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Unoki T, Konami Y, Nakayama T, Suzuyama H, Horio E, Taguchi E, Saku K, Sawamura T, Nakao K, Sakamoto T. Efficacy and safety of post-closure technique using Perclose ProGlide/ProStyle device for large-bore mechanical circulatory support access sites. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 62:60-65. [PMID: 38184452 DOI: 10.1016/j.carrev.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 11/06/2023] [Accepted: 12/21/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE Mechanical circulatory support (MCS) using a venoarterial extracorporeal membrane oxygenation (VA-ECMO) device or a catheter-type heart pump (Impella) is critical for the rescue of patients with severe cardiogenic shock. However, these MCS devices require large-bore cannula access (14-Fr and larger) at the femoral artery or vein, which often requires surgical decannulation. METHODS In this retrospective study, we evaluated post-closure method using a percutaneous suture-mediated vascular closure system, Perclose ProGlide/ProStyle (Abbott Vascular, Lake Bluff, IL, Perclose), as an alternative procedure for MCS decannulation. Closure of 83 Impella access sites and 68 VA-ECMO access sites performed using Perclose or surgical method between January 2018 and March 2023 were evaluated. RESULTS MCS decannulation using Perclose was successfully completed in all access sites without surgical hemostasis. The procedure time of ProGlide was shorter than surgical decannulation for both Impella and VA-ECMO (13 min vs. 50 min; p < 0.001, 21 min vs. 65 min; p < 0.001, respectively). There were no significant differences in the 30-day survival rate and major adverse events by decannulation including arterial dissection requiring endovascular treatment, hemorrhage requiring a large amount of red blood cell transfusion, and access site infection. CONCLUSION Our results suggest that the post-closure technique using the percutaneous suture-mediated closure system appears to be a safe and effective method for large-bore MCS decannulation.
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Affiliation(s)
- Takashi Unoki
- Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan; Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | - Yutaka Konami
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Tomoko Nakayama
- Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Hiroto Suzuyama
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Eiji Horio
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Eiji Taguchi
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tadashi Sawamura
- Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Tomohiro Sakamoto
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
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Thevathasan T, Gregers E, Rasalingam Mørk S, Degbeon S, Linde L, Bønding Andreasen J, Smerup M, Eifer Møller J, Hassager C, Laugesen H, Dreger H, Brand A, Balzer F, Landmesser U, Juhl Terkelsen C, Flensted Lassen J, Skurk C, Søholm H. Lactate and lactate clearance as predictors of one-year survival in extracorporeal cardiopulmonary resuscitation - An international, multicentre cohort study. Resuscitation 2024; 198:110149. [PMID: 38403182 DOI: 10.1016/j.resuscitation.2024.110149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 02/27/2024]
Abstract
AIM Extracorporeal cardiopulmonary resuscitation (ECPR) can be considered in selected patients with refractory cardiac arrest. Given the risk of patient futility and high resource utilisation, identifying ECPR candidates, who would benefit from this therapy, is crucial. Previous ECPR studies investigating lactate as a potential prognostic marker have been small and inconclusive. In this study, it was hypothesised that the lactate level (immediately prior to initiation of ECPR) and lactate clearance (within 24 hours after ECPR initiation) are predictors of one-year survival in a large, multicentre study cohort of ECPR patients. METHODS Adult patients with refractory cardiac arrest at three German and four Danish tertiary cardiac care centres between 2011 and 2021 were included. Pre-ECPR lactate and 24-hour lactate clearance were divided into three equally sized tertiles. Multivariable logistic regression analyses and Kaplan-Meier analyses were used to analyse survival outcomes. RESULTS 297 adult patients with refractory cardiac arrest were included in this study, of which 65 (22%) survived within one year. The pre-ECPR lactate level and 24-hour lactate clearance were level-dependently associated with one-year survival: OR 5.40 [95% CI 2.30-13.60] for lowest versus highest pre-ECPR lactate level and OR 0.25 [95% CI 0.09-0.68] for lowest versus highest 24-hour lactate clearance. Results were confirmed in Kaplan-Meier analyses (each p log rank < 0.001) and subgroup analyses. CONCLUSION Pre-ECPR lactate levels and 24 hour-lactate clearance after ECPR initiation in patients with refractory cardiac arrest were level-dependently associated with one-year survival. Lactate is an easily accessible and quickly available point-of-care measurement which might be considered as an early prognostic marker when considering initiation or continuation of ECPR treatment.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany; Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Emilie Gregers
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Sivagowry Rasalingam Mørk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus, Denmark
| | - Sêhnou Degbeon
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 17, 5000 Odense, Denmark
| | - Jo Bønding Andreasen
- Department of Anesthesiology and Intensive Medicine, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Morten Smerup
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jacob Eifer Møller
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 17, 5000 Odense, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Helle Laugesen
- Department of Anesthesiology and Intensive Medicine, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Henryk Dreger
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Anna Brand
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; The Danish Heart Foundation, Vognmagergade 7, 3rd Floor, 1120 Copenhagen, Denmark
| | - Jens Flensted Lassen
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark; Department of Clinical Research, University of Southern Denmark, J. B. Winsløws Vej 17, 5000 Odense, Denmark
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Potsdamer Str. 58, 10785 Berlin, Germany.
| | - Helle Søholm
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark; Department of Cardiology, Zealand University Hospital Roskilde, Sygehusvej 10, 4000 Roskilde, Denmark
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3
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Thevathasan T, Füreder L, Fechtner M, Mørk SR, Schrage B, Westermann D, Linde L, Gregers E, Andreasen JB, Gaisendrees C, Unoki T, Axtell AL, Takeda K, Vinogradsky AV, Gonçalves-Teixeira P, Lemaire A, Alonso-Fernandez-Gatta M, Sern Lim H, Garan AR, Bindra A, Schwartz G, Landmesser U, Skurk C. Left-Ventricular Unloading With Impella During Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis. Crit Care Med 2024; 52:464-474. [PMID: 38180032 PMCID: PMC10876179 DOI: 10.1097/ccm.0000000000006157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (ECPR) is the implementation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO during ECPR. DATA SOURCES Medline, Cochrane Central Register of Controlled Trials, Embase, and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology, and European Society of Cardiology). STUDY SELECTION Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist. DATA EXTRACTION Patient and treatment characteristics and in-hospital mortality from 13 study records at 32 hospitals with a total of 1014 ECPR patients. Odds ratios (ORs) and 95% CI were computed with the Mantel-Haenszel test using a random-effects model. DATA SYNTHESIS Seven hundred sixty-two patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared with VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable electrocardiogram rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%), and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest, and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR, 0.53 [95% CI, 0.30-0.91]) and higher odds of good neurologic outcome (OR, 2.22 [95% CI, 1.17-4.22]) compared with VA-ECMO support alone. ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses. CONCLUSIONS ECMELLA support was predominantly used in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. However, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Lisa Füreder
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | - Marie Fechtner
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | | | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Emilie Gregers
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jo Bønding Andreasen
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | | | - Takashi Unoki
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Andrea L Axtell
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Koji Takeda
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
| | - Alice V Vinogradsky
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
| | | | - Anthony Lemaire
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Hoong Sern Lim
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Arthur Reshad Garan
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Amarinder Bindra
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Gary Schwartz
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
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4
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Morooka M, Shirakabe A, Okazaki H, Matsushita M, Shigihara S, Nishigoori S, Sawatani T, Tani K, Kiuchi K, Kawakami S, Michiura Y, Kamitani S, Kobayashi N, Asai K. Late Kidney Injury After Admission to Intensive Care Unit for Acute Heart Failure. Int Heart J 2024; 65:433-443. [PMID: 38825492 DOI: 10.1536/ihj.23-603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Late kidney injury (LKI) in patients with acute heart failure (AHF) requiring intensive care is poorly understood.We analyzed 821 patients with AHF who required intensive care. We defined LKI based on the ratio of the creatinine level 1 year after admission for AHF to the baseline creatinine level. The patients were categorized into 4 groups based on this ratio: no-LKI (< 1.5, n = 509), Class R (risk; ≥ 1.5, n = 214), Class I (injury; ≥ 2.0, n = 78), and Class F (failure; ≥ 3.0, n = 20). Median follow-up after admission for AHF was 385 (346-426) days. Multivariate logistic regression analysis revealed that acute kidney injury (AKI) during hospitalization (Class R, odds ratio [OR]: 1.710, 95% confidence interval [CI]: 1.138-2.571, P = 0.010; Class I, OR: 6.744, 95% CI: 3.739-12.163, P < 0.001; and Class F, OR: 9.259, 95% CI: 4.078-18.400, P < 0.001) was independently associated with LKI. Multivariate Cox regression analysis showed that LKI was an independent predictor of 3-year all-cause death after final follow-up (hazard ratio: 1.545, 95% CI: 1.099-2.172, P = 0.012). The rate of all-cause death was significantly lower in the no-AKI/no-LKI group than in the no-AKI/LKI group (P = 0.048) and in the AKI/no-LKI group than in the AKI/LKI group (P = 0.017).The incidence of LKI was influenced by the presence of AKI during hospitalization, and was associated with poor outcomes within 3 years of final follow-up. In the absence of LKI, AKI during hospitalization for AHF was not associated with a poor outcome.
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Affiliation(s)
- Masaki Morooka
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Akihiro Shirakabe
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Hirotake Okazaki
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Masato Matsushita
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Shota Shigihara
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Suguru Nishigoori
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Tomofumi Sawatani
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Kenichi Tani
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Kazutaka Kiuchi
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Shohei Kawakami
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Yu Michiura
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Shogo Kamitani
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Nobuaki Kobayashi
- Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School
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5
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Gandhi KD, Moras EC, Niroula S, Lopez PD, Aggarwal D, Bhatia K, Balboul Y, Daibes J, Correa A, Dominguez AC, Birati EY, Baran DA, Serrao G, Mahmood K, Vallabhajosyula S, Fox A. Left Ventricular Unloading With Impella Versus IABP in Patients With VA-ECMO: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 208:53-59. [PMID: 37812867 DOI: 10.1016/j.amjcard.2023.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/11/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in cardiogenic shock results in increased left ventricular (LV) afterload. The use of concomitant Impella or intra-aortic balloon pump (IABP) have been proposed as adjunct devices for LV unloading. The authors sought to compare head-to-head efficacy and safety outcomes between the 2 LV unloading strategies. We conducted a search of Medline, EMBASE, and Cochrane databases to identify studies comparing the use of Impella to IABP in patients on VA-ECMO. The primary outcome of interest was in-hospital mortality. The secondary outcomes included transition to durable LV assist devices/cardiac transplantation, stroke, limb ischemia, need for continuous renal replacement therapy, major bleeding, and hemolysis. Pooled risk ratios (RRs) with 95% confidence interval and heterogeneity statistic I2 were calculated using a random-effects model. A total of 7 observational studies with 698 patients were included. Patients on VA-ECMO unloaded with Impella vs IABP had similar risk of short-term all-cause mortality, defined as either 30-day or in-hospital mortality- 60.8% vs 64.9% (RR 0.93 [0.71 to 1.21], I2 = 71%). No significant difference was observed in transition to durable LV assist devices/cardiac transplantation, continuous renal replacement therapy initiation, stroke, or limb ischemia between the 2 strategies. However, the use of VA-ECMO with Impella was associated with increased risk of major bleeding (57.2% vs 39.7%) (RR 1.66 [1.12 to 2.44], I2 = 82%) and hemolysis (31% vs 7%) (RR 4.61 [1.24 to 17.17], I2 = 66%) compared with VA-ECMO, along with IABP. In conclusion, in patients requiring VA-ECMO for circulatory support, the concomitant use of Impella or IABP had comparable short-term mortality. However, Impella use was associated with increased risk of major bleeding and hemolysis.
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Affiliation(s)
- Kruti D Gandhi
- Department of Internal Medicine, Mount Sinai Morningside/West, New York, New York
| | - Errol C Moras
- Department of Internal Medicine, Mount Sinai Morningside/West, New York, New York
| | - Shailesh Niroula
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Persio D Lopez
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, New York
| | - Devika Aggarwal
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, New York
| | - Kirtipal Bhatia
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, New York
| | - Yoni Balboul
- Department of Internal Medicine, Mount Sinai Morningside/West, New York, New York
| | - Joseph Daibes
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, New York
| | - Ashish Correa
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai
| | | | - Edo Y Birati
- Poriya Medical Center, Bar-Ilan University, Israel
| | - David A Baran
- Heart, Vascular Thoracic Institute, Cleveland Clinic Florida, Weston, Florida
| | - Gregory Serrao
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai
| | - Kiran Mahmood
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Arieh Fox
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai.
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6
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Sugane H, Hoji H, Kawai K. Unexpected deformation of the right coronary artery during percutaneous coronary intervention with venoarterial extracorporeal membrane oxygenation combined with Impella: a case report. Eur Heart J Case Rep 2023; 7:ytad402. [PMID: 37637092 PMCID: PMC10456214 DOI: 10.1093/ehjcr/ytad402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 08/29/2023]
Abstract
Background The establishment of cautionary notes regarding percutaneous coronary intervention (PCI) with venoarterial extracorporeal membrane oxygenation combined with Impella (ECMELLA) is still lacking. Case summary A 68-year-old man was transferred to our hospital with cardiac arrest. ECMELLA insertion was performed via the bilateral femoral artery and vein for refractory ventricular fibrillation. Coronary angiography revealed an occluded lesion in the right coronary artery (RCA). Contrast injection was administered after confirming backflow through the guide catheter (GC) to avoid coronary dissection because the artery pressure was non-pulsatile during total circulation support. Prudent coronary angiography revealed a couple of accordion phenomena. Additionally, coronary angiography showed a shorter distance from the right border of the cardiac silhouette to the RCA and the venous line of extracorporeal membrane oxygenation than before PCI. This drastic change in the cardiac silhouette suggested that ECMELLA induced the collapse of the right heart system. Subsequently, a drug-eluting stent was implanted successfully. Final coronary angiography confirmed severe bending in the proximal segment of the RCA, which was absent in the reference coronary angiography. The patient had an uneventful course except for mild cognitive impairment. The computed tomography coronary angiography after ECMELLA removal indicated the RCA without deformation. Discussion In the present case, the collapse of the right heart system caused by ECMELLA resulted in RCA deformation. This case also underscored that contrast injection to the coronary artery in total circulation support should be administered after confirmation of backflow through a GC.
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Affiliation(s)
- Hiroki Sugane
- Department of Cardiology, Chikamori Hospital, Kochi, Japan
| | - Haruki Hoji
- Department of Cardiology, Chikamori Hospital, Kochi, Japan
| | - Kazuya Kawai
- Department of Cardiology, Chikamori Hospital, Kochi, Japan
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Modi SP, Hong Y, Sicke MM, Hess NR, Klass WJ, Ziegler LA, Rivosecchi RM, Hickey GW, Kaczorowski DJ, Ramanan R. Concomitant Use of VA-ECMO and Impella Support for Cardiogenic Shock. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.24.23293127. [PMID: 37546750 PMCID: PMC10402237 DOI: 10.1101/2023.07.24.23293127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background VA-ECMO with concomitant Impella support (ECpella) is an emerging treatment modality for cardiogenic shock (CS). Survival outcomes by CS etiology with ECpella support have not been well-described. Methods This study was a retrospective, single-center analysis of patients with cardiogenic shock due to acute myocardial infarction (AMI-CS) or decompensated heart failure (ADHF-CS) supported with ECpella from December 2020 to January 2023. Primary outcomes included 90-day survival post-discharge and destination after support. Secondary outcomes included complications post-ECpella support. Results A total of 44 patients were included (AMI-CS, n = 20, and ADHF-CS, n = 24). Patients with AMI-CS and ADHF-CS had similar survival 90 days post-discharge (p = .267) with similar destinations after ECpella support (p = .220). Limb ischemia and acute kidney injury occurred more frequently in patients presenting with AMI-CS (p=.013; p = .030). Patients with initial Impella support were more likely to survive ECpella support and be bridged to transplant (p=.033) and less likely to have a cerebrovascular accident (p=.016). Sub-analysis of ADHF-CS patients into acute-on-chronic decompensated heart failure and de novo heart failure demonstrated no difference in survival or destination. Conclusion ECpella can be used to successfully manage patients with CS. There is no difference in survival or destination for AMI-CS and ADHF-CS in patients with ECpella support. Patients with initial Impella support are more likely to survive ECpella support and bridge to transplant. Future multicenter studies are required to fully analyze the differences between AMI-CS and ADHF-CS with ECpella support.
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Affiliation(s)
- Shan P Modi
- Department of Critical Care Medicine, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center Pittsburgh, PA
| | - McKenzie M Sicke
- School of Medicine, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Nicholas R Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Wyatt J Klass
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Luke A Ziegler
- Heart and Vascular Institute, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Gavin W Hickey
- Division of Cardiology, University of Pittsburgh Medical Center Pittsburgh, PA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Pittsburgh, PA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center Pittsburgh, PA
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Shirakabe A, Matsushita M, Shibata Y, Shighihara S, Nishigoori S, Sawatani T, Kiuchi K, Asai K. Organ dysfunction, injury, and failure in cardiogenic shock. J Intensive Care 2023; 11:26. [PMID: 37386552 DOI: 10.1186/s40560-023-00676-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 06/18/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is caused by primary cardiac dysfunction and induced by various and heterogeneous diseases (e.g., acute impairment of cardiac performance, or acute or chronic impairment of cardiac performance). MAIN BODY Although a low cardiac index is a common finding in patients with CS, the ventricular preload, pulmonary capillary wedge pressure, central venous pressure, and systemic vascular resistance might vary between patients. Organ dysfunction has traditionally been attributed to the hypoperfusion of the organ due to either progressive impairment of the cardiac output or intravascular volume depletion secondary to CS. However, research attention has recently shifted from this cardiac output ("forward failure") to venous congestion ("backward failure") as the most important hemodynamic determinant. Both hypoperfusion and/or venous congestion by CS could lead to injury, impairment, and failure of target organs (i.e., heart, lungs, kidney, liver, intestines, brain); these effects are associated with an increased mortality rate. Treatment strategies for the prevention, reduction, and reversal of organ injury are warranted to improve morbidity in these patients. The present review summarizes recent data regarding organ dysfunction, injury, and failure. CONCLUSIONS Early identification and treatment of organ dysfunction, along with hemodynamic stabilization, are key components of the management of patients with CS.
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Affiliation(s)
- Akihiro Shirakabe
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan.
| | - Masato Matsushita
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Yusaku Shibata
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Shota Shighihara
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Suguru Nishigoori
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Tomofumi Sawatani
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Kazutaka Kiuchi
- Division of Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamagari, Inzai, Chiba, 270-1694, Japan
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
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Ikeda Y, Ako J, Toda K, Hirayama A, Kinugawa K, Kobayashi Y, Ono M, Nishimura T, Sato N, Shindo T, Takayama M, Yasukochi S, Shiose A, Sawa Y. Short-Term Outcomes of Impella Support in Japanese Patients With Cardiogenic Shock Due to Acute Myocardial Infarction - Japanese Registry for Percutaneous Ventricular Assist Device (J-PVAD). Circ J 2023; 87:588-597. [PMID: 36682787 DOI: 10.1253/circj.cj-22-0476] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Impella®percutaneous left ventricular assist device has been available in Japan since 2017. This is the first large-scale registry study to analyze the efficacy and safety of Impella in Japanese patients with acute myocardial infarction with cardiogenic shock (AMICS).Methods and Results: The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) has registered all consecutive Japanese patients treated with Impella. We extracted data for 593 AMICS patients from J-PVAD and analyzed 30-day survival and safety profiles. Overall 30-day survival was 63.1%. The 30-day survival of the Impella alone and Impella plus venoarterial extracorporeal membrane oxygenation (ECPELLA) groups was 80.9% and 45.7%, respectively. The Impella alone group was older and had a lower rate of cardiac arrest, milder consciousness disturbance, less inotrope use, lower serum lactate concentrations, higher B-type natriuretic peptide concentrations, and higher left ventricular ejection fraction (LVEF) than the ECPELLA group. Cox regression analysis revealed that older age and comorbid renal disturbance were common risk factors affecting 30-day mortality in both groups. Major adverse events were hemolysis (10.8%), hemorrhage/hematoma (7.6%), peripheral ischemia (4.4%), stroke (1.3%), and thrombosis (0.7%). LVEF improved in both groups during support. CONCLUSIONS AMICS treatment with Impella showed favorable 30-day survival and safety profiles. The survival rate of patients treated with Impella alone was particularly high. Further studies are needed to improve outcomes of patients with ECPELLA support.
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Affiliation(s)
- Yuki Ikeda
- Department of Cardiovascular Medicine, Kitasato University, School of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University, School of Medicine
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | | | | | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Chiba University
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, University of Tokyo
| | - Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Ehime University
| | - Naoki Sato
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital
| | - Takahiro Shindo
- Division of Cardiology, National Center for Child Health and Development
| | - Morimasa Takayama
- Department of Cardiovascular Internal Medicine, Sakakibara Heart Institute
| | | | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
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Thevathasan T, Füreder L, Donker DW, Nix C, Wurster TH, Knie W, Girke G, Al Harbi AS, Landmesser U, Skurk C. Case report: Refractory cardiac arrest supported with veno-arterial-venous extracorporeal membrane oxygenation and left-ventricular Impella CP ®-Physiological insights and pitfalls of ECMELLA. Front Cardiovasc Med 2022; 9:1045601. [PMID: 36407456 PMCID: PMC9674118 DOI: 10.3389/fcvm.2022.1045601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/19/2022] [Indexed: 10/21/2023] Open
Abstract
INTRODUCTION To the best of our knowledge, this is the first case report which provides insights into patient-specific hemodynamics during veno-arterio-venous-extracorporeal membrane oxygenation (VAV ECMO) combined with a left-ventricular (LV) Impella® micro-axial pump for therapy-refractory cardiac arrest due to acute myocardial infarction, complicated by acute lung injury (ALI). PATIENT PRESENTATION A 54-year-old male patient presented with ST-segment elevation acute coronary syndrome complicated by out-of-hospital cardiac arrest with ventricular fibrillation upon arrival of the emergency medical service. As cardiac arrest was refractory to advanced cardiac life support, the patient was transferred to the Cardiac Arrest Center for immediate initiation of extracorporeal cardiopulmonary resuscitation (ECPR) with peripheral VA ECMO and emergency percutaneous coronary intervention using drug eluting stents in the right coronary artery. Due to LV distension and persistent asystole after coronary revascularization, an Impella® pump was inserted for LV unloading and additional hemodynamic support (i.e., "ECMELLA"). Despite successful unloading by ECMELLA, post-cardiac arrest treatment was further complicated by sudden differential hypoxemia of the upper body. This so called "Harlequin phenomenon" was explained by a new onset of ALI, necessitating escalation of VA ECMO to VAV ECMO, while maintaining Impella® support. Comprehensive monitoring as derived from the Impella® console allowed to illustrate patient-specific hemodynamics of cardiac unloading. Ultimately, the patient recovered and was discharged from the hospital 28 days after admission. 12 months after the index event the patient was enrolled in the ECPR Outpatient Care Program which revealed good recovery of neurologic functions while physical exercise capacities were impaired. CONCLUSION A combined mechanical circulatory support strategy may successfully be deployed in complex cases of severe cardio-circulatory and respiratory failure as occasionally encountered in clinical practice. While appreciating potential clinical benefits, it seems of utmost importance to closely monitor the physiological effects and related complications of such a multimodal approach to reach the most favorable outcome as illustrated in this case.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Berlin, Germany
- Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Lisa Füreder
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Dirk W. Donker
- Intensive Care Center, University Medical Centre Utrecht, Utrecht, Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Center, University of Twente, Enschede, Netherlands
| | | | - Thomas H. Wurster
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Wulf Knie
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Girke
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Abdulla S. Al Harbi
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Berlin, Germany
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