Apostolos Zacharoulis

Γενικό Νοσοκομείο Ασκληπιείο Βούλας, Βούλα, Attica, Greece

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Publications (26)76.1 Total impact

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    ABSTRACT: Invasive hemodynamic monitoring with Swan-Ganz catheterization to guide treatment decisions in heart failure may be hazardous and may lack prognostic value. We assessed the clinical utility of B-type natriuretic peptide (BNP) in estimating left ventricular filling pressures in patients with inconclusive tissue Doppler indexes. In this study, 50 patients with systolic heart failure and an early transmitral velocity to early diastolic mitral annular velocity ratio (E/Ea) between 8 and 15 were studied. Among them, 25 had been admitted for acutely decompensated heart failure (group A) and the remainder were clinically stable outpatients (group B). All patients underwent simultaneous invasive pulmonary capillary wedge pressure (PCWP) determination, BNP measurement, and echocardiography. In group A, BNP correlated with PCWP (r = 0.803, P < 0.001), deceleration time (DT, r = -0.602, p = 0.001), and end-systolic wall stress (SWS, r = 0.565, P = 0.003). In multivariate analysis, BNP was the only parameter independently associated with PCWP (P = 0.023). In group B, no correlation was found between BNP and PCWP or SWS, while DT correlated significantly with both PCWP (r = -0.817, P < 0.001) and BNP (r = -0.8, P < 0.001). We conclude that BNP may be a useful noninvasive tool for the assessment of left ventricular filling pressures in patients with acutely decompensated heart failure and inconclusive tissue Doppler indexes.
    Heart and Vessels 05/2008; 23(3):181-6. DOI:10.1007/s00380-007-1022-9 · 2.11 Impact Factor
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    ABSTRACT: Osteoprotegerin (OPG) and receptor activator of nuclear factor kappa-B ligand (RANKL) are critical regulators of bone remodeling and RANKL/RANK signaling could also play an important role in the remodeling process of several tissues, such as myocardium. Therefore, we investigated whether the serum concentrations of OPG and RANKL correlate with the serum levels of metalloproteinase-1 (MMP-1), MMP-9 and tissue inhibitors of MMP-1 (TIMP-1), which are known regulators of myocardial healing in acute myocardial infarction (AMI) patients. We analyzed blood samples from 51 consecutively hospitalized men with AMI, 12 men with established ischemic heart failure (New York Heart Association category II, NYHA-II) and 12 healthy men age-matched to the NYHA-II patients. Serum levels of MMP-1, MMP-9, TIMP-1, OPG and RANKL were quantified using commercially available ELISA kits. AMI patients were sampled 4 days and 6 months after MI. Our data revealed increased serum levels of OPG, RANKL, MMP-1 and TIMP-1 levels and significant correlations between increased RANKL levels and MMP-1 and TIMP-1 serum levels 6 months after MI. In addition, the ratio OPG/RANKL was very low 6 months after MI, suggesting that the nuclear factor kappa-B signaling is possibly more active 6 months post-MI than it is on day 4 post-MI. Our data suggest that OPG, RANKL, MMP-1 and TIMP-1 serum levels can be potential mediators of myocardial healing after MI. However, further large studies are needed to confirm the utility of OPG and RANKL as markers of healing after ST elevation in MI.
    Clinical Chemistry and Laboratory Medicine 02/2008; 46(4):510-6. DOI:10.1515/CCLM.2008.091 · 2.96 Impact Factor
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    ABSTRACT: To evaluate coronary flow reserve (CFR) changes following stent implantation in the descending thoracic aorta (DTA) of a porcine model. Six pigs (3 males; 40 to 44 kg) were anesthetized and kept on mechanical ventilation. A 6-F guiding right Judkins catheter was advanced under fluoroscopy to the right coronary artery, and a pressure wire with a temperature sensor was placed within the vessel lumen at a distance of 4 cm from the ostium. CFR was estimated by the thermodilution method before and after maximal coronary vasodilation with 20 mg of intracoronary papaverine. Aortography was also performed to measure aortic diameter. Subsequently, a self-expanding vascular stent was deployed into the DTA just below the left subclavian artery (LSA), and CFR was measured again. All animals were maintained for 3 weeks; at the end of this period, a further CFR was calculated using the same procedure. The mean aortic diameter below the LSA was 12.15+/-0.15 mm. Following stent deployment, the mean aortic diameter measured at the stented segment was 12.58+/-0.11 (p=0.001 versus baseline). The mean CFR value was 4.70+/-2.00 before stent implantation, 2.68+/-0.86 immediately after, and 4.05+/-1.15 at 3 weeks after stenting. Accordingly, CFR values were significantly depressed immediately after stent placement compared with baseline (p=0.027). However, CFR values obtained 3 weeks following stent deployment were similar to the initial values (p=0.59). Stent deployment in the normal swine DTA produces a significant immediate decrease in CFR, which is attenuated 3 weeks later. The clinical impact of CFR changes following DTA endografting remain to be elucidated.
    Journal of Endovascular Therapy 09/2007; 14(4):544-50. DOI:10.1583/1545-1550(2007)14[544:CICFRF]2.0.CO;2 · 3.59 Impact Factor
  • International journal of cardiology 07/2007; 118(3):e106-7. DOI:10.1016/j.ijcard.2007.01.064 · 6.18 Impact Factor
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    ABSTRACT: The non-invasive assessment of coronary artery disease (CAD) in patients with left bundle branch block (LBBB) is troublesome. In this study, we investigated the diagnostic accuracy of myocardial contrast echocardiography (MCE) with adenosine to detect CAD in asymptomatic patients with LBBB, and we compared it with single photon emission computed tomography (SPECT) with adenosine. Forty-seven patients with LBBB, and no previously documented CAD, initially underwent SPECT imaging and 1-3 days later MCE. Coronary arteriography was performed within 1 week from the latter procedure. The overall sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, and kappa index of concordance of SPECT were 73%, 72%, 44%, 90%, 72%, and 0.37+/-0.13, respectively, whereas those of MCE were 91%, 92%, 77%, 97%, 92%, and 0.77+/-0.1, respectively (p<0.05 for all comparisons). Significant CAD was present in 11 patients (23%). Left anterior descending coronary artery was involved in 8 patients, left circumflex artery in 2 patients, and right coronary artery in 4 patients. Concerning the left anterior descending artery disease detection, SPECT had a sensitivity of 75%, a specificity of 79%, a positive predictive value of 43%, a negative predictive value of 94%, and a diagnostic accuracy of 79%. The respective values of MCE were 100% for all of the above variables. MCE with adenosine has a higher global diagnostic accuracy compared to SPECT for the detection of CAD in patients with LBBB, mainly due to the poor specificity of SPECT concerning perfusion defects detection in the left anterior descending artery territory.
    International journal of cardiology 10/2006; 112(3):334-40. DOI:10.1016/j.ijcard.2005.10.004 · 6.18 Impact Factor
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    ABSTRACT: Previous studies have shown beneficial effects of functional electrical stimulation (FES) on muscle performance and exercise capacity of patients with chronic heart failure. This study evaluates the impact of FES on endothelial function and peripheral markers of immune activation in patients with moderate to severe heart failure. Twenty-four patients with a left ventricular ejection fraction of less than 40% and New York Heart Association class II-III symptoms, undergoing optimized drug therapy, were randomly assigned (2 : 1) to a 6-week training programme of FES (n=16) or served as controls (n=8). Endothelial function was assessed by Doppler flow-mediated dilatation (FMD) of the brachial artery before and after the training programme. Peripheral pro-inflammatory/anti-inflammatory markers such as tumour necrosis factor (TNF)-alpha, interleukin (IL)-6, soluble intercellular adhesion molecule (sICAM)-1, soluble vascular cell adhesion molecule (sVCAM)-1 and IL-10 were also measured before and after training. A significant improvement on the 6-min walk test (7.5+/-3.3%), Minnesota Living Score (18.2+/-8.6%) and FMD (38.5+/-15.1%) was observed only in the FES-treated group. FES also causes a significant reduction of TNF-alpha (-11.5+/-8.9%), sICAM-1 (-13.1+/-9.8%), and sVCAM-1 (-10.6+/-6.6%), as well as a respective increase in the ratio IL-10/TNF-alpha (37.1+/-29.4%). In the FES group, the percentage improvement in the Minnesota Living Score was significantly correlated with respective changes in circulating TNF-alpha (r=0.624, P<0.01), sVCAM-1 (r=0.665, P<0.001) and the ratio IL-10/TNF-alpha (r=-0.641, P<0.01). FES is an exercise training programme that improves endothelial function in patients with chronic heart failure, and also has anti-inflammatory effects.
    European Journal of Cardiovascular Prevention and Rehabilitation 08/2006; 13(4):592-7. DOI:10.1097/01.hjr.0000219111.02544.ff · 3.69 Impact Factor
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    ABSTRACT: Recent studies have shown that the odds ratio for high-sensitivity C-reactive protein (CRP) in predicting a coronary events in healthy subjects is 1.4, a value substantially less than previously reported. It is unclear whether this extends to acute coronary syndrome patients or if CRP would predict long-term events in this population. We evaluated the predictive value of CRP in patients with non-ST segment elevation myocardial infarction (NSTEMI) as their first manifestation of coronary artery disease and compared it with that of left ventricle diastolic function. Serum CRP concentration measurement and left ventricle diastolic function evaluation were performed in 51 consecutive patients with NSTEMI 48 hours, 3 months, and 6 months after infarction. Patients were followed for 1 year and events comprising the endpoints of death, new myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting were reported. Thirty of 51 patients developed the endpoints. Mean CRP concentration in patients who developed any endpoint and those who did not was similar at 48 hours, 3 months, and 6 months. A strong correlation between the presence of impaired relaxation 6 months after the infarction and development of the combined endpoints was noted (P < 0.001). CRP has limited value in predicting future cardiovascular events in subjects with NSTEMI. Other biomarkers or a combination of other biomarkers may be needed to identify patients at high risk. Evaluation of diastolic left ventricular function not during the acute phase but 6 months later could predict adverse outcome in our series.
    The American Journal of the Medical Sciences 04/2006; 331(3):113-8. DOI:10.1097/00000441-200603000-00001 · 1.52 Impact Factor
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    ABSTRACT: To assess by tissue Doppler echocardiography (TDE), the tissue velocities, both at rest and after exercise stress testing, in subjects with mitral valve prolapse (MVP) and those with thick mitral valve (TMV). Twenty individuals with typical MVP, 30 with TMV, and 30 healthy controls were enrolled. TDE was performed at the basal-inferior wall and the parameters evaluated were the S, Em, and Am velocities, as well as the Em/Am ratio. The mean S-wave at rest was higher in subjects with MVP compared to that of the TMV (P < 0.01) and the control groups (P = 0.00005), whereas after exercise it was higher in the control group compared to either MVP (P = 0.013) or TMV group (P = 0.00002). The mean Em wave at rest was higher in the control individuals both at rest (P = 0.007 compared with MVP group and P = 0.013 compared with TMV group), and after exercise (P = 0.0002 and 0.0009, respectively). The Am wave in the MVP group was higher compared with TMV and control subjects at rest (P = 0.022 and 0.00001, respectively) but it was not after exercise (P = ns for both comparisons). The Em/Am ratio of the control group at rest was higher than that of the MVP (P = 0.0000) and TMV (P = 0.00028) groups. However, after exercise, it was higher only when compared with the MVP group (P = 0.016). Subjects with MVP and those with TMV exhibit a less effective contractile response to exercise compared to healthy individuals. Some degree of diastolic dysfunction, particularly after exercise, was also detected in the individuals with MVP.
    Echocardiography 02/2006; 23(2):114-9. DOI:10.1111/j.1540-8175.2006.00184.x · 1.25 Impact Factor
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    ABSTRACT: Clinically apparent pulmonary embolism is a rare complication of permanent transvenous pacing catheters. Here we report an unusual case of a 71-year-old man who developed massive pulmonary embolism 12 hours after a permanent transvenous pacemaker implantation in the absence of any patient-related predisposing factor. Transesophageal echocardiography showed a large thrombus within the right atrium closely attached to the pacemaker lead. Anticoagulation with heparin, followed by warfarin therapy, led to a complete resolution of the thrombus. (ECHOCARDIOGRAPHY, Volume 21, July 2004)
    Echocardiography 06/2004; 21(5):429 - 432. DOI:10.1111/j.0742-2822.2004.03078.x · 1.25 Impact Factor
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    ABSTRACT: Restoration of blood flow in the infarct-related artery and subsequent myocardial reperfusion are major goals of both thrombolysis and primary percutaneous interventions. Whether percutaneous transluminal coronary angioplasty (PTCA) with immediate stenting (primary stenting) produces reperfusion more rapidly than primary PTCA alone is uncertain. This study determines whether primary stenting produces earlier myocardial reperfusion than primary PTCA alone in patients with acute ST segment elevation myocardial infarction using troponin T release kinetics. Primary stenting was performed on 60 patients and primary PTCA alone on 44 patients with typical ischemic chest pain and greater than 1.5 MV ST segment elevation in more than 2 contiguous electrocardiographic leads. Serum troponin T concentrations were measured before and after intervention; every 6 hours for 24 hours; then at 36, 48 and 72 hours. The mean time from onset of chest pain to peak serum troponin T concentration was 7.8 +/- 2.7 hours after primary stenting and 14.5 +/- 4.4 hours after primary PTCA (p < 0.0005). The mean peak serum troponin T concentration was 9.8 +/- 6.3 ng/dL after primary stenting and 13.6 +/-6.4 ng/dL after primary PTCA (p < 0.012). A significant univariate association with time to peak concentration of serum troponin T was identified for primary stenting (p < 0.0005), time from onset of chest pain to intervention (p < 0.04), and diabetes mellitus (p < 0.01). The only significant univariate marker associated with peak concentration of serum troponin T was primary stenting (p < 0.012). Multivariate analysis indicated that primary stenting (p < 0.0005), time from onset of chest pain to intervention (p < 0.048), and diabetes mellitus (p < 0.022) significantly influenced time to peak serum concentration or troponin T. Primary stenting produces earlier myocardial reperfusion than primary PTCA in patients with acute ST segment elevation myocardial infarction.
    Angiology 03/2003; 54(2):195-203. DOI:10.1177/000331970305400209 · 2.97 Impact Factor
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    ABSTRACT: The purpose of this study was to determine the relation of troponin T release kinetics to long-term clinical outcome in patients with an acute ST segment elevation myocardial infarction treated with a primary percutaneous intervention. One hundred and four patients with typical ischemic chest pain and > 1.5 mm ST segment elevation in > 2 contiguous leads underwent primary stenting (n = 60) or primary percutaneous transluminal coronary angioplasty (n = 44). Serum troponin T concentrations were obtained prior to and serially postintervention for 72 hr. Mean time to peak serum troponin T concentration was significantly longer in patients with cardiac death (P = 0.02), reinfarction (P = 0.007), target lesion reintervention (P = 0.03), and the composite of these events (13.2 +/- 5.3 vs. 9.3 +/- 4.0 hr; P < 0.0005). Multivariate analysis identified age, Killip class > 2, and time to peak serum troponin T concentration as independent predictors of long-term cardiac event-free survival. Thus, time to peak serum troponin T concentration independently predicts long-term cardiac event-free survival in patients with acute ST segment elevation myocardial infarction treated with a primary percutaneous intervention.
    Catheterization and Cardiovascular Interventions 07/2002; 56(3):312-9. DOI:10.1002/ccd.10229 · 2.40 Impact Factor
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    ABSTRACT: A 54-year-old man developed unstable angina pectoris and was found to have both an anomalous left coronary artery, which arose from the right sinus of Valsalva and followed an intramyocardial (septal) course, and severe atherosclerotic stenosis of the mid-right coronary artery. Stress perfusion imaging showed ischemia in the distribution of the right coronary artery, leading to successful percutaneous transluminal balloon angioplasty of the right coronary artery rather than surgical correction of the congenital anomaly.
    The American Journal of the Medical Sciences 05/2002; 323(4):223-6. DOI:10.1097/00000441-200204000-00010 · 1.52 Impact Factor
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    ABSTRACT: Fungal infections involving the pacemaker pocket after pacemaker implantation procedure are extremely rare. This report describes the case of a 53-year-old woman with pacemaker pocket infection due to acremonium species. The authors emphasize that this patient did not have any predisposing factors to fungal infections.
    Pacing and Clinical Electrophysiology 04/2002; 25(3):378-9. DOI:10.1046/j.1460-9592.2002.00378.x · 1.25 Impact Factor
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    ABSTRACT: A 19-year-old male presented with fever, substernal pain, dyspnea, and distended neck veins. Diagnostic investigations, such as echocardiography and magnetic resonance imaging, provided evidence of a large mass within the pericardial sac, attached by a broad base to the parietal pericardium and lying along the right ventricular free wall. A partial pericardiectomy was performed to relieve the patient's symptoms, and histologic examination of a biopsy specimen showed features of a malignant, spindle cell, mesenchymal neoplasm. The patient underwent surgical treatment during which the tumor was found to infiltrate the anterior surface of the right ventricle. Histologically, the tumor was identified as a high-grade fibrosarcoma, and additional chemotherapy was given.
    Clinical Cardiology 02/2002; 25(2):83-5. DOI:10.1002/clc.4950250210 · 2.23 Impact Factor
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    ABSTRACT: Aneurysm of the sinus of Valsalva (ASV) is a rare cardiac disease that may be acquired or congenital. It is usually an asymptomatic condition; however, when it ruptures, symptoms appear and the condition deteriorates rapidly. Atrial septal aneurysm (ASA) is a localized "saccular" deformity of the interatrial septum that is associated with cerebrovascular events of embolic origin. We will report on a case of a 69-year-old woman who was referred to our department because of congestive heart failure. Echocardiographic evaluation, both transthoracic and transesophageal, disclosed a ruptured aneurysm of the right sinus of Valsalva into the right atrium (RA), which was associated with an aneurysm of the atrial septum.
    Echocardiography 12/2000; 17(8):733-6. DOI:10.1111/j.1540-8175.2000.tb01228.x · 1.25 Impact Factor
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    ABSTRACT: Massive pulmonary embolism (PE) constitutes the most unexpected cause of death in necropsy. Consequently, prompt diagnosis and treatment is considered imperative. This article reports the case of a 37-year-old man who presented with cardiogenic shock due to PE as detected with bedside echocardiography in the emergency department. The authors wish to emphasize the usefulness of emergency bedside echo-Doppler for a prompt diagnosis and treatment of this life threatening condition.
    Angiology 12/2000; 51(12):1021-1025. DOI:10.1177/000331970005101207 · 2.37 Impact Factor
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    ABSTRACT: We present the case of a 35-year-old man with a history of beta-thalassemia complicated with heart failure who was admitted to our department because of right arm painful swelling. A transthoracic echo-Doppler study revealed a mass within the right jugular vein (RJV) lumen and absence of flow within the right subclavian vein (RSV). Subsequently, color tissue Doppler echocardiography clearly demonstrated the intraluminal mass by means of its different color hues as compared with the surrounding vessel wall, further enforcing the suspicion of upper extremity vein thrombosis (UEVT). It is emphasized that tissue Doppler echocardiography, a safe and reproducible method, can contribute to the diagnosis of UEVT.
    Echocardiography 12/2000; 17(8):721-3. DOI:10.1111/j.1540-8175.2000.tb01225.x · 1.25 Impact Factor
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    ABSTRACT: Congenital coronary artery fistulas (CAFs) constitute an unusual cardiovascular anomaly. The aneurysmal appearance of CAFs is not uncommon and depends on the shunt size. However, few cases of ectatic coronary arteries (type III according to Markis et al. classification-diffuse ectasia in one vessel) supplying the fistulas have been reported. Below, we report the case of a 65-year-old woman, who referred to our department because of worsening exertional dyspnea. Echocardiographic evaluation, both transthoracic and transesophageal, performed after admission disclosed a giant tortuous ectatic right coronary artery with a fistulous connection to the coronary sinus. The presence of the CAF was confirmed by cardiac catheterization. In addition, we discuss the pathophysiology of the above congenital anomaly, as well as its management.
    Echocardiography 11/1999; 16(7):663-666. DOI:10.1111/j.1540-8175.1999.tb00121.x · 1.25 Impact Factor
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    ABSTRACT: Fifteen hypertensive patients (13 men) with left ventricular hypertrophy, mean age 69 6 5 years, having complete heart block and paced in the DDD mode, were studied by two-dimensional and Doppler echo in 100 and 200 ms atrioventricular delays. ANF plasma levels were measured at rest and at peak exercise, during pacing with the two different atrioventricular delays. ANF plasma levels were significantly higher at pacing with long atrioventricular delays (200 ms), at rest (152.47 6 12.38 pg/mL vs 119 6 12.38 pg/mL, P, 0.001) and at exercise (180.93 6 11.51 vs 123.67 6 16.24 pg/mL, P, 0.0001). ANF plasma levels were significantly increased at exercise, compared to those at rest during pacing with the two different atrioventricular delays, but we found a more pronounced increase of ANF levels (from 152.47 6 10.49 pg/mL to 180.93 6 11.51 pg/mL), when the atrioventricular delays was set to 200 ms (P, 0.0001). A significant decrease of isovolumic relaxation time (from 123.33 6 20.5 to 105.33 6 11.06 ms, P, 0.001) was observed, during pacing with the short atrioventricular delays. Moreover, the peak early (E) to peak atrial (A) velocity ratio (E/A) was declined (from 0.89 6 0.7 to 0.57 6 0.18, P, 0.05). We also noticed that patients with small left ventricles exhibit greater increase in ANF plasma levels during DDD pacing with long atrioventricular delays (r 5 20.792, P 5 0.000). In conclusion, left ventricular diastolic function of our patients seems to be improved during DDD pacing with short (100 ms) atrioventricular delays, as it was expressed by echocardiographic and hormonal measurements.
    Pacing and Clinical Electrophysiology 05/1999; 22(4 Pt 1):635-42. DOI:10.1111/j.1540-8159.1999.tb00505.x · 1.25 Impact Factor
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    ABSTRACT: Left atrial (LA) adaptation during the development of left ventricular (LV) dysfunction is not fully understood. We performed echocardiographic assessment of LA volumes simultaneously with recordings of pulmonary wedge pressures in 60 patients. Twenty patients had no structural or functional LV abnormalities, 20 had a recent myocardial infarction with LV dysfunction, and 20 suffered from congestive heart failure (CHF). Pressure-volume loops were obtained at baseline and during increases in LA pressure produced by normal saline infusion. LA afterload was estimated by the effective LV elastance (E(LV)). Atrioventricular coupling was calculated by the E(LV)/E(es) ratio (where E(es) is the end-systolic elastance). E(es) increased in patients with myocardial infarction (0.80 +/- 0.09 mm Hg/ml, p <0.001), whereas it decreased in patients with CHF (0.22 +/- 0.05 mm Hg/ml, p <0.001) compared with controls (0.61 +/- 0.07 mm Hg/ml). Similarly, stroke workload increased in patients with myocardial infarction (60.7 +/- 7.3 mm Hg x ml, p <0.001), whereas it decreased in patients with CHF (25.4 +/- 2.2 mm Hg x ml, p <0.001) compared with controls (44.8 +/- 5.5 mm Hg x ml). In all patients LA stiffness (slope of the relation of the filling portion of the pressure-volume loop) was increased compared with controls (controls: 0.13 +/- 0.04, patients with myocardial infarction: 0.22 +/- 0.05, and patients with CHF: 0.27 +/- 0.05 mm Hg/ml, p <0.001 for both comparisons). Moreover, the E(LV)/E(es) ratio increased gradually as LV function deteriorated (controls: 1.06 +/- 0.10, patients with myocardial infarction: 1.35 +/- 0.16, and patients with CHF: 6.90 +/- 0.84, p <0.001). Thus, early in heart failure, LA pump function is augmented but LA stiffness increases and work mismatch occurs. With further progression of LV dysfunction, LA pump function decreases as a result of increased afterload imposed on the LA myocardium.
    The American Journal of Cardiology 06/1998; 81(9):1138-43. DOI:10.1016/S0002-9149(98)00134-9 · 3.43 Impact Factor

Publication Stats

222 Citations
76.10 Total Impact Points

Institutions

  • 2004–2008
    • Γενικό Νοσοκομείο Ασκληπιείο Βούλας
      Βούλα, Attica, Greece
  • 1997–2008
    • ΓΕΝΙΚΟ ΝΟΣΟΚΟΜΕΙΟ ΑΘΗΝΩΝ "Γ. ΓΕΝΝΗΜΑΤΑΣ"
      • Department of Cardiology
      Athínai, Attica, Greece
  • 2006
    • Emory University
      Atlanta, Georgia, United States
  • 1998
    • Hippokration General Hospital, Athens
      Athínai, Attica, Greece
    • Amalia Flemig General Hospital
      Μελίσσια, Attica, Greece