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   Table of Contents - Current issue
Coverpage
October-December 2021
Volume 24 | Issue 4
Page Nos. 427-516

Online since Monday, October 18, 2021

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ORIGINAL ARTICLES  

Retrograde autologous priming method reduces plasma free hemoglobin level in aortic surgery Highly accessed article p. 427
Eda Balci, Aslihan Aykut, Asli Demir, Kübra Vardar, Gülsüm Karduz, Uğur Aksu
DOI:10.4103/aca.ACA_193_20  
Background: Although conventional cardiopulmonary bypass (cCPB) is still the most widely used method in open heart surgery, methods such as retrograde autologous priming (RAP) are increasingly popular in terms of limiting hemodilution. Our hypothesis is that the use of the RAP method in aortic surgery may result in a limitation of hemodilution and a decrease in fHb levels. For this purpose, plasma free hemoglobin (fHb) levels were investigated in adult open aortic arch repair with axillary artery cannulation patients using cCPB and rRAP methods. Materials and Methods: In this study, a total of 36 patients undergoing aortic surgery using rRAP and standard cCPB were investigated. Measurements were performed at five time points: After induction of anesthesia, 5th minute of CPB, 10th minute of antegrade cerebral perfusion, 30th minute after declamping of aorta, and at sternum closure. Besides hemodynamic variables, arterial blood gas analysis and postoperative variables, patients were assessed for fHb levels. Results: The rRAP group had a significantly lower increase in fHb levels in T3, T4, and T5 time points, when compared to the cCPB group (p = 0.002, 0.047, 0.009, respectively). There was no significant difference between the rRAP and cCPB groups in other intraoperative, and postoperative variables. Also, it was observed that rRAP did not make a difference in terms of blood and blood product transfusion. Conclusion: In this study, in patients undergoing aortic surgery, a reduction in the increase of fHb was observed with the rRAP method which is a simple procedure that does not require high cost or advanced technology.
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Renal function and inflammatory response in neonates undergoing cardiac surgery with or without antegrade cerebral perfusion—a post hoc analysis Highly accessed article p. 434
Timo Jahnukainen, Paula Rautiainen, Juuso Tainio, Tommi Pätilä, Jukka T Salminen, Juho Keski-Nisula
DOI:10.4103/aca.ACA_183_20  
Background: Cardiopulmonary bypass (CPB) may lead to tissue hypoxia, inflammatory response, and risk for acute kidney injury (AKI). We evaluated the prevalence of AKI and inflammatory response in neonates undergoing heart surgery requiring CPB with or without antegrade cerebral perfusion (ACP). Methods: Forty neonates were enrolled. The patients were divided into two groups depending on the use of ACP. AKI was classified based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Inflammatory response was measured using plasma concentrations of interleukins 6 (IL-6) and 10 (IL-10), white blood cell count (WBC), and C-reactive protein (CRP). Results: Eight patients (20%) experienced AKI: five (29%) in the ACP group and three (13%) in the non-ACP group (P = 0.25). Postoperative peak plasma creatinine and urine neutrophil gelatinase-associated lipocalin were significantly higher in the ACP group than in the non-ACP group [46.0 (35.0–60.5) vs 37.5 (33.0-42.5), P = 0.044 and 118.0 (55.4–223.7) vs 29.8 (8.1–109.2), P = 0.02, respectively]. Four patients in the ACP group and one in the non-ACP group required peritoneal dialysis (P = 0.003). Postoperative plasma IL-6, IL-10, and CRP increased significantly in both groups. There were no significant differences between the ACP and non-ACP groups in any of the inflammatory parameters measured. Conclusions: No significant difference in the AKI occurrence or inflammatory response related to CPB modality could be found. In our study population, inflammation was not the key factor leading to AKI. Due to the limited number of patients, these findings should be interpreted with caution.
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Fluid resuscitation after cardiac surgery in the intensive care unit: A bi-national survey of clinician practice. (The FRACS-ICU clinician survey) p. 441
Mahesh Ramanan, Shaun Roberts, James Patrick Adrian McCullough, Rishendran Naidoo, Ivan Rapchuk, Mbakise Matebele, Alexis Tabah, Peter Kruger, Julian Smith, Kiran Shekar
DOI:10.4103/aca.ACA_190_20  
Context and Aims: To describe current fluid and vasopressor practices after cardiac surgery in Australia and New Zealand cardiothoracic intensive care units (ICU). Design and Setting: This web-based survey was conducted in cardiothoracic ICUs in Australia and New Zealand. Methods: Intensivists, cardiac surgeons, and anesthetists were contacted to complete the online survey that asked questions regarding first and second choice fluids and vasopressors and the tools and factors that influenced these choices. Results: There were 96 respondents including 51 intensivists, 27 anesthetists, and 18 cardiac surgeons. Balanced crystalloids were the most preferred fluids (70%) followed by 4% albumin (18%) overall and among intensivists and anesthetists; however, cardiac surgeons (41%) preferred 4% albumin as their first choice. The most preferred second choice was 4% albumin (74%). Among vasopressors, noradrenaline was the preferred first choice (93%) and vasopressin the preferred second choice (80%). 53% initiated blood transfusion at a hemoglobin threshold of 70 g/L. Clinical acumen and mean arterial pressure were the most commonly used modalities in determining the need for fluids. Conclusions: There is practice variation in preference for fluids used in cardiac surgical patients in Australia and New Zealand; however, balanced crystalloids and 4% albumin were the most popular choices. In contrast, there is broad agreement with the use of noradrenaline and vasopressin as first and second-line vasopressors. These data will inform the design of future studies that aim to investigate hemodynamic management post cardiac surgery.
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Analyzing the impact of preoperative interrogation of cardiac implantable electronic devices p. 447
Jose R Navas-Blanco, Derrick V Williams, Raj K Modak
DOI:10.4103/aca.ACA_32_20  
Background: Cardiac implantable electronic devices (CIED) are becoming more common for the management of underlying of cardiac dysrhythmias, and more patients with these devices are presenting for cardiac and noncardiac procedures. Methods: We performed a retrospective, cohort, single-center study at a tertiary teaching medical center, gathering 151 patients with CIED undergoing elective and emergent surgeries for the time period between November 2013 and December 2016. We aimed to determine whether patients with CIED had the device interrogated before surgery as recommended by the Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) consensus, whether this lack of compliance led to delay in the holding area before surgery and determine the presence of intra- or postoperative cardiac events in these patients. Results: A total of 76% of patients had interrogation of the device before surgery. Emergent cases were not interrogated as much as elective cases preoperatively (43% vs. 18%, respectively; P < 0.05). In total, 6% of cases had a CIED-related average holding area delay time of 54 minutes. Patients without preoperative device interrogation had more perioperative cardiac events than those who had the device checked (25% vs. 8%, respectively; odds ratio [OR] 0.26; 95% CI, 0.09–0.7, P < 0.013). Conclusions: Our findings suggest that preoperative interrogation of the device plays a significant role to minimize the incidence of perioperative cardiac adverse events. Institutional providers show a lack of compliance with HRS/ASA recommendations for preoperative CIED management. Further research is required to determine if improved compliance to recommendations will lead to enhanced outcomes.
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Inhaled nitric oxide before induction of anesthesia in patients with pulmonary hypertension p. 452
Vedat Eljezi, Laetitia Rochette, Christian Dualé, Bruno Pereira, Henri Boby, Jean Michel Constantin
DOI:10.4103/aca.ACA_82_20  
Background: The aim of this study was to examine the action of inhaled nitric oxide in the patients with pulmonary hypertension administered with a face mask before anesthesia induction. Methods: Ten adult patients scheduled for heart surgery with sternotomy were included in this prospective, interventional, single centre study. The inclusion criteria were patients scheduled for heart surgery with sternotomy with cardiopulmonary bypass (CPB), aged >18 years which presents a pulmonary hypertension (PH) (class 2 or 3 according to the Dana Point classification) with systolic pulmonary arterial pressure (PAPS) >40 mmHg diagnosed by preoperative right cardiac catheterization or by transthoracic echocardiography. The exclusion criteria were: heart transplant, PH of type 1, 4, 5, according to the Dana Point classification, methemoglobin reductase deficit, incapacity to understand the protocol and sign the consent. Results: The administration of iNO decrease pulmonary hypertension (P < 0,001 compared to room air; P = 0,01 compared to pure oxygen administration). The iNO administration did not improve arterial blood oxygenation. The hyperoxia, decrease the cardiac index even with right ventricular post charge decrease. The increased blood oxygenation content cause systemic vascular vasoconstriction and decrease the peripheral oxygen extraction showed with VO2 linear increase (P < 0,001). Conclusions: The administration of inhaled nitric oxide with a face mask before anaesthesia induction is safe and effective method to reduce pulmonary hypertension. The oxygen and hyperoxia influences the systemic vascular resistance and peripheral oxygen consumption.
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New combined risk score to predict atrial fibrillation after cardiac surgery: COM-AF p. 458
Lucrecia M Burgos, Andreína Gil Ramírez, Leonardo Seoane, Juan F Furmento, Juan P Costabel, Mirta Diez, Daniel Navia
DOI:10.4103/aca.ACA_34_20  
Background and Aims: Atrial fibrillation frequently occurs in the postoperative period of cardiac surgery, associated with an increase in morbidity and mortality. The scores POAF, CHA2DS2-VASc and HATCH demonstrated a validated ability to predict atrial fibrillation after cardiac surgery (AFCS). The objective is to develop and validate a risk score to predict AFCS from the combination of the variables with highest predictive value of POAF, CHA2DS2-VASc and HATCH models. Methods: We conducted a single-center cohort study, performing a retrospective analysis of prospectively collected data. The study included consecutive patients undergoing cardiac surgery in 2010-2016. The primary outcome was the development of new-onset AFCS. The variables of the POAF, CHA2DS2-VASc and HATCH scores were evaluated in a multivariate regression model to determine the predictive impact. Those variables that were independently associated with AFCS were included in the final model. Results: A total of 3113 patients underwent cardiac surgery, of which 21% presented AFCS. The variables included in the new score COM-AF were: age (≥75: 2 points, 65-74: 1 point), heart failure (2 points), female sex (1 point), hypertension (1 point), diabetes (1 point), previous stroke (2 points). For the prediction of AFCS, COM-AF presented an AUC of 0.78 (95% CI 0.76-0.80), the rest of the scores presented lower discrimination ability (P < 0.001): CHA2DS2-VASc AUC 0.76 (95% CI 0.74-0.78), POAF 0.71 (95% CI 0.69-0.73) and HATCH 0.70 (95% CI: 0, 67-0.72). Multivariable analysis demonstrated that COM-AF score was an independent predictor of AFCS: OR 1,91 (IC 95% 1,63-2,23). Conclusion: From the combination of variables with higher predictive value included in the POAF, CHA2DS2-VASc, and HATCH scores, a new risk model system called COM-AF was created to predict AFCS, presenting a greater predictive ability than the original ones. Being necessary future prospective validations.
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Postoperative atrial fibrillation in coronary artery bypass grafting herald poor outcome p. 464
Pulkit Malhotra, Shantanu Pande, Supaksh Mahindru, Ankit Thukral, Ankush Singh Kotwal, Rajan Prasad Gupta, Prabhat Tewari, Surendra Kumar Agarwal
DOI:10.4103/aca.ACA_30_20  
Introduction: Atrial fibrillation in postoperative period is common. Although the event of atrial fibrillation is associated with reduced cardiac output and its consequences and cerebrovascular events, its effect on outcome is not clearly documented. This study is done to evaluate the effect of atrial fibrillation on outcome of the operation. Materials and Methods: This is a retrospective case-control study. A total of 263 patients received coronary artery bypass grafting during this period. The data for demographics, comorbidities, preoperative medications, operative details, and echocardiographic parameters of left ventricular functions were acquired. A total of 24 patients had atrial fibrillation (Group I), while 239 remained in normal sinus rhythm (Group II). The outcome is measured as combined of death and postoperative myocardial infarction (MI). Results: The groups are comparable in demographic, preoperative medications, operative, and left ventricular parameters. Of the 24 (9.12%) patients who had postoperative atrial fibrillation, 11 were discharged on medical management. Nine patients reverted to sinus rhythm at discharge. Atrial fibrillation persisted in 8 patients 1 week after discharge and 3 patients after 1 month. The requirement of intraaortic balloon pump (IABP) was statistically significant in group I (5 in group I vs. 10 in group II, n = 0.001). There were 4 deaths in group 1 and 7 in group 2 (P = 0.002), however, the combined end point was achieved in 4 (16.6%) vs. 22 (9.2%), respectively, P = 0.1. Conclusion: The appearance of atrial fibrillation heralds increased requirement of IABP, MI, and death in patients undergoing coronary artery bypass grafting.
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CASE REPORTS Top

A rare case of cardiac hydatid cyst p. 470
Amrita Guha, Rajeev Ranjan, Pravin Saxena, Yatin Mehta
DOI:10.4103/aca.ACA_42_20  
Hydatid infection of the heart is rare and there is always the lethal hazard of cyst perforation. We present an 18-year-old male from Kashmir valley who was admitted to the emergency department of our hospital with fever and chest pain for the last 4 days. Using echocardiography and cardiac tomography (CT), cardiac Echinococcosis was diagnosed. The results of surgical treatment of cardiac Echinococcosis were better than the conservative strategy. Surgical excision was performed. The patient had an uneventful recovery.
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Left ventricle pseudoaneurysm-recurrence following surgical repair p. 473
Vinit Garg, Dheeraj Arora, Manisha Mishra
DOI:10.4103/aca.ACA_11_20  
Left ventricular (LV) pseudoaneurysm is a rare complication following free wall rupture post transmural myocardial infarction or left ventricular surgery. A lot of imaging modalities like echocardiography, computerised tomography and cardiac magnetic resonance imaging are available to diagnose it. Echocardiography plays a significant role in delineating the cavity, orifice and impact on the surrounding structures. We present a case of LV pseudoaneurysm recurrence following surgical repair.
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Emergent pulmonary thromboembolectomy and atrial septal aneurysmectomy for intracardiac impending paradoxical embolism: An en bloc approach to prevent clot embolism and facilitate repair p. 476
Allan M Klompas, Kevin Greason, Roger L Click, William J Mauermann
DOI:10.4103/aca.ACA_186_20  
Although a patent foramen ovale (PFO) is relatively common, confirmed reports of thrombus entrapped within a PFO are uncommon. Management of impending paradoxical embolism (IPE), also called a thrombus in transit, lacks consensus but includes systemic anticoagulation (e.g., heparin), systemic thrombolysis, or surgical thrombectomy. We present a case of IPE diagnosed with intraoperative transesophageal echocardiography (TEE) as well as a novel en bloc approach to atrial septal aneurysmectomy to minimize embolism and facilitate repair of the interatrial septum. Timely use of intraoperative TEE may aid in diagnosis and help guide the surgical approach to minimize embolic risk with an IPE.
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Partial atrioventricular septal defect associated with wolff-parkinson-white syndrome: Perioperative dysrhythmias during the intracardiac repair p. 479
Anand Mammen, Prabhat Tewari, Pallavi Horo, Shantanu Pande
DOI:10.4103/aca.ACA_49_20  
Wolff-Parkinson-White syndrome (WPW) is rarely seen in association with atrioventricular septal defect. Although paroxysm's of palpitation due to supraventricular tachycardia can occur in these patients, rare, fatal, ventricular dysrhythmias can also occur. Herein, we report the case of a 20-year-old male patient with partial atrioventricular septal defect and WPW syndrome for intracardiac repair, developing intraoperative Torsades de pointes and postoperative cardiac arrest, adding to the difficulty in overall patient management.
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Intracardiac extension of intravenous leiomyomatosis in a patient with vascular pelvic tumor and prior hysterectomy: A case report p. 483
Palanisamy Nithiyanandhan, Puthuvasserry R Suneel, Aspari M Azeez, Vivek V Pillai, Shivanesan Pitchai
DOI:10.4103/aca.ACA_25_20  
Uterine leiomyoma (UL) is the most common benign smooth muscle tumour of the premenopausal women. Rarely it shows malignant behaviour by metastasizing through the pelvic veins into systemic veins, inferior vena cava (IVC), there it is termed as intravenous leiomyomatosis (IVL). IVL may restrict itself within the IVC or it may extend into right heart chambers reaching up to pulmonary arteries. Here we report a case of single staged excision of intracardiac(IC) extension of IVL of a 45 -year -old premenopausal women, who have undergone abdominal hysterectomy five years ago, with the complaints of shortness of breath aggravated on bending forward for the past two years.
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A rare case of double orifice mitral valve: A case report p. 487
Shweta S Kandpal, Anil Kumar, Manisha Mishra, Yatin Mehta
DOI:10.4103/aca.ACA_24_20  
Double-orifice mitral valve is a rare congenital anomaly being associated with other cardiac defects and rarely presented in isolation. Valve function can be preserved for long and it is usually an incidental finding. We present an unusual case of double-orifice mitral valve with mitral regurgitation in a middle-aged man associated with the atrial septal defect, highlighting the role of three-dimensional transesophageal echocardiography.
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Recurrent cardiac myxoma: A case report p. 490
Ravi K Mahavar, Dheeraj Arora, Ajmer Singh, Manisha Mishra
DOI:10.4103/aca.ACA_7_20  
Cardiac myxomas are the most common benign tumors of the heart. They are most commonly found in the left atrium, followed by a right atrium and rarely in the left ventricle. Herein, we report a rare case of left ventricular myxoma in a patient who had twice undergone removal of left atrial myxoma. Complete removal of the tumor through aortotomy, without causing fragmentation led to the uneventful recovery of the patient.
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Massive intrathoracic solitary fibrous tumor of the right hemithorax p. 493
Michael R Boswell, Bradford B Smith, Dennis Wigle, Phillip G Rowse, Mark M Smith
DOI:10.4103/aca.ACA_14_20  
Solitary fibrous tumors of the pleura (SFTP) are rare mesenchymal tumors that arise from visceral or parietal tissue. Surgical resection of massive SFTP can be complicated by airway collapse, vascular compression/hemodynamic instability, and hemorrhage. Patients with SFTP may also present with metabolic derangements secondary to paraneoplastic processes. We present a case of successful removal of massive right-sided SFTP via clamshell sternotomy and discuss the perioperative considerations for which providers should be familiar.
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INTERESTING IMAGES Top

When echocardiography fails, intravascular ultrasound as an alternative for adequate graft patency in hybrid elephant trunk surgery p. 495
Fnu Thida, Tomas Carvajal, Shinya Unai, Sergio E Bustamante
DOI:10.4103/aca.ACA_131_20  
Aortic pathology is a common cardiovascular disease in the US. Transesophageal Echocardiogram is an invaluable imaging modality in the management of aortic pathology in perioperative setting. Intravascular ultrasound can assess coronary obstruction during coronary interventions and can be used in endovascular aneurysm repair. A 54-year-old male underwent Hybrid Elephant Trunk Surgery, for complex open aorta repair. There was functional confirmation graft patency via the femoral arterial line tracing, there was surgical confirmation via visual and physical inspection of graft, but there was lacking anatomical confirmation. Epiaortic ultrasound reassured the graft patency at level of the arch. However, transesophageal echocardiogram was not reassuring for adequate anatomical confirmation of patency. Intravascular ultrasound was used for anatomical confirmation of graft patency and position. This technology provides real time graft patency and is a great tool in open aorta reconstruction surgery.
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Anesthetic management of right brachiocephalic artery aneurysm causing tracheal compression p. 498
Varun Arora, Ritesh Shah, Hashmukh Patel, Vivek Wadhawa
DOI:10.4103/aca.ACA_195_20  
The airway compression poses a challenge for the anesthesiologist in airway management during aneurysm repair surgery.
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Giant aortic root pseudoaneurysm surrounding the left main coronary artery p. 500
Zjuul Segers, Patrick Houthuizen, Albert H M van Straten, Kathinka C Peels, R Arthur Bouwman
DOI:10.4103/aca.ACA_39_20  
A 69-year-old patient underwent an urgent aortic valve replacement because of Streptococcus agalactiae endocarditis of his native aortic valve. Since a rapid progression of the former abscess cavity into an aortic root pseudoaneurysm with increasing paravalvular regurgitation during postoperative follow-up, reoperation was performed. In the preoperative transesophageal echocardiography (TEE) images the pseudoaneurysm completely surrounds the left coronary artery (LCA) without any signs of myocardial ischemia.
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COMMENTARY Top

Transthoracic echocardiography—simulator-based training versus training using human models p. 503
Amarja Sachin Nagre
DOI:10.4103/aca.ACA_102_19  
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LETTERS TO EDITOR Top

Dynamic exercise-induced right ventricular outflow tract obstruction in a patient with hypertrophic cardiomyopathy p. 505
Ali Hosseinsabet
DOI:10.4103/aca.ACA_47_20  
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Patent ductus arteriosus mimicking hypertrophic cardiomyopathy p. 506
Zahra Khajali, Ali Hosseinsabet
DOI:10.4103/aca.ACA_53_20  
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Air entrainment after de-airing p. 507
Pushkar M Desai, Rahul V Shabadi, Suresh Chengode
DOI:10.4103/aca.ACA_68_20  
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Severe hypokalemia precipitated under anesthesia due to conventional amphotericin b in a patient with invasive aspergillosis p. 509
Satyen Parida, Sri Rama Ananta Nagabhushanam Padala, Sireesha Chilakapati, Hemachandren Munuswamy
DOI:10.4103/aca.ACA_77_20  
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VSD in a kyphoscoliotic child: A perilous liaison! p. 510
Souvik Dey, Rohan Magoon, Uma Balasubramaniam, Jasvinder K Kohli, Ramesh Kashav
DOI:10.4103/aca.ACA_37_20  
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Catheter-related superior vena cava thrombosis—how do we face it? p. 512
Meenupriya Arasu, Chitra R Thangaswamy, Deepak Chakravarthy, Lenin B Elakkumanan
DOI:10.4103/aca.ACA_119_20  
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Describing right ventricular dysfunction: Diagnostic accuracy studies and sources of bias p. 514
Chitra Rajeswari Thangaswamy, Rajkumar Sundararaj, Satyen Parida, Ajay Kumar Jha
DOI:10.4103/aca.ACA_104_20  
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In response to describing right ventricular dysfunction: Diagnostic accuracy studies and sources of bias p. 515
Naveen G Singh, Karthik Narendra Kumar, PS Nagaraja, N Manjunatha
DOI:10.4103/aca.ACA_148_20  
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