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H G Fieguth

Publications and source records attributed to H G Fieguth.

At least 19 recordsLinked to original sources
PubMed2004

[Laser-induced thermotherapy of lung metastases and primary lung tumors].

We present laser-induced thermotherapy (LITT) of primary and secondary lung tumors analysing indications and technical concepts. Thirty patients with lung metastases of different primary tumors (n=24) as well as localized lung tumors (n=6) were prospectively treated in 41 sessions using laser-induced thermotherapy (LITT). An MR-compatible puncture system was used with direct puncture technique. The puncture was performed via CT guidance in care vision technique. Eight patients were thermoablated using MR tomographical monitoring, 22 patients using CT monitoring. Local therapy effects, tumor control rate, side effects, complications, and survival were evaluated. In 74% of cases (28/38 lesions) of 24 patients with lung metastases and in all cases of the 6 patients with lung carcinoma a complete local ablation could be achieved. The complication rate (pneumothorax) was 9,8%. One patient with bronchial carcinoma had to be thoracotomized and resected. 93% of the patients are still alive. Percutaneous LITT of lung tumors permits a complete ablation of lung metastases and lung carcinomas with a low complication rate. Indications for the procedure were defined for patients with no more than 5 metastases up to 3 cm in size.

Adult↗
PubMed1999

Ten year survival after heart transplantation: palliative procedure or successful long term treatment?

OBJECTIVE: To investigate the long term outcome and prognostic factors after heart transplantation. SETTING: University hospital. SUBJECTS: 120 heart transplant patients (98 male, 22 female; underlying disease: dilated cardiomyopathy in 69, coronary artery disease in 42, miscellaneous in nine) who had undergone heart transplantation between October 1984 and October 1987. Immunosuppressive treatment was comparable in all patients and rejection episodes were treated in a uniform manner. METHODS: Functional status, quality of life, and potential predictors for long term survival were investigated. RESULTS: Actuarial survival rates were 65% at five years and 48% at 10 years; 58 patients survived > 10 years. The major causes of death were cardiac allograft vasculopathy (39%), acute rejection (18%), infection (11%), and malignancy (11%). Long term survivors had good exercise tolerance assessed by the New York Heart Association classification: 47 (81%) in grade I/II; 11 (19%) in grade III/IV. Echocardiography showed good left ventricular function in 48 patients. On angiography, severe allograft vasculopathy was present in only 16 patients (28%). Renal function was only slightly impaired, with mean (SD) serum creatinine of 148.5 (84.9) micromol/l. Multiple potential predictors of long term survival were analysed but none was found useful. CONCLUSIONS: Heart transplantation represents a valuable form of treatment. Survival for more than 10 years with a good exercise tolerance and acceptable side effects from immunosuppression can be achieved in about 50% of patients.

Adult↗
PubMed1998

[Cerebral hemodynamics during implantation of cardioverter-defibrillator systems].

OBJECTIVE: During ICD-implantation it is necessary to prove the function and to determine the optimal threshold by means of induced ventricular fibrillation (VF). Provoked cardiac arrests cause a circulator stop of the cerebral perfusion. Our aim was to examine the changes of cerebral blood flow velocity (CBFV(MCA)) after induced VF depending on the duration of fibrillation and prior values of CBFV(MCA). PATIENTS AND METHODS: Sixty induced episodes of VF in 9 patients (mean age +/- SD 53.5 +/- 8 years) were examined during ICD-implantation. Beside the standardized anaesthesiological monitoring, transcranial Doppler sonography was used to record the cerebral blood flow velocity in the middle cerebri artery CBFV(MCA). The duration of the fibrillation-period and the range and duration of the CBFV increase during the post defibrillation-period were correlated. Additionally, we examined whether systematic differences existed between the episodes of each patient (time-trend) by means of 5 following episodes of a patient. RESULTS: During all episodes of VF and hyperperfusion was present, that means a time interval showing increased values of CBFV(MCA), compared to the values present before VF. The duration of hyperperfusion depended significantly on the fibrillation time (r = 0.57; p < 0.001). The equation of regression is: hyperperfusion time = 11.1 + 1.22 x fibrillation time. The amount of hyperperfusion, that means the maximal CBFV after defibrillation, increase significantly with CBFV(MCA) before VF (correlation = 0.88; p < 0.001). The equations of regression is hyperperfusion height = 6.11 + 1.22 x CBFV(MCA) before VF. The duration of hyperperfusion is not influenced by the maximal CBFV(MCA) after defibrillation (r = 0.08; p = 0.52). In the examined patients no significant differences in the hyperperfusion time maximal CBFV(MCA) after defibrillation between the episodes were found. CONCLUSION: After induced VF you always have to expect a reactive cerebral hyperperfusion. The amount of increase of CBFV after defibrillation depends on the prior values of CBFV before fibrillation and shows a nearly proportional relation to these. The duration of hyperperfusion shows a linear dependency on VF-times. This may show that we had VF-times, in which the cerebral autoregulation and other cerebral physiological reactions compensate the drop of the CBFV(MCA) during VF in the postfibrillation time. In further studies will be examined if there are similar changes in the cerebral metabolism as in CBFV(MCA).

Adult↗
PubMed1997

Inhibition of atrial fibrillation by pulmonary vein isolation and auricular resection--experimental study in a sheep model.

OBJECTIVE: The MAZE procedure has proven effective for surgically treating atrial fibrillation, but its acceptance has been limited due to the complex dissection pattern. A new simplified operative technique, that comprises two important components of the MAZE procedure, has been evaluated in an established animal model of induced sustained atrial fibrillation. METHODS: In eight sheep, median sternotomy was performed for cardiopulmonary bypass via femoral and bicaval cannuiation. Bipolar atrial and ventricular electrodes (16) were applied for computerized EKG-sampling. Atrial fibrillation was induced during continuous theophylline infusion (0.5 mg/kg/min) by repetitive (10x) biatrial stimulation. Atrial response was monitored and mapped. The operative procedure was accomplished in induced ventricular fibrillation: Right and left atrial appendices were resected and a circumferential transmural incision around all pulmonary veins was performed and closed. After defibrillation, the atria were stimulated again using the above protocol and EKGs were sampled. RESULTS: Sustained atrial fibrillation was inducible in all animals (80 stimulation episodes, median duration 31 s, 6 incessant episodes) prior to dissection. Post resection of the atrial appendices and pulmonary vein isolation, atrial fibrillation was not inducible in any of the eight animals (80 stimulation episodes). A significant interatrial (104 +/- 13 ms) and atrioventricular (208 +/- 19 ms) conduction delay was observed post dissection. CONCLUSION: We conclude that the described procedure is effective for the inhibition of sustained atrial fibrillation in morphologically unaltered atria. The operative approach involves less dissection than the MAZE procedure, which could facilitate its use in concomitant mitral procedures. The clinical significance of the observed AV-Delay has to be evaluated.

Animals↗
PubMed1997

Transvenous defibrillation leads: is there an ideal position of the defibrillation anode?

A potential benefit of two-lead transvenous defibrillation systems is the ability to independently position the defibrillation electrodes, changing the vector field and possibly decreasing the DFT. Using the new two-lead transvenous TVL lead system, we studied whether DFT is influenced by SVC lead position and whether there is an optimal position. TVL leads and Cadence pulse generators were implanted in 24 patients. No intraoperative or perioperative complications were observed. In each patient, the DFTs were determined for three SVC electrode positions, which were tested in random order: the brachiocephalic vein, the mid-RA, and the RA-SVC junction. The mean DFTs in the three positions were not statistically different, nor was any single lead position consistently associated with lower DFTs. However, an optimal electrode position was identified in 83% of patients, and the DFT from the best lead position for each patient was significantly lower than for any one of the electrode positions (P < 0.01). The mean safety margin for the best SVC lead position was approximately 27 J. These results demonstrate the advantage of a two-lead system, as well as the importance of testing multiple SVC lead positions when the patient's condition permits. Both of these factors can decrease the DFT and maximize the defibrillation safety margin. This will become increasingly important as pulse generator capacitors become smaller (as part of the effort to decrease generator size) and the energy output of the generators consequently decreases.

Adult↗
PubMed1997

Long-term follow up of patients with implantable cardioverter-defibrillators and mild, moderate, or severe impairment of left ventricular function.

OBJECTIVE: To determine whether patients with life threatening ventricular tachyarrhythmias, impaired left ventricular function, and severe heart failure will benefit from implantable cardioverter-defibrillator (ICD) treatment. DESIGN: 410 patients were followed up after ICD implant. Left ventricular function was assessed by the New York Heart Association (NYHA) functional class of heart failure: 50 patients (12%) were in NYHA I-II, 151 (37%) in NYHA II, 117 (29%) in NYHA II-III, and 92 (22%) in NYHA III. Epicardial ICD implantation was performed in 209 patients (51%) and 201 patients (49%) received non-thoracotomy ICDs. RESULTS: Perioperatively, 12 patients (3%) died, more often after epicardial ICD implant (11/209 patients, 5%) than after transvenous implant (1/201 patients, < 1%) (P < 0.05). During a mean (SD) follow up of 28 (24) months (range < 1 to 114 months), 90 patients (23%) died: nine (2%) died from sudden arrhythmia; five (1%) also died suddenly but probably not from arrhythmic causes; 55 (14%) died from cardiac causes (congestive heart failure, myocardial reinfarction); 21 (5%) died from non-cardiac causes. The three year, five year, and seven year survival was 92-96% for arrhythmic mortality in NYHA class I, II and III, compared to a three year survival of 94% and a five year and seven year survival of 84% for patients in NYHA class II-III. 338 patients (82%) received ICD shocks (21 (SD 43) shocks per patient); patients in NYHA class II (83%), class II-III (84%), and class III (90%) received ICD discharges more often than those in class I-II (64%) (P < 0.05). The mean (SD) time interval between ICD implant and the first ICD shock was shorter in NYHA class II (16 (17) months), class II-III (19 (27) months), and class III (16 (19) months) than in class 0-I (22 (24) months) (P < 0.05). CONCLUSIONS: Patients with mild, moderate, and severe left ventricular dysfunction benefit from ICD treatment and these patients survive for a considerable time after the first shock. Survival is influenced by the degree of left ventricular dysfunction; aggressive treatment of heart failure is necessary as well as ICD therapy.

Adolescent↗
PubMed1997

Contractile responses to histamine, serotonin, and angiotensin II are impaired by 17 beta-estradiol in human internal mammary arteries in vitro.

There is accumulating evidence that estrogen replacement therapy protects against the development of coronary atherosclerosis and myocardial infarction in postmenopausal women. The mechanism of this protective effect is uncertain. The purpose of the present study was to determine whether 17 beta-estradiol acutely modifies vascular smooth muscle contractile responses to various agonists in human arteries in vitro. Human mammary artery rings were obtained during aortocoronary bypass operations. Rings were suspended in organ baths for isometric tension measurements. Concentration response curves induced by serotonin (0.01-30 mumol/l), histamine (0.01-300 mumol/l), and angiotensin II (0.1-100 nmol/l) were generated after pre-incubation for 30 min with either 17 beta-estradiol (3 mumol/l) or solvent (0.2% ethanol). The presence of 17 beta-estradiol significantly reduced the maximal contractile effects induced by histamine, serotonin, and angiotensin II, but not by 80 mmol/l potassium chloride. It is concluded that short-term incubation with 17 beta-estradiol reduces the maximal contractile responses to serotonin, histamine, and angiotensin II. These modulating effects of estrogen on vascular tone may contribute to the proposed beneficial role of estrogen replacement therapy on the incidence of myocardial infarction in postmenopausal women.

Aged↗
PubMed1997

Age dependent efficacy of implantable cardioverter-defibrillator treatment: observations in 450 patients over an 11 year period.

OBJECTIVE: To determine whether implantable cardioverter-defibrillator (ICD) treatment is beneficial in elderly patients with life threatening ventricular tachyarrhythmias. DESIGN: Since January 1984, ICDs were implanted in 450 patients to evaluate surgical risk, complications and mean survival in relation to patient age; 81 patients (18%) were < or = 50 years at the time of ICD implant, 254 patients (56%) were between 51 and 64 years, and the remaining 115 (26%) were > or = 65 years. Epicardial lead systems were implanted in 209 patients (46%), while transvenous lead systems were implanted in 241 (54%). RESULTS: 13 patients (3%) died perioperatively, more often after epicardial (11 of 209 patients, 5%) than after transvenous ICD implantation (one of 241 patients, < 1%) (p < 0.05). During a mean (SD) follow up of 28 (24) months (range < 1 to 114 months), 90 patients (20%) died. Of these, nine (2%) died from sudden arrhythmic death; five (1%) died suddenly, probably as a result of non-arrhythmic causes; 55 (12%) died from other cardiac causes (congestive heart failure, myocardial infarction); and 21 (5%) died from non-cardiac causes. The three, five, and seven year survival for arrhythmic mortality was 95% in patients < or = 50 years compared with a three year survival of 93% and a five and seven year survival of 91% in patients of 51 to 64 years, and a three, five, and seven year survival of 99% in patients > or = 65 years. 362 patients (80%) received ICD discharges (21 (43) shocks per patient), with a similar incidence among all three patient groups (< or = 50 years, 80%; 51 to 64 years, 81%; > or = 65 years, 79%). The time interval between ICD implant and the first ICD treatment was shorter in patients > or = 65 years (8 (8) months) than in patients between 51 and 64 years (11 (14) months) or < or = 50 years (11 (11) months) (p < 0.05). Survival time following first appropriate shock was 30 (24) months in patients < or = 50 years, 30 (26) months in patients of 51 to 64 years, and 19 (20) months in patients > or = 65 years. CONCLUSIONS: Elderly patients benefit from ICD treatment, and survive for a considerable time after the first treatment. Therefore, elderly patients should be considered candidates for ICD implantation if life threatening ventricular tachy-arrhythmias are present.

Adolescent↗
PubMed1996

Arrhythmogenic mortality in heart-transplant candidates.

Sudden cardiac death represents a major problem in patients awaiting heart transplantation (HTx). A retrospective analysis of 1019 patients accepted for HTx revealed a high actuarial risk for sudden death accounting to 14% after 1 year and 20% after 2 years waiting time. Underlying disease and hemodynamic characteristics had no predictive value. The use of implantable cardioverter/defibrillator therapy is discussed.

Adult↗
PubMed1996

Valve reconstruction or replacement for long-term biopsy-induced tricuspid regurgitation following heart transplantation.

Tricuspid regurgitation following heart transplantation can become a severe problem in a subset of patients, where medical therapy fails. Operative findings are described and results of subsequent results with surgical intervention including repair and replacement are analysed. Although follow-up is short, tricuspid replacement seems superior to reconstruction following heart transplantation. Best results are obtained, if replacement is performed, before right ventricular function deteriorates.

Adult↗
PubMed1996

First experience with a new nonthoracotomy defibrillation lead system.

The clinical efficacy and safety of a new nonthoracotomy defibrillation lead system (TVL lead system, Ventritex, inc., Sunnyvale, Calif.) was studied in patients with ventricular tachycardia or fibrillation. Implantation of the TVL lead system and a Cadence pulse generator (Ventritex, Inc.) was attempted in 27 patients. A subcutaneous patch lead was added if required to achieve adequate defibrillation energy. Patients were monitored for an average of 6 +/- 4 months (range 1 week to 14 months). Implantation was successful in 26 patients (96%). Twenty-three of those patients (88%) were implanted in a lead-alone configuration; the remaining three (12%) required a subcutaneous patch lead. The mean defibrillation threshold was 401 +/- 120 V (12 +/- 7 J) at implantation, 467 +/- 134 V (15 +/- 8 J) at predischarge testing, and 452 +/- 151 V (14 +/- 9 J) at 4-month follow-up. The mean defibrillation threshold at 4 months was not significantly different from that at implant. No deaths, sensing anomalies, infections, lead fractures, or lead dislodgments occurred. One patient required addition of a subcutaneous patch 4 months after device implantation because of an elevated defibrillation threshold. Eight patients (31%) experienced 545 spontaneous arrhythmic episodes, and all episodes were successfully terminated by the device. In conclusion, the TVL lead system combined with Cadence tiered-therapy defibrillator has a high success rate and low complication rate, and it can be recommended for treatment of patients with life-threatening ventricular tachyarrhythmias.

Adult↗
PubMed1996

Graft coronary vasculopathy in cardiac transplantation--evaluation of risk factors by multivariate analysis.

The development of coronary vasculopathy is the main determinant of long-term survival in cardiac transplantation. The identification of risk factors, therefore, seems necessary in order to identify possible treatment strategies. Ninety-five out of 397 patients, undergoing orthotopic cardiac transplantation from 10/1985 to 10/1992 were evaluated retrospectively on the basis of perioperative and postoperative variables including age, sex, diagnosis, previous operations, renal function, cholesterol levels, dosage of immunosuppressive drugs (cyclosporin A, azathioprine, steroids), incidence of rejection, treatment with calcium channel blockers at 3, 6, 12, and 18 months postoperatively. Coronary vasculopathy was assessed by annual angiography at 1 and 2 years postoperatively. After univariate analysis, data were evaluated by stepwise multiple logistic regression analysis. Coronary vasculopathy was assessed in 15 patients at 1 (16%), and in 23 patients (24%) at 2, years. On multivariate analysis, previous operations and the incidence of rejections were identified as significant risk factors (P < 0.05), whereas the underlying diagnosis had borderline significance (P = 0.058) for the development of graft coronary vasculopathy. In contrast, all other variables were not significant in our subset of patients investigated. We therefore conclude that the development of coronary vasculopathy in cardiac transplant patients mainly depends on the rejection process itself, aside from patient-dependent factors. Therapeutic measures, such as the administration of calcium channel blockers and regulation of lipid disorders, may therefore only reduce the progress of native atherosclerotic disease in the posttransplant setting.

Adult↗
PubMed1996

[Lung transplantation in obstructive diseases].

The transplantation of the lung is a therapeutical option in the treatment of patients with terminal lung emphysema. In the presence of limiting prognostic factors, like severe obstruction without massive air trapping and pulmonary hypertension, the results are superior to lung volume reduction. Guidelines for indications, perioperative course and functional development are discussed. Bilateral transplantation provides early rehabilitation due to excellent functional recovery of the lungs.

Adult↗
PubMed1995

Cardioverter-defibrillator implantation in the catheterization laboratory: initial experiences in 48 patients.

The exponential increase in cardioverter-defibrillator implantations has resulted in a need for safe implantations that do not require long waiting periods. We report intraoperative and follow-up results in 48 patients with ventricular tachyarrhythmias who underwent cardioverter-defibrillator implantation in the catheterization laboratory. Twenty-six (54%) patients had their first cardioverter-defibrillator implant (group 1), and 22 (46%) patients underwent pulse-generator replacement (group 2). In all patients, cardioverter-defibrillator implant or pulse-generator replacement was performed with the patient under general anesthesia. In 25 (96%) of 26 patients in group 1, cardioverter-defibrillator implantation was possible with a mean defibrillation threshold of 13 +/- 8 J. One patient had a defibrillation threshold of > 25 J, and therefore cardioverter-defibrillator implant was not achieved. This patient underwent epicardial device implantation 1 day later. Another patient in group 1 had vessel rupture (vena subclavia) intraoperatively. During a mean follow-up of 2 +/- 1 months, two patients died from congestive heart failure 2 and 4 months after device implantation. An infection occurred in one patient in group 2, 3 months after generator replacement. In conclusion, these data show that in the majority of patients cardioverter-defibrillator implantation in the catheterization laboratory is safe and has a low complication rate and therefore can generally be recommended.

Adolescent↗
PubMed1995

Retransplantation of the lung. A single center experience.

While lung retransplantation remains the only therapeutic option in early or late graft failure, its value is viewed controversially. Of 134 patients undergoing pulmonary transplantation in our institution, 13 patients underwent 14 redos following heart-lung transplantation (n = 3), bilateral lung transplantation (n = 5), and unilateral lung transplantation (n = 5). Indications for retransplantation were acute graft failure (n = 2), persistent graft dysfunction (n = 3), airway complications (n = 2), and chronic graft failure (n = 7). Prior to retransplantation, six patients had been in stable respiratory failure, the remaining eight patients were on mechanical ventilation or extracorporeal membrane oxygenation (n = 2). Four patients died, 19, 43, 142, and 683 days following retransplantation due to pneumonia (n = 2), early onset of obliterative bronchiolitis (n = 1), and pulmonary embolism (n = 1). There was no correlation between mortality and intubation prior to re-operating, timing of operation, donor cytomegalovirus (CMV) status, or type of operation. Postoperative need for intensive care treatment was prolonged in patients undergoing acute retransplantation (P < 0.05). Actuarial 1- and 2-year survival rates were calculated at 77 and 64%. This was slightly lower than in the overall population following primary isolated lung transplantation (83 and 80%). Actuarial freedom from obliterative bronchiolitis (stage 3) at 1 and 2 years was calculated at 88 and 27% (primary grafts: 88% vs 72%; P < 0.05). Retransplantation is a realistic option in early and late graft failure after lung transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1995

Epicardial and nonthoracotomy defibrillation lead systems combined with a cardioverter defibrillator.

The intraoperative and long-term results were reviewed in 67 patients who underwent implantation of the Ventritex Cadence defibrillator with either epicardial patch (EPI, 25 patients) or nonthoracotomy CPI Endotak (ENDO, 42 patients) defibrillation lead systems. In the ENDO group, 35 patients (83%) had a defibrillation threshold (DFT) of < or = 20 joules and did not require a subcutaneous patch. Intraoperatively, the DFT was 13 +/- 9 joules (mean +/- SD) for EPI and 15 +/- 8 joules for ENDO (P = NS). There was no perioperative death in either group. During a mean follow-up of 12 +/- 8 months, there was no sudden death, and four patients died from congestive heart failure (3 EPI, 1 ENDO). During follow-up, 875 spontaneous arrhythmia episodes (AE) occurred in 15 of 25 EPI patients (60%), versus 652 in 28 of 42 ENDO patients (67%; P = NS). Ventricular tachycardia at a rate > or = 222 beats/min or ventricular fibrillation represented 167 AE for EPI (19%) and 182 AE for ENDO (28%), and was terminated by the first shock in 76% and 75% of attempts, respectively. Ventricular tachycardia at a rate < 222 beats/min represented a total of 1,178 AE and antitachycardia pacing was successful in 660 of 708 AE (93%) with EPI and 414 of 470 AE (88%) with ENDO lead systems (P = NS). Therefore, a nonthoracotomy approach using the Cadence V-100 is safe and effective and has clinical results that are not significantly different from epicardial defibrillation lead systems.

Cardiac Pacing, Artificial↗
PubMed1995

Implantation and follow-up of a third-generation cardioverter defibrillator: comparison of epicardial and nonthoracotomy defibrillation lead system.

OBJECTIVE: The intraoperative and follow-up results were compared in 67 patients with ventricular tachyarrhythmias who underwent implantation of the Ventritex Cadence defibrillator with either epicardial patch (EPI, 25 patients) or nonthoracotomy CPI Endotak (ENDO, 42 patients) defibrillation lead systems. RESULTS: There was no significant difference between groups in age, sex, structural heart disease, ejection fraction, arrhythmia history, or drug therapy. Successful implantation was accomplished in all patients using either lead system. In the ENDO group, 35 patients (83%) had a defibrillation threshold < or = 550 V and did not require a subcutaneous patch. Intraoperatively, the defibrillation threshold was 453 +/- 139 V (13 +/- 9 J) for EPI and 490 +/- 113 V (15 +/- 8 J) for ENDO (P = NS). There were no perioperative deaths in either group. At predischarge testing, the defibrillation threshold was 445 +/- 183 V (14 +/- 12 J) for EPI and 439 +/- 133 V (13 +/- 7 J) for ENDO (P = NS). During a mean follow-up of 16 +/- 8 months, there were no sudden deaths, and four patients died from congestive heart failure (3 EPI, 1 ENDO). During follow-up, 916 spontaneous arrhythmia episodes occurred in 16 of 25 EPI patients (64%) and 967 episodes occurred in 31 of 42 ENDO patients (74%) (P = NS). The number of episodes detected as ventricular fibrillation were 192 for EPI (21%) and 232 for ENDO (24%), with first shock success in 76% and 75%, respectively; all episodes were successfully terminated by the device. In the remaining episodes detected as ventricular tachycardia, antitachycardia pacing was attempted and was successful in 672 of 724 episodes (93%) with EPI and 666 of 735 episodes (91%) with ENDO lead systems (P = NS). Acceleration of ventricular tachycardia with antitachycardia pacing occurred in 21 episodes (3%) with EPI and in 37 episodes (5%) with ENDO leads (P = NS). CONCLUSIONS: A nonthoracotomy approach using the third generation cardioverter defibrillator Cadence V-100 is safe and effective and has clinical results that are not significantly different from epicardial defibrillation lead systems.

Adolescent↗