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Editors: Barash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael K.; Stock, M. ChristineTitle: Cli nical Anest hesia, 6t h Edit ion
Copyright 2009 Lippincott Williams & Wilkins
> Back of Book > Appendix - Electrocardiography
AppendixElectrocardiography
James R. Zaidan
Paul G. Barash
Electrocardiogram
Lead PlacementELECTRODE
POSITIVE NEGATIVE
BIPOLAR LEADS
I LA RA
II LL RA
III LL LA
AUGMENTED UNIPOLAR
avr RA LA, LL
avl LA RA, LL
avf LL RA, LA
PRECORDIAL
V1 4 ICSRSB
V2 4 ICSLSB
V3 Midway between V 2 and V 4
V4 5 ICSMCL
V5 5 ICSAAL
V6 5 ICSMAL
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THREE-LEAD SYSTEMS
FootnoteWe wish to thank Dr. Malcom S. Thaler for graciously permitting reproduction of electrocardiographic tracingsfrom his book, The Only EKG Book You'll Ever Need (Philadelphia, JB Lippincott, 1988).
The Normal Elect rocardiogramCar diac Cycle
In this section the electrocardiogram (ECG) complex is divided into the atrial (PR interval) and ventricular (QTinterval) components.
BIPOLAR LEAD SYSTEM ELECTRODE PLACEMENT ECG LEADa ADVANTAGE
II RA Rclavicle
LA L10th rib (midclavicular line)
LL Ground
II (II) Dysrhythmias
MCL 1 RA Ground
LA LclavicleLL V1
III (V1) Dysrhythmias and conduction defects
CS 5 RA RclavicleLA V5
LL Ground
I (V5) Precordial ischemia
CB 5 RA RscapulaLA V5
LL Ground
I (V5) Precordial ischemia and dysrhythmias
ECG, electrocardiogram; MCL, modified central lead; CB, central back; CS, central subclavian.aSelected lead on monitor: ( ) = simulated E CG lead.
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Ashman Beat s
Rate: Variable.
Rhythm: Irregular.
PR interval: P wave may be present if supraventricular premature beat.
QT interval: QRS prolonged (>0.12 second) and altered, revealing bundle-branch pattern, most commonly rightbundle. ST segment abnormal.
Note: Ashman beats are often confused with ventricular premature contractions. Ashman beats, usually seenwith atrial fibrillation, have no compensatory pause and are a benign ECG finding, requiring no treatment.
Atrial Fibrillation
Rate: Variable (approximately 150 to 200 beats/min).
Rhythm: Irregular.
PR interval: No P wave, and PR interval not discernible.
QT interval: QRS normal.
Note: Must be differentiated from atrial flutter: (1) absence of flutter waves and presence of fibrillatory line,and (2) flutter usually associated with higher ventricular rates (>150 beats/min). Loss of atrial contractionreduces cardiac output (10 to 20%). Mural atrial thrombi may develop. Considered controlled if ventricular rate
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Rate: Rapid, atrial usually regular (250 to 350 beats/min); ventricular usually regular (0.20 second) and constant.
QT interval: Normal.
Note: Usually clinically insignificant; may be early harbinger of drug toxicity.
At r iovent r icular Block (Second-Degr ee), Mobi t z Type I/Wenckebach
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Block
Rate: 60 to 100 beats/min.
Rhythm: Atrial regular; ventricular irregular.
PR interval: P wave normal; PR interval progressively lengthens with each cycle until QRS complex is dropped(dropped beat). PR interval following the dropped beat is shorter than normal.
QT interval: QRS complex normal but dropped periodically.
Note: Commonly seen (1) in trained athletes and (2) with drug toxicity.
At r iovent r icular Block (Second-Degr ee), Mobit z Type II
P.1581
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Rate: Variable.
Rhythm: Atrial regular; ventricular regular; ventricular rate faster than atrial rate; no relationship between Pwave and QRS complex.
PR interval: Variable because atria and ventricles beat independently.
QT interval: QRS morphology depends on location of ventricular pacemaker. ST segment and T wave abnormal.
Note: Digitalis toxicity can present as atrioventricular dissociation.
Bundl e-Br anch BlockLeft
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Rate: 0.12 second); incomplete LBBB.
(QRS = 0.10 to 0.12 second); Lead V 1 negative rS complex; I, aVL, V 6 wide R wave without Q or S component. ST
segment and T-wave defection opposite direction of the R wave.
Note: LBBB does not occur in healthy patients and usually indicates serious heart disease with a poorerprognosis. In patients with LBBB, insertion of a pulmonary artery catheter may lead to complete heart block.
Bundle-Branch BlockRight
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Rate: 0.12 second); incomplete RBBB (QRS = 0.10 to0.12 second). Varying patterns of QRS complex; rSR (V 1); RS, wide R with M pattern. ST segment and T wave
opposite direction of the R wave.
Note: In the presence of RBBB, Q waves may be seen with a myocardial infarction.
Electrolyte Disturbances
Digit ali s Ef f ect
Ca2+ Ca2+ K + K +
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vasospasm (Prinzmetal) ST segment elevation.
Note: Intraoperative ischemia is usually seen in the presence of normal vital signs (e.g., 20% of preinductionvalues).
Coronary Artery DiseaseMyocardial Infarction
Subendocar dial Myocardi al Inf arct ion Persistent ST segment depression and/or T-wave inversion in the absence of Q wave. Usually requires additionallaboratory data (e.g., isoenzymes) to confirm diagnosis.
Tr ansmural Myocardial Inf arct ion Q waves seen on ECG useful in confirming diagnosis. Associated with poorer prognosis and more significanthemodynamic impairment; dysrhythmias frequently complicate course.
Paroxysmal At r ial Tachycardia
Rate: 150 to 250 beats/min.
Rhythm: Regular.
PR interval: Difficult to distinguish because of tachycardia obscuring P wave. P wave may precede, be included
ANATOMIC SITE LEADS ECG CHANGES CORONARY ARTERY
Inferior II, III, aVF Q, ST, T Right
Lateral I, aVL, V 5V6 Q, ST, T Left circumflex
Anterior I, aVL, V 1V4 Q, ST, T Left
Anteroseptal V1V4 Q, ST, T Left anterior descending
ECG, electrocardiogram.
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in, or follow QRS complex.
QT interval: Normal, but ST segment and T wave may be difficult to distinguish.
Note: Therapy depends on degree of hemodynamic compromise. In contrast to management of paroxysmal atrialtachycardia (PAT) in awake patients, synchronized cardioversion rather than pharmacologic treatment ispreferred in hemodynamically unstable anesthetized patients.
Premature Atrial Contraction
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Rate: Usually 0.12 second); ST segment cannot be evaluated (e.g., ischemia); T wave oppositedirection of QRS with compensatory pause ( A). Bigeminy: every other beat a premature ventricular contraction(PVC) (B); trigeminy: every third beat a PVC. R-on-T occurs when PVC falls in the T wave and can lead toventricular tachycardia or fibrillation.
Note: If compensatory pause is not seen following an ectopic beat, the complex is most likely supraventricular inorigin.
Sinus Tachycar dia
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Rate: 100 to 160 beats/min.
Rhythm: Regular.
PR interval: Normal; P wave may be difficult to see.
QT interval: Normal.
Note: Should be differentiated from PAT. With PAT, carotid massage terminates dysrhythmia. Sinus tachycardiamay respond to vagal maneuvers but reappears as soon as vagal stimulus is removed.
Tor sades De Point es
Rate: 150 to 250 beats/min.
Rhythm: No atrial component seen; ventricular rhythm regular or irregular.
PR interval: P wave buried in QRS complex.
QT interval: QRS complexes usually wide and with phasic variation twisting around a central axis (a fewcomplexes point upward then a few point downward). ST segments and T waves difficult to discern.
Note: Type of ventricular tachycardia associated with prolonged QT interval. Seen with electrolyte disturbances(e.g., hypokalemia, hypocalcemia, and hypomagnesemia) and bradycardia. Administering standardantidysrhythmics (e.g., lidocaine, procainamide) may worsen torsades de pointes. Treatment includes increasingheart rate pharmacologically or by pacing.
P.1585
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Vent ri cular Fibri llat ion
Rate: Absent.
Rhythm: None.
PR interval: Absent.
QT interval: Absent.
Note: Pseudoventricular fibrillation may be the result of a monitor malfunction (e.g., ECG lead disconnect).Always check for carotid pulse before instituting therapy.
Ventricular Tachycardia
Rate: 100 to 250 beats/min.
Rhythm: No atrial component seen; ventricular rhythm irregular or regular.
PR interval: Absent; retrograde P wave may be seen in QRS complex.
QT interval: Wide, bizarre QRS complex. ST segment and T wave difficult to determine.
Note: In the presence of hemodynamic compromise, immediate DC synchronized cardioversion is required. If thepatient is stable, with short bursts of ventricular tachycardia, pharmacologic management is preferred. Shouldbe differentiated from supraventricular tachycardia with aberrancy (SVT-A). Compensatory pause andatrioventricular dissociation suggest a PVC. P waves and SR (V1) and slowing to vagal stimulus suggest SVT-A.
Wolf f -Parkinson-Whit e Syndrome
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Generic Defibrillator Code (NBG): NASPE/BPEG
Example of A Stepwise Approach to the Perioperative Treatment of thePatient with A Cardiac Rhythm Management Device (CRMD)
A = atrium A = atrium I = inhibited R = rate modulation A = atrium
V = ventricle V = ventricle T = triggered V = ventricle
D = dual (A + V) D = dual (A + V) D = dual (T + I) D = dual (A + V)
aNBG: N refers to North American Society of Pacing and E lectrophysiology (NASPE), now called the Heart Rhythm Society (HRS); B r efers to British
Pacing and Electrophysiology Group (BPEG); and G r efers to generic.
From Practice advisory for perioperative management of patients with cardiac rhythm management devices: Pacemakers and implantable
cardioverter-defibrillators. A report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with
Cardiac Rhythm Management Devices. Anesthesiology 2005; 103: 186, with permission.
POSITION I, SHOCK
CHAMBER(S)
POSITION II, ANTITACHYCARDIA
PACING CHAMBER(S)
POSITION III, TACHYCARDIA
DETECTIONPOSITION IV,a ANTIBRADYCARDIA
PACING CHAMBER(S)
O = none O = none E = electrogram O = none
A = atrium A = atrium H = hemodynamic A = atrium
V = ventricle V = ventricle V = ventricle
D = dual (A + V) D = dual (A + V) D = dual (A + V)
NASPE, North American Society of Pacing and Electrophysiology; BPEG, British Pacing and Electrophysiology Group.aFor robust identification, position IV is expanded into its complete NBG code. For example, a biventricular pacingdefibrillator with ventricular
shock and antitachycardia pacing functionality would be identified as VVE-DDDRV, assuming that the pacing section was programmed DDDRV.
Currently, no hemodynamic sensors have been approved for tachycardia detection (position III).
From Practice advisory for perioperative management of patients with cardiac rhythm management devices: Pacemakers and implanta ble
cardioverter-defibrillators. A report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with
Cardiac Rhythm Management Devices. Anesthesiology 2005; 103: 186, with permission.
P.1587
PERIOPERATIVE PERIOD PATIENT/CRMD CONDITION INTERVENTION
Pr eoperative evaluation Patient has CRMD Focused history
Focused physical examination
Determine CRMD type (pacemaker, ICD,
CRT)Manufacturer's CRMD identification card
Chest x-ray studies (no data available)
Supplemental resources a
Determine whether patient is CRMD-
dependent for pacing functionVerbal history
Bradyarrhythmia symptoms
Atrioventricular node ablation
No spontaneous ventricular activity b
Determine CRMD function Comprehensive CRMD evaluation C
Determine whether pacing pulses are present and create
paced beats
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Preoperative preparation EMI unlikely during procedure If EMI unlikely, special precautions are not needed
EMI likely: CRMD is pacemaker Reprogram to asynchronous mode when indicated
Suspend rate-adaptive functions d
EMI likely: CRMD is ICD Suspend antitachyarrhythmia functions
If patient is dependent on pacing function, after pacingfunctions as above
EMI likely: all CRMD Use bipolar cautery; ultrasonic scalpel
Temporary pacing and external cardioversiondefibrillation
available
Intraoperative physiologic changes likely
(e.g., bradycardia, ischemia)Plan for possible adverse CRMDpatient interaction
Intraoperative management Monitoring Electrocardiographic monitoring per ASA standard
Peripheral pulse monitoring
Electrocautery interference CT/CRPno current through PG/leads
Avoid proximity of CT to PG/leads
Short bursts at lowest possible energy
Use bipolar cautery; ultrasonic scalpel
Radiofrequency catheter ablation Avoid contact of radiofrequency catheter with PG/leads
Radiofrequency current path far away from PG/leads
Discuss these concerns with operator
Lithotripsy Do not focus lithotripsy beam near PG
R wave triggers lithotripsy? Disable atrial pacing e
MRI Generally contraindicated
If required, consult ordering physician, cardiologist,
radiologists, and manufacturer
RT PG/leads must be outside of RT field
Possible surgical relocation of PG
Verify PG function during/after RT course
ECT Consult with ordering physician, patient's cardiologist, a
CRMD service, or CRMD manufacturer
Emergency defibrillation
cardioversion
ICD: magnet disabled Terminate all EMI sources
Remove magnet to re-enable therapiesObserve for appropriate therapies
ICD: programming disabled Programming to re-enable therapies or proceed directly with
external cardioversiondefibrillation
ICD: either of above Minimize current flow through PG/leads
PP as far as possible from PG
PP perpendicular to major axis PG/leads
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Treatment of Pacemaker Failure
Pacemaker Tracings Atrial Pacing
To extent possible, PP in anteriorposterior location
Regardless of CRMD type Use clinically appropriate cardioversion/defibrillation energy
Postoperative management Immediate postoperative period Monitor cardiac R&R continuously
Backup pacing and cardioversion/defibrillation capability
Postoperative interrogation and
restoration of CRMD functionInterrogation to assess function
Setting appropriate? f
Is CRMD an ICD?g
Use cardiology/pacemakerICD service if needed
ICD, internal cardioverterdefibrillator; CRT, cardiac resynchronization therapy; EMI, electromagnetic interference; ASA, American Society of
Anesthesiologists; CT, cautery tool; CRP, current return pad; PG, pulse generator; MRI, magnetic resonance imaging; RT, radiation therapy; ECT,
electroconvulsive therapy; PP, external cardioversiondefibrillation pads or paddles; R&R, rhythm and rate.aManufacturer's databases, pacemaker clinic records, cardiology consultation. bWith cardiac rhythm management device (CRMD) programmed WI at lowest programmable rate. CIdeally, CRMD function assessed by interrogation, with function altered by reprogramming if required. dMost times this will be necessary; when in doubt, assume so. eAtrial pacing spikes may be interpreted by the lithotriptor as R waves, possibly inciting the lithotriptor to deliver a shock during a vulnerable
period in the heart.f If necessary, reprogram appr opriate setting. gRestore all antitachycardia therapies.
From Practice advisory for perioperative management of patients with cardiac rhythm management devices: Pacemakers and implanta ble
cardioverter-defibrillators. A report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with
Cardiac Rhythm Management Devices. Anesthesiology 2005; 103: 186, with permission.
P.1588
RATE POSSIBLE RESPONSE
Adequate to maintain blood
pressure
1. Oxygen, airway control
2. Place magnet over pacemaker3. Atropine if sinus bradycardia
Severe bradycardia and
hypotension1. Oxygen, airway control
2. Place magnet over pacemaker
3. Other types of pacing if magnet does not activate the pacemaker (transcutaneous, esophageal, or
transvenous)
4. Atropine if sinus bradycardia
5. Isoproterenol to increase ventricular rate
No escape rhythm 1. Cardiopulmonary resuscitation
2. Place magnet over pacemaker
3. Other types of pacing if magnet does not activate the pacemaker (transcutaneous, esophageal, or
transvenous)
4. Isoproterenol to increase ventricular rate
From Zaidan JR: Pacemakers, Cardiac, Vascular and Thoracic Anesthesia. Edited by Youngberg JA, Lake CL, Roizen MF et al. New Yo rk, Churchill
Livingstone, 2000, with permission.
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Atrial pacing as demonstrated in this f igure is used when the atrial impulse can proceed through theatrioventricular (AV) node. 1 Examples are sinus bradycardia and junctional rhythms associated with clinicallysignificant decreases in blood pressure.
Vent r icular Pacing
In this tracing ventricular pacing is evident by absence of atrial wave (P wave) and pacemaker spike precedingQRS complex. Ventricular pacing is employed in the presence of bradycardia secondary to AV block or atrialfibrillation.
Dual-Chamber Pacing
The dual-chamber (DDD) pacemaker (generator), one of the most commonly used, paces and senses both atrium
and ventricle. In the first four beats, the P waves were not followed by a QRS complex within the programmedPR interval. Therefore, a ventricular pacing spike and a ventricular paced beat occurred. In the last four beats(after the arrow in the figure), atrial activity proceeded through the AV node in the allotted amount of time;therefore, ventricular pacing was inhibited.
At ri al Elect r ogr am
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The atrial electrogram (AEG) is useful in differentiating various atrial dysrhythmias. The AEG is obtained from anintra-cardiac or esophageal lead if P waves are not clearly seen on the surface ECG. In this trace, the V lead
does not have obvious P waves; however, the AEG reveals large P waves ( arrows ) that precede each QRScomplex. Locate the QRS on the AEG by matching the R wave on the surface ECG to the AEG. The surface andAEG must be simultaneously recorded.
Guidelines for Using the Electrocautery
P.1589
1. Electromagnet interference created by an electrocautery can cause a number of problems with pacemaker or ICD function including, but not
limited to, reprogramming, inhibition, noise reversion mode, electrical reset, myocardial burns, increase in threshold, rate increment
changes in rate adaptive pacemakers, and inappropriate sensing and charging in ICDs. 2, 3
2. When positioning the return plate of the electrocautery:
a. Ensure it is located so the pacemaker or ICD is not between this return plate and the active electrode.
b. Ensure the plane described by the return plate and the active electrode of the electrocautery is perpendicular to a plane described by
the pacemaker or ICD and the pa cemaker's electrodes.
3. Use the smallest current required to cut or coagulate.
4. Use the electrocautery in short bursts.
5. Avoid using the electrocautery within 6 inches of the device or leads.
6. Consider using the bipolar electrocautery or the ultrasonic scalpel 4, 5 to minimize interference with pacemaker or IC D function.
7. Activating the electrocautery in the area of the pacemaker or ICD, even if the active electrode is not touching the patient, will cause
interference. 6
8. Do not use the electrocautery when an ICD is programmed to sense and deliver therapy.
9. Convert the ICD to no response either by programming or by using the magnet, depending on the manufacturer of the ICD, so the device will
not deliver therapy secondary to misinterpretation of signals from the electrocautery as a dysr hythmia. These maneuvers will not change
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Additional Issues for Patients with Implanted Cardioverter Defibrillators
References
1. Epstein AE, DiMarco JP, Ellenbogen KA et al: ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. A report of the American College of Cardiology/American Heart AssociationTask Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 GuidelineUpdate for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation 2008; 117: e350
2. Levine P: Evaluation and management of pacing system malfunctions, Cardiac Pacing and ICDs, 4thedition. Edited by Ellenbogen KA, Ward MA. Boston, Blackwell Publishing, 2005
3. Atlee JL, Bernstein AD: Cardiac rhythm management devices (part II): Perioperative management.Anesthesiology 2001; 95: 1492
4. Nandalan SP, Vanner RG: Use of the harmonic scapel in a patient with a permanent pacemaker.Anaesthesia 2001; 94: 710
5. Ozeren M, Dogan OV, Duzgun C et al: Use of an ultrasonic scalpel in the open-heart reoperation of a
the program of a pacemaker that is incorporated into an ICD.
10. If desired, convert a pacemaker that does not have an ICD to the asynchronous mode so it is not inhibited by the electrocautery.
11. A magnet will not change bradycardia-related pacing parameters in the ICD.
12. ICDs must be programmed to respond to a magnet.
ICD, implanted cardioverter defibrillator.
1. All ICDs have pacemakers incorporated into the circuitry.
2. Preoperative assessments should include those procedures that are standard for patients with heart disease.
3. Obtain a cardiology consult to help assess the patient, interrogate the ICD, program the device to no response, and program the device to
respond to the magnet.
4. There is no particular anesthetic technique that is clearly right or wrong for a patient who has an ICD.
5. Apply patches for external defibrillation when the ICD is programmed to no response. Ensure these external patches are as far away as
possible from the device and, if possible, not in the same plane as the device and electrodes.
6. Monitor as required for patient care. If monitoring with a pulmonary arterial catheter, discuss the issues of dislodgment of the ICD
electrodes with the patient and cardiologist. Document in the chart your discussions and the logic supporting the necessity for a p ulmonary
arterial catheter. Maintain sterile technique, and consider administering antibiotics just before inserting central lines.
7. Continue antidysrhythmic agents until the time of surgery. Discuss with the cardiologist the necessity of administering an additional dose of
an antidysrhythmic agent if the patient experiences an intraoperative dysrhythmia.
8. Intraoperative dysrhythmias:a. If the patient has a dysrhythmia, rule out and treat the usual intraoperative causes to prevent a recurrence.
b. If the dysrhythmia continues and a magnet has been used to create the no-response mode, remove the magnet from the ICD and allow
the ICD to charge and deliver a resp onse.
c. If the ICD has been programmed to the no-response mode, then either quickly reprogram the ICD to deliver a response or proceed
directly to external defibrillation.
d. If external defibrillation or cardioversion is required, apply the defibrillator paddles in an anterior-posterior position, if possible, and
deliver the shock at a level sufficient to terminate the dysrhythmia.
e. External pacing might be required if the pacemaker/ICD is damaged with the shock.
9. Monitor the patient's ECG and be prepared to deliver an external defibrillation when transporting the patient to and from the operating
room.
10. Interrogate and reprogram the ICD when the patient has entered the postoperative care unit.
ICD, implanted cardioverter defibrillator; ECG, electrocardiogram.
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patient with pacemaker. Eur J Cardiothorac Surg 2002; 21: 761
6. Stevenson WG, Chaitman BR, Ellenbogen KA et al, for the Subcommittee on Electrocardiography andArrhythmias of the American Heart Association Council on Clinical Cardiology, in collaboration with theHeart Rhythm Society: Clinical assessment and management of patient with implanted cardioverter-defibrillators presenting to nonelectrophysiologists. Circulation 2004; 110: 3866
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