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1.
BMJ Case Rep ; 12(12)2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31852692

RESUMO

Transcatheter aortic valve implantations (TAVIs) may be complicated by a need for permanent pacemaker implantation post procedure, usually due to local trauma or compression on the conduction system. There are some features that might help predict that a patient is high risk for developing conduction disease following TAVI, for example, underlying right bundle branch block or use of certain types of TAVI. It might also become apparent during the procedure, or before temporary wire removal post procedure. Higher risk patients may undergo rhythm monitoring for longer periods post TAVI. We present a case where a patient required an unexpected emergency pacemaker following a TAVI, despite low risk clinical features, a low risk baseline ECG, and the use of a low risk TAVI valve. In addition, this very significant conduction disease only became apparent over 72 hours following implantation, despite normal resting ECGs and telemetry up to that point.


Assuntos
Nó Atrioventricular/diagnóstico por imagem , Doença do Sistema de Condução Cardíaco/cirurgia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Nó Atrioventricular/fisiopatologia , Doença do Sistema de Condução Cardíaco/diagnóstico por imagem , Doença do Sistema de Condução Cardíaco/etiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Eletrocardiografia , Feminino , Humanos , Marca-Passo Artificial , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/cirurgia , Resultado do Tratamento
2.
Circ Arrhythm Electrophysiol ; 12(9): e007337, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31505948

RESUMO

BACKGROUND: Nodofascicular and nodoventricular (NFV) accessory pathways connect the atrioventricular node and the Purkinje system or ventricular myocardium, respectively. Concealed NFV pathways participate as the retrograde limb of supraventricular tachycardia (SVT). Manifest NFV pathways can comprise the anterograde limb of wide-complex SVT but are quite rare. The purpose of this report is to highlight the electrophysiological properties and sites of ablation for manifest NFV pathways. METHODS: Eight patients underwent electrophysiology studies for wide-complex tachycardia (3), for narrow-complex tachycardia (1), and preexcitation (4). RESULTS: NFV was an integral part of the SVT circuit in 3 patients. Cases 1 to 2 were wide-complex tachycardia because of manifest NFV SVT. Case 3 was a bidirectional NFV that conducted retrograde during concealed NFV SVT and anterograde causing preexcitation during atrial pacing. NFV was a bystander during atrioventricular node re-entrant tachycardia, atrial fibrillation, atrial flutter, and orthodromic atrioventricular re-entrant tachycardia in 4 cases and caused only preexcitation in 1. Successful NFV ablation was achieved empirically in the slow pathway region in 1 case. In 5 cases, the ventricular insertion was mapped to the slow pathway region (2 cases) or septal right ventricle (3 cases). The NFV was not mapped in cases 5 and 7 because of its bystander role. QRS morphology of preexcitation predicted the right ventricle insertion sites in 4 of the 5 cases in which it was mapped. During follow-up, 1 patient noted recurrent palpitations but no documented SVT. CONCLUSIONS: Manifest NFV may be critical for wide-complex tachycardia/manifest NFV SVT, act as the retrograde limb for narrow-complex tachycardia/concealed NFV SVT, or cause bystander preexcitation. Ablation should initially target the slow pathway region, with mapping of the right ventricle insertion site if slow pathway ablation is not successful. The QRS morphology of maximal preexcitation may be helpful in predicting successful right ventricle ablation site.


Assuntos
Feixe Acessório Atrioventricular/fisiopatologia , Nó Atrioventricular/fisiopatologia , Fascículo Atrioventricular/fisiopatologia , Ablação por Cateter/métodos , Síndromes de Pré-Excitação/cirurgia , Taquicardia por Reentrada no Nó Atrioventricular/cirurgia , Feixe Acessório Atrioventricular/cirurgia , Adulto , Idoso , Nó Atrioventricular/cirurgia , Fascículo Atrioventricular/cirurgia , Criança , Eletrocardiografia , Feminino , Átrios do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Síndromes de Pré-Excitação/fisiopatologia , Taquicardia por Reentrada no Nó Atrioventricular/fisiopatologia , Adulto Jovem
3.
Cardiol Young ; 29(11): 1375-1379, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31507257

RESUMO

BACKGROUND: Atrioventricular interval optimisation is important in patients with dual-chamber pacing, especially with heart failure. In patients with CHD, especially in those with Fontan circulation, the systemic atrial contraction is supposed to be more important than in patients without structural heart disease. METHODS: We retrospectively evaluated two patients after Fontan procedure with dual-chamber pacemaker with a unique setting of optimal sensed atrioventricular interval. RESULTS: The optimal sensed atrioventricular interval determined by echocardiogram was extremely short sensed atrioventricular interval at 25 and 30 ms in both cases; however, the actual P wave and ventricular pacing interval showed 180 and 140 ms, respectively. In both cases, the atrial epicardial leads were implanted on the opposite site of the origin of their own atrial rhythm. The time differences between sensed atrioventricular interval and actual P wave and ventricular pacing interval occurred because of the site of the epicardial atrial pacing leads and the intra-atrial conduction delay. CONCLUSION: We need to consider the origin of the atrial rhythm, the site of the epicardial atrial lead, and the atrial conduction delay by using electrocardiogram and X-ray when we set the optimal sensed atrioventricular interval in complicated CHD.


Assuntos
Arritmias Cardíacas/fisiopatologia , Nó Atrioventricular/fisiopatologia , Eletrocardiografia/métodos , Técnica de Fontan/efeitos adversos , Átrios do Coração/fisiopatologia , Cardiopatias Congênitas/cirurgia , Marca-Passo Artificial , Adolescente , Adulto , Arritmias Cardíacas/etiologia , Feminino , Cardiopatias Congênitas/fisiopatologia , Frequência Cardíaca/fisiologia , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Complicações Pós-Operatórias
4.
Pediatr Cardiol ; 40(7): 1388-1400, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31372681

RESUMO

In this article, we provide a brief summary of work by us and others to discover the molecular underpinnings of early conduction system development and function. We focus on how the multifunctional protein Tbx3 contributes to acquisition and homeostasis of the tissue-specific properties of the sinoatrial and atrioventricular nodes. We also provide unpublished, preliminary findings supporting the role of Tbx3-regulated alternative RNA processing in the developing conduction system.


Assuntos
Regulação da Expressão Gênica no Desenvolvimento , Sistema de Condução Cardíaco/metabolismo , Animais , Nó Atrioventricular/fisiopatologia , Expressão Gênica , Sistema de Condução Cardíaco/embriologia , Humanos , RNA/metabolismo , Proteínas com Domínio T
5.
Circ Arrhythm Electrophysiol ; 12(8): e007256, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31401852

RESUMO

BACKGROUND: Impaired myocardial conduction is the underlying mechanism for re-entrant arrhythmias. Carbon nanotube fibers (CNTfs) combine the mechanical properties of suture materials with the conductive properties of metals and may form a restorative solution to impaired myocardial conduction. METHODS: Acute open chest electrophysiology studies were performed in sheep (n=3). Radiofrequency ablation was used to create epicardial conduction delay after which CNTf and then silk suture controls were applied. CNTfs were surgically sewn across the right atrioventricular junction in rodents, and acute (n=3) and chronic (4-week, n=6) electrophysiology studies were performed. Rodent toxicity studies (n=10) were performed. Electrical analysis of the CNTf-myocardial interface was performed. RESULTS: In all cases, the large animal studies demonstrated improvement in conduction velocity using CNTf. The acute rodent model demonstrated ventricular preexcitation during sinus rhythm. All chronic cases demonstrated resumption of atrioventricular conduction, but these required atrial pacing. There was no gross or histopathologic evidence of toxicity. Ex vivo studies demonstrated contact impedance significantly lower than platinum iridium. CONCLUSIONS: Here, we show that in sheep, CNTfs sewn across epicardial scar acutely improve conduction. In addition, CNTf maintain conduction for 1 month after atrioventricular nodal ablation in the absence of inflammatory or toxic responses in rats but only in the paced condition. The CNTf/myocardial interface has such low impedance that CNTf can facilitate local, downstream myocardial activation. CNTf are conductive, biocompatible materials that restore electrical conduction in diseased myocardium, offering potential long-term restorative solutions in pathologies interrupting efficient electrical transduction in electrically excitable tissues.


Assuntos
Arritmias Cardíacas/cirurgia , Nó Atrioventricular/fisiopatologia , Fibra de Carbono , Ablação por Cateter/métodos , Átrios do Coração/fisiopatologia , Miocárdio/patologia , Nanotubos de Carbono , Animais , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/fisiopatologia , Nó Atrioventricular/cirurgia , Modelos Animais de Doenças , Eletrocardiografia , Feminino , Masculino , Ovinos
6.
Int Heart J ; 60(3): 761-767, 2019 May 30.
Artigo em Inglês | MEDLINE | ID: mdl-31105149

RESUMO

A 70-year-old woman was admitted for treatment of supraventricular tachycardia. Ventriculoatrial conduction was revealed through programmed ventricular stimulation; the coronary sinus ostium (CSos) was the earliest atrial activation site. The fast-slow forms of atrioventricular nodal reentrant tachycardia (AVNRT) were induced by ventricular extra-stimuli. During tachycardia, the earliest atrial activation site was located at the bottom of CSos. Radiofrequency (RF) energy application to this site resulted in the delay of local electrical potential, prolongation of tachycardia cycle length, and a shift of the earliest retrograde activation site to the roof of CSos. Subsequent ablation induced a similar shift to the inferior tricuspid annulus and to the right posterior septum. Finally, RF energy application to the right posterior septum resulted in the termination of tachycardia, which was not induced afterward. Multiple shifts in the earliest retrograde atrial activation site along the tricuspid annulus after each slow pathway ablation suggested that annular tissue plays a substantial role as a substrate for AVNRT.


Assuntos
Nó Atrioventricular/fisiopatologia , Ablação por Cateter/métodos , Taquicardia por Reentrada no Nó Atrioventricular/diagnóstico , Taquicardia por Reentrada no Nó Atrioventricular/terapia , Idoso , Eletrofisiologia Cardíaca/instrumentação , Eletrocardiografia/métodos , Feminino , Humanos , Taquicardia por Reentrada no Nó Atrioventricular/fisiopatologia , Taquicardia Supraventricular/diagnóstico , Taquicardia Supraventricular/fisiopatologia , Taquicardia Supraventricular/terapia , Resultado do Tratamento
8.
Cardiol Clin ; 37(2): 221-230, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30926023

RESUMO

Catheter ablation is recommended in patients with symptomatic atrial fibrillation (AF) refractory to pharmacologic therapy. AF recurrence is common postablation, particularly in patients with heart failure, because of multiple structural and functional changes that can occur. Determining predictors of AF recurrence has become increasingly important. These include increased left atrial volume, termination of AF during the index ablation, electrocardiogram parameters, and serum biomarkers. Cardiac MRI can also determine the degree of scarring and left atrial sphericity, which is used in risk prediction scores. In patients with recurrence, further treatment options include pharmacologic therapy and atrioventricular nodal ablation with pacing.


Assuntos
Fibrilação Atrial/cirurgia , Nó Atrioventricular/cirurgia , Ablação por Cateter/métodos , Gerenciamento Clínico , Insuficiência Cardíaca/epidemiologia , Volume Sistólico/fisiologia , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Nó Atrioventricular/fisiopatologia , Comorbidade , Eletrocardiografia , Saúde Global , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/cirurgia , Humanos , Recidiva , Resultado do Tratamento
9.
Clin Cardiol ; 42(4): 452-458, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30801746

RESUMO

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia, with its incidence making up nearly one-third of all hospital admissions. Atrioventricular block (AVB) is a conduction abnormality along the atrioventricular node or the His-Purkinje system. The relationship between atrioventricular conduction block and AF is controversial. HYPOTHESIS: This study is designed to observe whether there is a correlation between AVB and AF, and which type of AVB has the most obvious correlation with AF. METHODS: This study retrospectively reviewed 1345 patients. We classified the AVB according to the AVB classification criteria. One hundred and two patients were excluded, and the final total sample size was 1243 patients, including 679 patients in the AF group (378, 55.7% males) and 564 patients in the non-AF group (287, 50.8% males). AF group and non-AF group were compared to observe the relationship between AVB and AF. RESULTS: The I AVB have a relative statistical risk of 1.927 (95% confidence interval [CI]: 1.160-3.203, P < 0.05) with the occurrence of AF. II AVB occupied the largest proportion, accounting for 67 cases (9.87%), and the statistical risk of II AVB in AF is 16.845 (95% CI: 6.099-46.524, P < 0.000). III AVB has a comparative statistical risk of 17.599 (95% CI: 4.212-73.541, P < 0.000). CONCLUSIONS: The three types of AVB in the AF group were significantly higher than that in the non-AF group. II AVB has the highest incidence rate compared with other types of AVB in the AF group. AVB can be used as a risk factor for AF occurrence.


Assuntos
Fibrilação Atrial/etiologia , Bloqueio Atrioventricular/complicações , Nó Atrioventricular/fisiopatologia , Medição de Risco/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Bloqueio Atrioventricular/epidemiologia , Bloqueio Atrioventricular/fisiopatologia , China/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Tempo , Adulto Jovem
10.
Med Hypotheses ; 124: 56-59, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30798917

RESUMO

The atrioventricular node (AV) is considered the electrical connection between the atria and ventricles. There is an electrical pause between activation of the atria and the ventricles (PR segment), but to date the mechanism responsible for this interruption remains unclear. The present communication focuses on the hypothesis that magnetic field dynamics could provide the answer. Proof of this hypothesis is that in Wolff-Parkinson-White syndrome, where there is physical connection between the atria and ventricles (bundle of Kent), there is electrical AV continuity, no PR segment is detected, and catheter ablation of the abnormal bundle restores AV discontinuity. Spontaneous initiation of the heart at the level of the sinus node, the pacemaker of the heart, could also be explained via field dynamics. The known transmembrane pacemaker protein CHN4, present in both sinoatrial and AV nodal cells, could interact with field information to provide specificity in an electronic key-to-lock mechanism interaction.


Assuntos
Nó Atrioventricular/fisiopatologia , Átrios do Coração/fisiopatologia , Sistema de Condução Cardíaco/fisiopatologia , Ventrículos do Coração/fisiopatologia , Nó Sinoatrial/fisiopatologia , Arritmias Cardíacas/fisiopatologia , Ablação por Cateter , Eletrocardiografia , Eletrofisiologia , Coração , Humanos , Síndrome de Wolff-Parkinson-White/diagnóstico , Síndrome de Wolff-Parkinson-White/fisiopatologia
12.
Clin Res Cardiol ; 108(7): 815-823, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30788620

RESUMO

BACKGROUND: Heart failure (HF) and atrial fibrillation (AF) often coexist, but data on the prognostic value of differing ablation strategies according to left ventricular ejection fraction (LVEF) are rare. METHODS AND RESULTS: From January 2007 until January 2010, 728 patients with HF were enrolled in the multi-center German ablation registry prior to AF catheter ablation. Patients were divided into three groups according to LVEF: HF with preserved LVEF (≥ 50%, HFpEF, n = 333), mid-range LVEF (40-49%, HFmrEF, n = 207), and reduced LVEF (< 40%, HFrEF, n = 188). Ablation strategies differed significantly between the three groups with the majority of patients with HFpEF (83.4%) and HFmrEF (78.4%) undergoing circumferential pulmonary vein isolation vs. 48.9% of patients with HFrEF. The latter underwent ablation of the atrioventricular (AV) node in 47.3%. Major complications did not differ between the groups. Kaplan-Meier survival analysis demonstrated a significant mortality increase in patients with HFrEF (6.1% in HFrEF vs. 1.5% in HFmrEF vs. 1.9% in HFpEF, p = 0.009) that was limited to patients undergoing ablation of the AV node. CONCLUSIONS: Catheter ablation strategies differ significantly in patients with HFpEF, HFmrEF, and HFrEF. In almost 50% of patients with HFrEF AV-node ablation was performed, going along with a significant increase in mortality rate. These results should raise efforts to further evaluate the prognostic effect of ablation strategies in HF patients.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/normas , Insuficiência Cardíaca/cirurgia , Guias de Prática Clínica como Assunto , Sistema de Registros , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Idoso , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Nó Atrioventricular/fisiopatologia , Feminino , Seguimentos , Alemanha/epidemiologia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Estudos Prospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento
16.
Clin Res Cardiol ; 108(4): 395-401, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30194475

RESUMO

BACKGROUND: We aimed to compare patient characteristics and outcome of patients who had either undergone pulmonary vein isolation (PVI) or AV-node ablation (AVN) to control AF-related symptoms. METHODS: From the German Ablation Registry, we analyzed data of 4444 patients (95%) who had undergone PVI and 234 patients (5%) with AVN. RESULTS: AVN patients were on average 10 years older than PVI patients (71 ± 10 vs. 61 ± 10 years, p < 0.001) with 33% aged > 75 years. AVN patients had significantly more cardiovascular comorbidities (diabetes 21% vs. 8%, renal insufficiency 24% vs. 3%, underlying heart disease 80% vs. 36%, severely reduced left ventricular function 28% vs. 1%, all p < 0.001). Significantly more PVI patients had paroxysmal AF (63% vs. 18%, p < 0.001), and more AVN patients had long-standing persistent AF (44% vs. 7%, p < 0.001). At 1-year follow-up, mortality in the AVN group was much higher (Kaplan-Meier estimates 9.8% vs. 0.5%). 20% of PVI patients had undergone another ablation vs. 3% AVN patients (p < 0.001). Symptomatic improvement was equally achieved in about 80%. Re-hospitalization for cardiovascular reasons occurred significantly more often in PVI vs. AVN patients (31% vs. 18%, p < 0.001). CONCLUSION: In the large German Ablation Registry, AVN ablation was performed much less frequently than PVI for symptomatic treatment of AF and typically in older patients with more comorbidity. Symptomatic improvement was similar in both groups. Hospitalizations for cardiovascular reasons were lower in AVN patients despite older age and more cardiovascular comorbidities. 20% of PVI patients had undergone at least one re-ablation.


Assuntos
Fibrilação Atrial/cirurgia , Nó Atrioventricular/cirurgia , Ablação por Cateter/métodos , Frequência Cardíaca/fisiologia , Satisfação do Paciente , Veias Pulmonares/cirurgia , Sistema de Registros , Idoso , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Nó Atrioventricular/fisiopatologia , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento
17.
Heart Lung Circ ; 28(5): 707-718, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30509786

RESUMO

BACKGROUND: Catheter ablation (CA) is highly efficacious for symptomatic atrial fibrillation (AF) but data predominantly comes from patients with preserved ventricular function. We performed an updated systematic review and meta-analysis of randomised controlled trials (RCT) comparing CA versus medical therapy for AF associated with heart failure (HF). METHODS: Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs reporting clinical outcomes of CA versus medical therapy for AF in HF patients with ≥6 months' follow-up (atrioventricular-node ablation/device therapy studies excluded). Primary endpoint was change in left ventricular ejection fraction (LVEF). Secondary endpoints were 6-minute walk test (6MWT) distance, quality of life (QoL; measured by the Minnesota Living with Heart Failure Questionnaire [MLHFQ]), peri-procedural mortality, major peri-procedural complications and mid-term (≥1-year) survival. RESULTS: Six RCTs (n=772 patients; mean age 62±11years, LVEF 30±9%) were included. Catheter ablation, compared to medical therapy was associated with: greater improvement in LVEF (mean difference [MD] 5.67%; 95% Confidence Interval [CI], 3-8; I2=87%; p<0.001), greater increase in 6MWT distance (MD 25.1 metres; 95% CI, 0.6-50; I2=94%; p=0.04), improved QoL with greater reduction in MLHFQ scores (MD 9.03; 95% CI, 2.5-15.6; I2=47%; p=0.007), and significantly reduced mid-term mortality (relative risk 0.52; 95% CI, 0.4-0.8; I2=0%; p=0.001). Freedom from AF after ≥1 procedure was 71%; major complications occurred in 8% of patients. CONCLUSION: Catheter ablation is superior to medical therapy for AF in patients with heart failure resulting in greater improvement in LVEF, quality of life and functional status, with a survival benefit.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/terapia , Nó Atrioventricular/fisiopatologia , Ablação por Cateter/métodos , Insuficiência Cardíaca/terapia , Função Ventricular Esquerda/fisiologia , Fibrilação Atrial/complicações , Fibrilação Atrial/fisiopatologia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
18.
Turk J Pediatr ; 61(4): 618-621, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31990485

RESUMO

Türe M, Bilici M, Akin A, Demir F, Balik H, Darakçi SM. Complete atrioventricular block associated with clozapine intoxication: case report. Turk J Pediatr 2019; 61: 618-621. Clozapine is one of the atypical anti-psychotic drugs used in the treatment of resistant schizophrenia. Although cardiac side-effects are rare, it has been reported that there may be development of myocarditis, dilated cardiomyopathy, postural orthostatic hypotension and prolonged QT duration. Complete atrioventricular (AV) block is characterized by the inability to transmit all of the atrial signal to the ventricles. Causes may be congenital, idiopathic or acquired which are associated with surgery, infection, or muscle disease. AV block is extremely serious and permanent pacemaker insertion is usually necessary for all patients. Complete AV block may develop due to clozapine intoxication through increase in vagal tonus, sinoatrial node (SN) and the inhibition of atrioventricular node signalling. The case presented here is of a 15-year old female patient who developed AV total cardiac block associated with the taking of clozapine in a suicide attempt.


Assuntos
Bloqueio Atrioventricular/induzido quimicamente , Nó Atrioventricular/fisiopatologia , Clozapina/envenenamento , Eletrocardiografia/efeitos dos fármacos , Adolescente , Antipsicóticos/envenenamento , Bloqueio Atrioventricular/fisiopatologia , Bloqueio Atrioventricular/terapia , Nó Atrioventricular/efeitos dos fármacos , Feminino , Humanos , Marca-Passo Artificial , Tentativa de Suicídio
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