1 patient (8%) achieved LP abolition (compared with the large balloon group; p = 0.002), whereas 3 patients experienced PN paralysis.
CONCLUSIONS:
The PN limited the epicardial ablation in 7% of patients. Because nerve-sparing ablations often resulted in PN injuries, a possible solution could be to displace the PN with a large balloon, leading to a safer procedure and completion of LP abolition.
Copyright © 2019. Published by Elsevier Inc.
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Usefulness of Electroanatomical Mapping with Contact Force Monitoring for Accessory Pathways Ablation in Pediatric Population.
Pediatr Cardiol2019 Apr;40(4):713-718. doi: 10.1007/s00246-019-02051-0.
Gulletta Simone, Vergara Pasquale, Gigli Lorenzo, D'Angelo Giuseppe, Radinovic Andrea, Melania Barbaro Carmela, Trevisi Nicola, Della Bella Paolo
Abstract
The current approach for catheter ablation (CA) of accessory pathways (AP) includes the use of standard catheters under fluoroscopic visualization. We hypothesize that use of contact force (CF) irrigated tip catheters might increase procedural safety in pediatric patients compared to standard irrigated tip catheters, by decreasing the number of radiofrequency (RF) pulses required to obtain AP elimination. Seventy-one pediatric patients (13.7?±?2.5 years, 45 male) with ventricular pre-excitation were enrolled in the study. CA was performed with a standard irrigated tip catheter up to June 2013 in 41 patients (Group S) and with a CF sensing irrigated tip catheter later on in 30 patients (Group CF). In the Group CF, RF was applied with a minimal CF of 5 g; CF?>?35 g was avoided. Group CF procedures required less fluoroscopy (6.8?±?4.8 min), compared to Group S (12.2?±?10.8 min, p?=?0.007). The number of RF pulses was smaller in Group CF compared to Group S (2.5?±?2.0 vs 5.5?±?1.9, p?0.01). The mean CF during the effective RF pulse was 18?±?7.7 g, force-time integral was 1040.7?±?955.9 gs, Ablation Index was 513.0?±?214.2. The procedure was acutely successful in 70 patients; at 12 months follow-up 2 patients had AP recurrence, one for each group. No major complications were reported. The use of CF irrigated tip catheters was associated with a smaller number of RF pulses and less fluoroscopy, as compared to mapping and ablation with standard irrigated tip catheters.
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Detachment Dynamics of Graphene Nanoribbons on Gold.
ACS Nano2019 Jan;13(1):689-697. doi: 10.1021/acsnano.8b07894.
Gigli Lorenzo, Kawai Shigeki, Guerra Roberto, Manini Nicola, Pawlak Rémy, Feng Xinliang, Müllen Klaus, Ruffieux Pascal, Fasel Roman, Tosatti Erio, Meyer Ernst, Vanossi Andrea
Abstract
Metal-surface physisorbed graphene nanoribbons (GNRs) constitute mobile nanocontacts whose interest is simultaneously mechanical, electronic, and tribological. Previous work showed that GNRs adsorbed on Au(111) generally slide smoothly and superlubrically owing to the incommensurability of their structures. We address here the nanomechanics of detachment, as realized when one end is picked up and lifted by an AFM cantilever. AFM nanomanipulations and molecular-dynamics (MD) simulations identify two successive regimes, characterized by (i) a progressively increasing local bending, accompanied by the smooth sliding of the adhered part, followed by (ii) a stick-slip dynamics involving sudden bending relaxation associated with intermittent jumps of the remaining adhered GNR segment and tail end. AFM measurements of the vertical force exhibit oscillations which, compared with MD simulations, can be associated with the successive detachment of individual GNR unit cells of length 0.42 nm. Extra modulations within one single period are caused by steplike advancements of the still-physisorbed part of the GNR. The sliding of the incommensurate moiré pattern that accompanies the GNR lifting generally yields an additional long-period oscillation: while almost undetectable when the GNR is aligned in the standard "R30" orientation on Au(111), we predict that such feature should become prominent in the alternative rotated "R0" orientation on the same surface, or on a different surface, such as perhaps Ag(111).
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Catheter ablation of ventricular tachycardia in nonischemic cardiomyopathy.
J Arrhythm2018 Aug;34(4):347-355. doi: 10.1002/joa3.12099.
Okubo Kenji, Gigli Lorenzo, Della Bella Paolo
Abstract
The number of patients with nonischemic cardiomyopathy (NICM) undergoing catheter ablation of ventricular tachycardia (VT) has increased by the years, however, there are no randomized studies of VT ablation in this population. Many studies have reported more mixed or inferior outcome after the ablation in patients with NICM as compared to in those with ischemic cardiomyopathy (ICM)-likely because of the heterogeneous VT substrates in each etiology. While, various ablation strategies for substrate modification in the setting of ICM, including low voltage area ablation, late potential abolition, and local abnormal ventricular activity elimination, have been well established, it is still unknown which ablation strategy is effective for prevention of recurrence VTs in NICM patients. Therefore, this review will highlight the recent progress made in VT ablation in patients with NICM.
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Juvenile myoclonic epilepsy and Brugada type 1 ECG pattern associated with (a novel) plakophillin 2 mutation.
J Neurol2017 Apr;264(4):792-795. doi: 10.1007/s00415-017-8414-2.
Gigli Lorenzo, Bertero Giovanni, Vidal Monica Coll, Iglesias Anna, Campuzano Oscar, Striano Pasquale, Oliva Antonio, Brugada Ramon
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Clinical characteristics and prognostic impact of atrial fibrillation in patients with chronic heart failure.
World J Cardiol2016 Nov;8(11):647-656.
Gigli Lorenzo, Ameri Pietro, Secco Gianmarco, De Blasi Gabriele, Miceli Roberta, Lorenzoni Alessandra, Torre Francesco, Chiarella Francesco, Brunelli Claudio, Canepa Marco
Abstract
AIM:
To assess the prevalence, clinical characteristics and independent prognostic impact of atrial fibrillation (AF) in chronic heart failure (CHF) patients, and the potential protective effect of disease-modifying medications, particularly beta-blockers (BB).
METHODS:
We retrospectively reviewed the charts of patients referred to our center since January 2004, and collected all clinical information available at their first visit. We assessed mortality to the end of June 2015. We compared patients with and without AF, and assessed the association between AF and all-cause mortality by multivariate Cox regression and Kaplan-Meyer analysis, particularly accounting for ongoing treatment with BB.
RESULTS:
A total of 903 patients were evaluated (mean age 68 ± 12 years, 73% male). Prevalence of AF was 19%, ranging from 10% to 28% in patients ? 60 and ? 77 years, respectively. Besides the older age, patients with AF had more symptoms (New York Heart Association II-III 60% 44%), lower prevalence of dyslipidemia (23% 37%), coronary artery disease (28% 52%) and left bundle branch block (9% 16%). On the contrary, they more frequently presented with an idiopathic etiology (50% 24%), a history of valve surgery (13% 4%) and received overall more devices implantation (31% 21%). The use of disease-modifying medications (., BB and ACE inhibitors/angiotensin receptor blockers) was lower in patients with AF (72% 80% and 71% 79%, respectively), who on the contrary were more frequently treated with symptomatic and antiarrhythmic drugs including diuretics (87% 69%) and digoxin (51% 11%). At a mean follow-up of about 5 years, all-cause mortality was significantly higher in patients with AF as compared to those in sinus rhythm (SR) (45% 34%, value
CONCLUSION:
AF was highly prevalent and associated with older age, worse clinical presentation and underutilization of disease-modifying medications such as BB in a population of elderly patients with CHF. AF had no independent impact on mortality, but the underutilization of BB in this group of patients was associated to a worse long-term prognosis.
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Biophysical aspects and novel treatments of atrial fibrillation.
Minerva Cardioangiol2017 Apr;65(2):157-172. doi: 10.23736/S0026-4725.16.04167-0.
Gigli Lorenzo, Rosa Gian M, Tagliasacchi Maria I, Bonaventura Aldo, Liberale Luca, Montecucco Fabrizio, Carbone Federico, Bertero Giovanni, Brunelli Claudio
Abstract
INTRODUCTION:
Atrial fibrillation (AF) is a cardiac arrhythmia caused by various mechanisms, such as multiple re-entering wavelets, high frequency activity, and rotor sources.
EVIDENCE ACQUISITION:
This narrative review was based on papers found on PubMed and MEDLINE up to May 2016. The search terms were "atrial fibrillation" in combination with "catheter ablation, pathophysiology, antiarrhythmic drugs".
EVIDENCE SYNTHESIS:
Antiarrhythmic drugs are the cornerstone of therapy in AF, but their efficacy and safety might have to be improved. In case of failure of pharmacologic therapies, other treatments can be considered. A better understanding of the important role of the pulmonary veins has led to new approaches, such as ablation procedures, which were initially only surgical, while percutaneous options were later added. However, these strategies may present various technical complications also when performed by skilled operators. A promising field of investigation is the genetics of AF, as highlighted by studies on the role of micro-RNA.
CONCLUSIONS:
Relevant improvement on the knowledge of the electrophysiological basis of genesis and maintenance of AF has been done in order to treat a very common arrhythmia, but further studies, as those in the genetics field, can open new challenging therapeutic horizons.
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Update on cardiotoxicity of anti-cancer treatments.
Eur J Clin Invest2016 Mar;46(3):264-84. doi: 10.1111/eci.12589.
Rosa Gian Marco, Gigli Lorenzo, Tagliasacchi Maria Isabella, Di Iorio Cecilia, Carbone Federico, Nencioni Alessio, Montecucco Fabrizio, Brunelli Claudio
Abstract
BACKGROUND AND AIMS:
Anti-cancer treatments markedly improved the prognosis of patients, but unfortunately might be hampered by cardiotoxicity. Both symptomatic and asymptomatic clinical forms of heart failure have been reported, which may be reversible or irreversible. The aim of this review is to provide an overview of the antineoplastic agents associated with cardiac toxicity and of the available diagnostic techniques.
METHODS AND METHODS:
This narrative review is based on material from MEDLINE and PUBMED up to November 2015. We looked at the terms antineoplastic drugs and cardiac toxicity in combination with echocardiography, troponins, cardiac magnetic resonance, and positron emission tomography.
RESULTS:
Anthracyclines, monoclonal antibodies, fluoropyrimidines, taxanes, alkylating agents, vinka alkaloids were reported to induce different clinical manifestations of cardioxicity. Chest radiotherapy is also associated with various forms of cardiac damage, which are indistinguishable from those found in patients with heart disease of other aetiologies and that may even appear several years after administration. Among diagnostic techniques, echocardiography is a noninvasive, cost-effective, and widely available imaging tool. Nuclear imaging and cardiac magnetic resonance may be used but are not so widely available and are more difficult to perform. Finally, some biomarkers, such as troponins, may be used to evaluate cardiac damage, but establishing the optimal timing of troponin assessment remains unclear and defining the cut-off point for positivity is still an important goal.
CONCLUSIONS:
Cardiotoxicity of anti-cancer treatments is associated with development of heart failure. Novel diagnostic tools might be relevant to early recognize irreversible forms cardiac diseases.
© 2016 Stichting European Society for Clinical Investigation Journal Foundation.
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The etiology-filling pattern-pulmonary artery pressure score: a simple tool for risk stratification of patients with systolic heart failure.
Congest Heart Fail2013 ;19(1):39-43. doi: 10.1111/j.1751-7133.2012.00294.x.
Vallebona Alessandro, Gigli Guido, Orlandi Sandro, Orlandi Davide, Gigli Lorenzo, Reggiardo Giorgio
Abstract
Heart failure (HF) is a leading cause of morbidity and mortality. The detection of patients at high risk for death is a major challenge in HF management. The authors compared the prognostic value of 23 clinical Doppler echocardiography and cardiopulmonary exercise indexes in a stable, moderately symptomatic, systolic HF outpatient population receiving optimal medical therapy. The end point was the incidence of overall mortality. Between January 2002 and December 2008, a total of 146 patients with left ventricular (LV) ejection fraction 0.31±0.8 and New York Heart Association functional class II or III were enrolled. The prognostic power of single variables was assessed using chi-square test for categoric variables and t test for continuous variables. Variables associated with the prespecified end point were included as predictors in a binary logistic regression multivariate model. At multivariate analysis, "restrictive" LV filling pattern (P=.004), ischemic etiology (P=.022), pulmonary artery systolic pressure (PASP) ?50 mm Hg (P=.027), and peak oxygen uptake (VO(2) )
© 2012 Wiley Periodicals, Inc.
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Trends in hospitalization for heart failure in Italy 2001-2003.
J Cardiovasc Med (Hagerstown)2009 May;10(5):367-71. doi: 10.2459/JCM.0b013e3283276e1c.
Gigli Guido, Lispi Lucia, Donati Carlo, Orlandi Sandro, Vallebona Alessandro, Gigli Lorenzo, Reggiardo Giorgio
Abstract
BACKGROUND:
Heart failure is one of the main causes of hospitalization in Italy. In some industrialized countries since the second half of 1990s a halt in the grow rate of hospitalization for this pathology has been observed, and in some cases a reversal. The aim of this study was to evaluate the trend of hospitalization for heart failure in Italy in the years 2001, 2002 and 2003.
MATERIALS AND METHODS:
National hospital discharge data for years 2001, 2002 and 2003 were analysed.
RESULTS:
Heart failure hospitalization increased from 193 042 in 2001 to 205 043 in 2002 (+6.2%) and to 211 183 in 2003 (+3% with respect to 2002). In 2003 heart failure was the primary medical cause of hospitalization (1.6%). Hospitalization for heart failure accounted in 2003 for 2% of global hospitalization costs.
CONCLUSIONS:
Heart failure is the primary cause of hospitalization in Italy and the rate of hospital admission from 2001 to 2003 continued to increase, as well as related costs. These data indicate the urgent need for implementation of new models for the management of heart failure, based on a healthcare network, including hospital, ambulatory and home care, potentially capable of ameliorating both quality of life and costs of assistance.
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