1
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Beer BN, Kellner C, Goßling A, Sundermeyer J, Besch L, Dettling A, Kirchhof P, Blankenberg S, Bernhardt AM, Brunner S, Colson P, Eckner D, Frank D, Eitel I, Frey N, Eden M, Graf T, Kupka D, Landmesser U, Majunke N, Maniuc O, Möbius-Winkler S, Morrow DA, Mourad M, Noel C, Nordbeck P, Orban M, Pappalardo F, Patel SM, Pauschinger M, Reichenspurner H, Schulze PC, Schwinger RHG, Wechsler A, Skurk C, Thiele H, Varshney AS, Sag CM, Krais J, Westermann D, Schrage B. Complications in patients with cardiogenic shock on veno-arterial extracorporeal membrane oxygenation therapy: distribution and relevance. Results from an international, multicentre cohort study. Eur Heart J Acute Cardiovasc Care 2024; 13:203-212. [PMID: 37875127 DOI: 10.1093/ehjacc/zuad129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/16/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023]
Abstract
AIMS Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) restores circulation and tissue oxygenation in cardiogenic shock (CS) patients, but can also lead to complications. This study aimed to quantify VA-ECMO complications and analyse their association with overall survival as well as favourable neurological outcome (cerebral performance categories 1 + 2). METHODS AND RESULTS All-comer patients with CS treated with VA-ECMO were retrospectively enrolled from 16 centres in four countries (2005-2019). Neurological, bleeding, and ischaemic adverse events (AEs) were considered. From these, typical VA-ECMO complications were identified and analysed separately as device-related complications. n = 501. Overall, 118 were women (24%), median age was 56.0 years, median lactate was 8.1 mmol/L. Acute myocardial infarction caused CS in 289 patients (58%). Thirty-days mortality was 40% (198/501 patients). At least one device-related complication occurred in 252/486 (52%) patients, neurological AEs in 108/469 (23%), bleeding in 192/480 (40%), ischaemic AEs in 123/478 (26%). The 22% of patients with the most AEs accounted for 50% of all AEs. All types of AEs were associated with a worse prognosis. Aside from neurological ones, all AEs and device-related complications were more likely to occur in women; although prediction of AEs outside of neurological AEs was generally poor. CONCLUSION Therapy and device-related complications occur in half of all patients treated with VA-ECMO and are associated with a worse prognosis. They accumulate in some patients, especially in women. Aside from neurological events, identification of patients at risk is difficult, highlighting the need to establish additional quantitative markers of complication risk to guide VA-ECMO treatment in CS.
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Affiliation(s)
- Benedikt N Beer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Sundermeyer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Lisa Besch
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Angela Dettling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Stefan Blankenberg
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Alexander M Bernhardt
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Brunner
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Derk Frank
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ingo Eitel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Eden
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Graf
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Danny Kupka
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | | | - David A Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Boston, USA
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, Montpellier, France
| | - Curt Noel
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würburg, Germany
| | - Martin Orban
- Department of Internal Medicine I, LMU University Hospital, Munich, Germany
| | - Federico Pappalardo
- Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sandeep M Patel
- Department of Interventional Cardiology, St.Rita's Medical Center, Lima, USA
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Hermann Reichenspurner
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
- Department of Cardiothoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Antonia Wechsler
- Department of Internal Medicine II, Klinikum Weiden, Weiden, Germany
| | - Carsten Skurk
- Department of Cardiology, Campus Benjamin Franklin, Charité University Hospital, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin/Institute of Health (BIH), Berlin, Germany
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Palo Alto, USA
| | - Can Martin Sag
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Jannis Krais
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Hamburg/Lübeck/Kiel, Hamburg, Germany
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2
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Gmeiner J, Bulach B, Lüsebrink E, Binzenhöfer L, Kupka D, Stocker T, Löw K, Weckbach L, Rudi WS, Petzold T, Kääb S, Hausleiter J, Hagl C, Massberg S, Orban M, Scherer C. Comparison of balanced and unbalanced crystalloids as resuscitation fluid in patients treated for cardiogenic shock. J Intensive Care 2023; 11:38. [PMID: 37674211 PMCID: PMC10481512 DOI: 10.1186/s40560-023-00687-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND The efficacy and safety of saline versus balanced crystalloid solutions in ICU-patients remains complicated by exceptionally heterogenous study population in past comparative studies. This study sought to compare saline and balanced crystalloids for fluid resuscitation in patients with cardiogenic shock with or without out-of-hospital cardiac arrest (OHCA). METHODS We retrospectively analyzed 1032 propensity score matched patients with cardiogenic shock from the Munich University Hospital from 2010 to 2022. In 2018, default resuscitation fluid was changed from 0.9% saline to balanced crystalloids. The primary endpoint was defined as 30-day mortality rate. RESULTS Patients in the saline group (n = 516) had a similar 30-day mortality rate as patients treated with balanced crystalloids (n = 516) (43.1% vs. 43.0%, p = 0.833), but a higher incidence of new onset renal replacement therapy (30.2% vs 22.7%, p = 0.007) and significantly higher doses of catecholamines. However, OHCA-patients with a lactate level higher than 7.4 mmol/L had a significantly lower 30-day mortality rate when treated with saline (58.6% vs. 79.3%, p = 0.013). In addition, use of balanced crystalloids was independently associated with a higher mortality in the multivariate cox regression analysis after OHCA (hazard ratio 1.43, confidence interval: 1.05-1.96, p = 0.024). CONCLUSIONS In patients with cardiogenic shock, use of balanced crystalloids was associated with a similar all-cause mortality at 30 days but a lower rate of new onset of renal replacement therapy. In the subgroup of patients after OHCA with severe shock, use of balanced crystalloids was associated with a higher mortality than saline. TRIAL REGISTRATION LMUshock registry (WHO International Clinical Trials Registry Platform Number DRKS00015860).
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Affiliation(s)
- Jonas Gmeiner
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Bernhardt Bulach
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Danny Kupka
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Stocker
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Kornelia Löw
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ludwig Weckbach
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Wolf-Stephan Rudi
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Tobias Petzold
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Stefan Kääb
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Christian Hagl
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
- Munich Heart Alliance, German Center for Cardiovascular Research (DZHK), Munich, Germany.
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3
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Schrage B, Sundermeyer J, Blankenberg S, Colson P, Eckner D, Eden M, Eitel I, Frank D, Frey N, Graf T, Kirchhof P, Kupka D, Landmesser U, Linke A, Majunke N, Mangner N, Maniuc O, Mierke J, Möbius-Winkler S, Morrow DA, Mourad M, Nordbeck P, Orban M, Pappalardo F, Patel SM, Pauschinger M, Pazzanese V, Radakovic D, Schulze PC, Scherer C, Schwinger RHG, Skurk C, Thiele H, Varshney A, Wechsler L, Westermann D. Timing of Active Left Ventricular Unloading in Patients on Venoarterial Extracorporeal Membrane Oxygenation Therapy. JACC Heart Fail 2023; 11:321-330. [PMID: 36724180 DOI: 10.1016/j.jchf.2022.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/25/2022] [Accepted: 11/03/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND It is currently unclear if active left ventricular (LV) unloading should be used as a primary treatment strategy or as a bailout in patients with cardiogenic shock (CS) treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). OBJECTIVES This study sought to evaluate the association between timing of active LV unloading and implantation of VA-ECMO with outcomes of patients with CS. METHODS Data from 421 patients with CS treated with VA-ECMO and active LV unloading at 18 tertiary care centers in 4 countries were analyzed. Patients were stratified by timing of device implantation in early vs delayed active LV unloading (defined by implantation before up to 2 hours after VA-ECMO). Adjusted Cox and logistic regression models were fitted to evaluate the association between early active LV unloading and 30-day mortality as well as successful weaning from ventilation. RESULTS Overall, 310 (73.6%) patients with CS were treated with early active LV unloading. Early active LV unloading was associated with a lower 30-day mortality risk (HR: 0.64; 95% CI: 0.46-0.88) and a higher likelihood of successful weaning from ventilation (OR: 2.17; 95% CI: 1.19-3.93) but not with more complications. Importantly, the relative mortality risk increased and the likelihood of successful weaning from ventilation decreased almost proportionally with the time interval between VA-ECMO implantation and (delayed) initiation of active LV unloading. CONCLUSIONS This exploratory study lends support to the use of early active LV unloading in CS patients on VA-ECMO, although the findings need to be validated in a randomized controlled trial.
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Affiliation(s)
- Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany.
| | - Jonas Sundermeyer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire Montpellier, University Montpellier, Montpellier, France
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Matthias Eden
- Department of Internal Medicine III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Ingo Eitel
- German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany; University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Derk Frank
- German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany; Department of Internal Medicine III-Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Norbert Frey
- Department of Internal Medicine III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Tobias Graf
- German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany; University Heart Center Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research, Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany; Institute of Cardiovascular Sciences, University of Birmingham and University Hospitals Birmingham and Sandwell and West Birmingham NHS Trusts, Birmingham, United Kingdom
| | - Danny Kupka
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany & German Center for Cardiovascular Research, Partner Site Berlin, Berlin, German
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Norman Mangner
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Octavian Maniuc
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Johannes Mierke
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany
| | | | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalier Universitaire Montpellier, University Montpellier, Montpellier, France
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Martin Orban
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
| | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Vita Salute University, Milan, Italy; Department of Cardiothoracic Anesthesia and Intensive Care, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Sandeep M Patel
- Department of Interventional Cardiology, St. Rita's Medical Center, Lima, Ohio, USA
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Vittorio Pazzanese
- Advanced Heart Failure and Mechanical Circulatory Support Program, Vita Salute University, Milan, Italy; Intensive Cardiac Care Unit, San Raffaele Hospital, Milan, Italy
| | - Darko Radakovic
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University of Bochum, Bad Oeynhausen, Germany
| | | | - Clemens Scherer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
| | | | - Carsten Skurk
- Department of Cardiology, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany & German Center for Cardiovascular Research, Partner Site Berlin, Berlin, German
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Anubodh Varshney
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lukas Wechsler
- Medizinische Klinik II, Klinikum Weiden, Weiden, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center, University Freiburg, Freiburg, Germany.
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4
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Scherer C, Theiss H, Istrefi M, Binzenhöfer L, Kupka D, Stocker T, Lüsebrink E, Stambollxhiu E, Alemic A, Petzold T, Stark K, Deseive S, Braun D, Joskowiak D, Peterss S, Hausleiter J, Hagl C, Massberg S, Orban M. Suture-based vs. pure plug-based vascular closure devices for VA-ECMO decannulation-A retrospective observational study. Front Cardiovasc Med 2023; 10:1106114. [PMID: 36776253 PMCID: PMC9908581 DOI: 10.3389/fcvm.2023.1106114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a valuable treatment option for patients in cardiogenic shock, but complications during decannulation may worsen the overall outcome. Therefore, the aim of this study was to compare the efficacy and safety of suture-based to pure plug-based vascular closure devices for VA-ECMO decannulation. Methods In this retrospective study, the procedural outcome of 33 patients with suture-based Perclose ProGlide closure devices was compared to 38 patients with MANTA plug-based closure devices. Results Rate of technically correct placement of closure devices was 88% in the suture-based group and 97% in the plug-based group (p = 0.27). There was a significant reduction of severe bleeding events during VA-ECMO decannulation in plug-based versus suture-based systems (3% vs. 21%, p = 0.04). Ischemic complications occurred in 6% with suture-based and 5% with plug-based device (p = 1.00). Pseudoaneurysm formation was detected in 3% in both groups (p = 1.00). No switch to vascular surgery due to bleeding after decannulation was necessary in both groups. Conclusion Based on our retrospective analysis, we propose that plug-based vascular closure should be the preferred option for VA-ECMO decannulation. This hypothesis should be further tested in a randomized trial.
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Affiliation(s)
- Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany,*Correspondence: Clemens Scherer,
| | - Hans Theiss
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Mario Istrefi
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Leonhard Binzenhöfer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Danny Kupka
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Stocker
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Enzo Lüsebrink
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Era Stambollxhiu
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Ahmed Alemic
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Tobias Petzold
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Konstantin Stark
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Simon Deseive
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Daniel Braun
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Christian Hagl
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany,Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Martin Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany,German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
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5
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Scherer C, Theiss H, Istrefi M, Stocker TJ, Kupka D, Luesebrink E, Hausleiter J, Hagl C, Massberg S, Orban M. Suture-based vs. pure plug-based vascular closure devices for VA-ECMO decannulation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
VA-ECMO is a valuable treatment option for patients in cardiogenic shock, but complications during decannulation may worsen the overall outcome. To date, no larger study has ever compared suture-based to pure plug-based vessel closure devices for VA-ECMO decannulation.
Purpose
The aim of the study was to compare the efficacy and safety of suture-based to pure plug-based vascular closure devices for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation for patients with cardiogenic shock.
Methods
In this retrospective study, the outcome of 33 patients with suture-based closure devices implanted between 02/2019 to 05/2020 were compared to 38 patients with plug-based closured device implanted between 06/2020 to 11/2021.
Results
Closure device success rate was 88% in the suture-based group versus 97% in the plug-based group (Figure 1, p=0.27). Median number of devices used was two for patients with suture-based closure device and 1 for patients with plug-based closure device (p<0.01). Severe bleeding was more frequent in the suture-based (21%) compared to the plug-based group (3%) (Figure 2, p=0.04). Ischemic complications occurred in 6% with suture-based and 5% with plug-based device (p=1.00). Pseudoaneurysm formation was detected in 3% in both groups (p=1.00). Application of the femoral compression system was required in 27% of patient with suture-based closure device and 11% of patients with plug-based closure device (p=0.13). No switch to open vascular surgery due to closure device failure occurred in both groups.
Conclusions
Based on our retrospective analysis, we propose that plug-based vascular closure should be the preferred option for VA-ECMO decannulation. This hypothesis should be further tested in a randomized trial.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft
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Affiliation(s)
- C Scherer
- Ludwig-Maximilians University, Department of Cardiology , Munich , Germany
| | - H Theiss
- Ludwig-Maximilians University, Department of Cardiology , Munich , Germany
| | - M Istrefi
- Ludwig-Maximilians University, Department of Cardiology , Munich , Germany
| | - T J Stocker
- Ludwig-Maximilians University, Department of Cardiology , Munich , Germany
| | - D Kupka
- University Hospital Zurich, Department of Medical Oncology and Hematology , Zurich , Switzerland
| | - E Luesebrink
- Ludwig-Maximilians University, Department of Cardiology , Munich , Germany
| | - J Hausleiter
- Ludwig-Maximilians University, Department of Cardiology , Munich , Germany
| | - C Hagl
- Ludwig-Maximilians University, Department of Cardiac Surgery , Munich , Germany
| | - S Massberg
- Ludwig-Maximilians University, Department of Cardiology , Munich , Germany
| | - M Orban
- Ludwig-Maximilians University, Department of Cardiology , Munich , Germany
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6
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Scherer C, Lüsebrink E, Binzenhöfer L, Stocker TJ, Kupka D, Chung HP, Stambollxhiu E, Alemic A, Kellnar A, Deseive S, Stark K, Petzold T, Hagl C, Hausleiter J, Massberg S, Orban M. Incidence and Outcome of Patients with Cardiogenic Shock and Detection of Herpes Simplex Virus in the Lower Respiratory Tract. J Clin Med 2022; 11:jcm11092351. [PMID: 35566477 PMCID: PMC9105969 DOI: 10.3390/jcm11092351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/29/2022] [Accepted: 04/18/2022] [Indexed: 11/25/2022] Open
Abstract
(1) Herpes simplex virus (HSV) reactivation in critically ill patients can cause infection in the lower respiratory tract, prolonging mechanical ventilation. However, the association of HSV reactivation with cardiogenic shock (CS) is unclear. As CS is often accompanied by pulmonary congestion and reduced immune system activity, the aim of our study was to determine the incidence and outcome of HSV reactivation in these patients. (2) In this retrospective, single-center study, bronchial lavage (BL) was performed on 181 out of 837 CS patients with mechanical ventilation. (3) In 44 of those patients, HSV was detected with a median time interval of 11 days since intubation. The occurrence of HSV was associated with an increase in C-reactive protein and the fraction of inspired oxygen at the time of HSV detection. Arterial hypertension, bilirubin on ICU admission, the duration of mechanical ventilation and out-of-hospital cardiac arrest were associated with HSV reactivation. (4) HSV reactivation could be detected in 24.3% of patients with CS on whom BL was performed, and its occurrence should be considered in patients with prolonged mechanical ventilation. Due to the limited current evidence, the initiation of treatment for these patients remains an individual choice. Dedicated randomized studies are necessary to investigate the efficacy of antiviral therapy.
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Affiliation(s)
- Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Enzo Lüsebrink
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Leonhard Binzenhöfer
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Thomas J. Stocker
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Danny Kupka
- Department of Medical Oncology and Hematology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Hieu Phan Chung
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
| | - Era Stambollxhiu
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
| | - Ahmed Alemic
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
| | - Antonia Kellnar
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Simon Deseive
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Konstantin Stark
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Tobias Petzold
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Christian Hagl
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Steffen Massberg
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
| | - Martin Orban
- Department of Medicine I, University Hospital, LMU Munich, 81377 Munich, Germany; (C.S.); (E.L.); (L.B.); (T.J.S.); (H.P.C.); (E.S.); (A.A.); (A.K.); (S.D.); (K.S.); (T.P.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany;
- Correspondence: ; Tel.: +49-89-4400-0
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7
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Mayer K, Hein-Rothweiler R, Schüpke S, Janisch M, Bernlochner I, Ndrepepa G, Sibbing D, Gori T, Borst O, Holdenrieder S, Kupka D, Petzold T, Bradaric C, Okrojek R, Leistner DM, Trippel TD, Münzel T, Landmesser U, Pieske B, Zeiher AM, Gawaz MP, Hapfelmeier A, Laugwitz KL, Schunkert H, Kastrati A, Massberg S. Efficacy and Safety of Revacept, a Novel Lesion-Directed Competitive Antagonist to Platelet Glycoprotein VI, in Patients Undergoing Elective Percutaneous Coronary Intervention for Stable Ischemic Heart Disease: The Randomized, Double-blind, Placebo-Controlled ISAR-PLASTER Phase 2 Trial. JAMA Cardiol 2021; 6:753-761. [PMID: 33787834 DOI: 10.1001/jamacardio.2021.0475] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The assessment of new antithrombotic agents with a favorable safety profile is clinically relevant. Objective To test the efficacy and safety of revacept, a novel, lesion-directed antithrombotic drug, acting as a competitive antagonist to platelet glycoprotein VI. Design, Setting, and Participants A phase 2 randomized clinical trial; patients were enrolled from 9 centers in Germany from November 20, 2017, to February 27, 2020; follow-up ended on March 27, 2020. The study included patients with stable ischemic heart disease (SIHD) undergoing elective percutaneous coronary intervention (PCI). Interventions Single intravenous infusion of revacept, 160 mg, revacept, 80 mg, or placebo prior to the start of PCI on top of standard antithrombotic therapy. Main Outcomes and Measures The primary end point was the composite of death or myocardial injury, defined as an increase in high-sensitivity cardiac troponin to at least 5 times the upper limit of normal within 48 hours from randomization. The safety end point was bleeding type 2 to 5 according to the Bleeding Academic Research Consortium criteria at 30 days. Results Of 334 participants (median age, 67.4 years; interquartile range, 60-75.1 years; 253 men [75.7%]; and 330 White participants [98.8%]), 120 were allocated to receive the 160-mg dose of revacept, 121 were allocated to receive the 80-mg dose, and 93 received placebo. The primary end point showed no significant differences between the revacept and placebo groups: 24.4%, 25.0%, and 23.3% in the revacept, 160 mg, revacept, 80 mg, and placebo groups, respectively (P = .98). The high dose of revacept was associated with a small but significant reduction of high-concentration collagen-induced platelet aggregation, with a median 26.5 AU × min (interquartile range, 0.5-62.2 AU × min) in the revacept, 160 mg, group; 43.5 AU × min (interquartile range, 22.8-99.5 AU × min) in the revacept, 80 mg, group; and 41.0 AU × min (interquartile range, 31.2-101.0 AU × min) in the placebo group (P = .02), while adenosine 5'-diphosphate-induced aggregation was not affected. Revacept did not increase Bleeding Academic Research Consortium type 2 or higher bleeding at 30 days compared with placebo: 5.0%, 5.9%, and 8.6% in the revacept, 160 mg, revacept, 80 mg, and placebo groups, respectively (P = .36). Conclusions and Relevance Revacept did not reduce myocardial injury in patients with stable ischemic heart disease undergoing percutaneous coronary intervention. There were few bleeding events and no significant differences between treatment arms. Trial Registration ClinicalTrials.gov Identifier: NCT03312855.
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Affiliation(s)
- Katharina Mayer
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Ralph Hein-Rothweiler
- Department of Cardiology, Medizinische Klinik und Poliklinik I, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Stefanie Schüpke
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Marion Janisch
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany.,Medizinische Klinik und Poliklinik Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gjin Ndrepepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Dirk Sibbing
- Department of Cardiology, Medizinische Klinik und Poliklinik I, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany.,Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf, Germany
| | - Tommaso Gori
- Department of Cardiology, University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany
| | - Oliver Borst
- Medizinische Klinik III-Kardiologie und Angiologie, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Stefan Holdenrieder
- Institut für Laboratoriumsmedizin, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany
| | - Danny Kupka
- Department of Cardiology, Medizinische Klinik und Poliklinik I, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Tobias Petzold
- Department of Cardiology, Medizinische Klinik und Poliklinik I, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Christian Bradaric
- Medizinische Klinik und Poliklinik Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Rainer Okrojek
- Medizinische Klinik und Poliklinik Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - David M Leistner
- Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Klinik für Kardiologie, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Tobias D Trippel
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany.,Charité-Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Kardiologie, Campus Virchow-Klinikum, Department of Internal Medicine and Cardiology, German Heart Center, Berlin, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany
| | - Ulf Landmesser
- Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Klinik für Kardiologie, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Burkert Pieske
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany.,Charité-Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Kardiologie, Campus Virchow-Klinikum, Department of Internal Medicine and Cardiology, German Heart Center, Berlin, Germany
| | - Andreas M Zeiher
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany.,Cardiology Division, Department of Medicine III, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Meinrad P Gawaz
- Medizinische Klinik III-Kardiologie und Angiologie, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich School of Medicine, Munich, Germany.,Institute of General Practice and Health Services Research, Technical University of Munich School of Medicine, Munich, Germany
| | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany.,Medizinische Klinik und Poliklinik Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, Medizinische Klinik und Poliklinik I, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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8
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Lüsebrink E, Orban M, Kupka D, Scherer C, Hagl C, Zimmer S, Luedike P, Thiele H, Westermann D, Massberg S, Schäfer A, Orban M. Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock. Eur Heart J 2021; 41:3753-3761. [PMID: 33099278 DOI: 10.1093/eurheartj/ehaa547] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/07/2020] [Accepted: 06/15/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiogenic shock is still a major driver of mortality on intensive care units and complicates ∼10% of acute coronary syndromes with contemporary mortality rates up to 50%. In the meantime, percutaneous circulatory support devices, in particular venoarterial extracorporeal membrane oxygenation (VA-ECMO), have emerged as an established salvage intervention for patients in cardiogenic shock. Venoarterial extracorporeal membrane oxygenation provides temporary circulatory support until other treatments are effective and enables recovery or serves as a bridge to ventricular assist devices, heart transplantation, or decision-making. In this critical care perspective, we provide a concise overview of VA-ECMO utilization in cardiogenic shock, considering rationale, critical care management, as well as weaning aspects. We supplement previous literature by focusing on therapeutic issues related to the vicious circle of retrograde aortic VA-ECMO flow, increased left ventricular (LV) afterload, insufficient LV unloading, and severe pulmonary congestion limiting prognosis in a relevant proportion of patients receiving VA-ECMO treatment. We will outline different modifications in percutaneous mechanical circulatory support to meet this challenge. Besides a strategy of running ECMO at lowest possible flow rates, novel therapeutic options including the combination of VA-ECMO with percutaneous microaxial pumps or implementation of a venoarteriovenous-ECMO configuration based on an additional venous cannula supplying towards pulmonary circulation are most promising among LV unloading and venting strategies. The latter may even combine the advantages of venovenous and venoarterial ECMO therapy, providing potent respiratory and circulatory support at the same time. However, whether VA-ECMO can reduce mortality has to be evaluated in the urgently needed, ongoing prospective randomized studies EURO-SHOCK (NCT03813134), ANCHOR (NCT04184635), and ECLS-SHOCK (NCT03637205). These studies will provide the opportunity to investigate indication, mode, and effect of LV unloading in dedicated sub-analyses. In future, the Heart Teams should aim at conducting a dedicated randomized trial comparing VA-ECMO support with vs. without LV unloading strategies in patients with cardiogenic shock.
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Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Danny Kupka
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Clemens Scherer
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Sebastian Zimmer
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53127 Bonn, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology, Leipzig Heart Institute, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Dirk Westermann
- Klinik für Allgemeine und Interventionelle Kardiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Andreas Schäfer
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
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9
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Scherer C, Lüsebrink E, Kupka D, Stocker TJ, Stark K, Kleeberger J, Orban M, Kellnar A, Petzold T, Deseive S, Krieg K, Würbel S, Kika S, Istrefi M, Brunner S, Braun D, Hagl C, Hausleiter J, Massberg S, Sibbing D, Orban M. ADP-induced platelet reactivity and bleeding events in patients with acute myocardial infarction complicated by cardiogenic shock. Platelets 2021; 33:371-380. [PMID: 33941008 DOI: 10.1080/09537104.2021.1913577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
While previous reports showed ADP-induced platelet reactivity to be an independent predictor of bleeding after PCI in stable patients, this has never been investigated in patients with cardiogenic shock. The association of bleeding events with respect to ADP-induced platelet aggregation was investigated in patients undergoing primary PCI for acute myocardial infarction complicated by cardiogenic shock and with available on-treatment ADP-induced platelet aggregation measurements. Out of 233 patients, 74 suffered from a severe BARC3 or higher bleed. ADP-induced platelet aggregation was significantly lower in patients with BARC≥3 bleedings (p < .001). Multivariate analysis identified on-treatment ADP-induced platelet aggregation as an independent risk factor for bleeding (HR = 0.968 per AU). An optimal cutoff value of <12 AU for ADP-induced platelet aggregation to predict BARC≥3 bleedings was identified via ROC analysis. Moreover, the use of VA-ECMO (HR 1.972) or coaxial left ventricular pump (HR 2.593), first lactate (HR 1.093 per mmol/l) and thrombocyte count (HR 0.994 per G/l) were independent predictors of BARC≥3 bleedings. In conclusion, lower on-treatment ADP-induced platelet aggregation was independently associated with severe bleeding events in patients with AMI-CS. The value of platelet function testing for bleeding risk prediction and guidance of anti-thrombotic treatment in cardiogenic shock warrants further investigation.
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Affiliation(s)
- Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Enzo Lüsebrink
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Danny Kupka
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Thomas J Stocker
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Konstantin Stark
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Jan Kleeberger
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Mathias Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Antonia Kellnar
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Tobias Petzold
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Simon Deseive
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Kathrin Krieg
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Sara Würbel
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Sara Kika
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Mario Istrefi
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Stefan Brunner
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Braun
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Jörg Hausleiter
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Dirk Sibbing
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Martin Orban
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
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10
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Stremmel C, Scherer C, Lüsebrink E, Kupka D, Schmid T, Stocker T, Kellnar A, Kleeberger J, Sinner MF, Petzold T, Mehilli J, Braun D, Orban M, Hausleiter J, Massberg S, Orban M. Treatment of acute cardiac tamponade: A retrospective analysis of classical intermittent versus continuous pericardial drainage. Int J Cardiol Heart Vasc 2021; 32:100722. [PMID: 33644296 PMCID: PMC7887384 DOI: 10.1016/j.ijcha.2021.100722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/08/2021] [Accepted: 01/13/2021] [Indexed: 01/06/2023]
Abstract
Acute cardiac tamponade is a highly relevant complication in modern cardiology. Continuous pericardial drainage is safe and does not increase total drainage volume. Continuous drainage associates with lower rates of open-heart surgical interventions. Continuous drainage associates with reduced re-tamponades and mortality on day 5.
Background Acute cardiac tamponade is a life-threatening pathology in modern cardiology as catheter-based interventions become increasingly relevant. Pericardiocentesis is usually the primary treatment of choice. However, protocols for handling of draining pigtail catheters are very variable due to limit data and require further investigation. Methods We retrospectively analyzed 52 patients with acute cardiac tamponade requiring immediate pericardiocentesis from January 2017 to August 2020. Patients were treated with a classical approach of intermittent manual aspiration or continuous pericardial drainage using a redon drainage system. Results Mean age of patients was 74 years in both groups. Most common causes for cardiac tamponade were percutaneous coronary interventions in about 50% and transaortic valve implantations in 25% of all cases. 28 patients were treated with classic intermittent drainage from 2017 to 2020. 24 patients were treated with continuous drainage from December 2018–2020. Compared to classical intermittent drainage treatment, continuous drainage was associated with a lower rate of a surgical intervention or cardiac re-tamponade and a lower mortality at 5 days (HR 0.2, 95% CI 0.1–0.9, log-rank p = 0.03). Despite a longer total drainage time under continuous suction, drainage volumes were comparable in both groups. Conclusion Acute cardiac tamponade can be efficiently treated by pericardiocentesis with subsequent continuous negative pressure drainage via a pigtail catheter. Our retrospective analysis shows a significantly lower mortality, a decreased rate of interventions and lower rates of cardiac re-tamponade without any relevant side effects when compared to classical intermittent manual drainage. These findings require further investigations in larger, randomized trials.
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Affiliation(s)
- Christopher Stremmel
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Clemens Scherer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Enzo Lüsebrink
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Danny Kupka
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Teresa Schmid
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Thomas Stocker
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Antonia Kellnar
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Jan Kleeberger
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Moritz F. Sinner
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Tobias Petzold
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Julinda Mehilli
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
- Medizinische Klinik I, Krankenhaus Landshut-Achdorf, Landshut, Germany
| | - Daniel Braun
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Mathias Orban
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
| | - Martin Orban
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Klinikum der Universität München, Munich, Germany
- Corresponding author at: Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.
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11
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Scherer C, Lüsebrink E, Kupka D, Stocker TJ, Stark K, Stremmel C, Orban M, Petzold T, Germayer A, Mauthe K, Kääb S, Mehilli J, Braun D, Theiss H, Brunner S, Hausleiter J, Massberg S, Orban M. Long-Term Clinical Outcome of Cardiogenic Shock Patients Undergoing Impella CP Treatment vs. Standard of Care. J Clin Med 2020; 9:jcm9123803. [PMID: 33255393 PMCID: PMC7760637 DOI: 10.3390/jcm9123803] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/02/2020] [Accepted: 11/21/2020] [Indexed: 12/13/2022] Open
Abstract
The number of patients treated with the mechanical circulatory support device Impella Cardiac Power (CP) for cardiogenic shock is steadily increasing. The aim of this study was to investigate long-term survival and complications related to this modality. Patients undergoing Impella CP treatment for cardiogenic shock were retrospectively enrolled and matched with cardiogenic shock patients not treated with mechanical circulatory support between 2010 and 2020. Data were collected from the cardiogenic shock registry of the university hospital of Munich (DRKS00015860). 70 patients with refractory cardiogenic shock without mechanical circulatory support were matched with 70 patients treated with Impella CP. At presentation, the mean age was 67 ± 15 years with 80% being male in the group without support and 67 ± 14 years (p = 0.97) with 76% being male (p = 0.68) in the group with Impella. There was no significant difference in the rate of cardiac arrest (47% vs. 51%, p = 0.73) and myocardial infarction was the predominant cause of cardiogenic shock in both groups (70% vs. 77%). A total of 41% of patients without cardiocirculatory support and 54% of patients with Impella support died during the first month (p = 0.17). After one year, mortality rates were similar in both groups (55% in conventional vs. 59% in Impella CP group, p = 0.30) as was mortality rate at long-term 5-years follow-up (64% in conventional vs. 73% in Impella CP group, p = 0.33). The rate of clinically significant bleedings during ICU stay was lower in the conventional group than in the Impella support group (15% vs. 43%, p = 0.002). In this small observational and non-randomized analysis no difference in long-term outcome between patients treated with Impella CP vs. guideline directed cardiogenic shock therapy without mechanical circulatory support could be detected. Care must be taken regarding the high rate of bleeding and vascular complications when using Impella CP. Large, adequately powered studies are urgently needed to investigate the efficacy and safety of Impella CP in cardiogenic shock.
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Affiliation(s)
- Clemens Scherer
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Enzo Lüsebrink
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Danny Kupka
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Thomas J. Stocker
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Konstantin Stark
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christopher Stremmel
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Tobias Petzold
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Antonia Germayer
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Katharina Mauthe
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Stefan Kääb
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Julinda Mehilli
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Daniel Braun
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Hans Theiss
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Stefan Brunner
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Jörg Hausleiter
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Steffen Massberg
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Martin Orban
- Intensive Care Unit and Department of Cardiology, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (C.S.); (E.L.); (D.K.); (T.J.S.); (K.S.); (C.S.); (M.O.); (T.P.); (A.G.); (K.M.); (S.K.); (J.M.); (D.B.); (H.T.); (S.B.); (J.H.); (S.M.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
- Correspondence: or ; Tel.: +49-(0)-4400-75221
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12
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Scherer C, Kupka D, Stocker T, Joskowiak D, Scheuplein H, Schoenegger C, Stremmel C, Luesebrink E, Stark K, Orban M, Peterss S, Hausleiter J, Hagl C, Massberg S, Orban M. Isoflurane sedation in patients undergoing VA-ECMO treatment for cardiogenic shock – an observational propensity-matched study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
The feasibility and hemodynamic effects of isoflurane sedation in cardiogenic shock in the presence of extracorporeal membrane oxygenation (VA-ECMO) treatment is currently unknown.
Methods
Thirty-two cardiogenic shock patients with VA-ECMO treatment under sedation with volatile isoflurane on a cardiac intensive care unit have been enrolled in this retrospective single-center study and were matched by propensity score in a 1:1 ratio with intravenously (IV) sedated patients.
Results
Administration of isoflurane was associated with lower IV sedative drug use during VA-ECMO treatment (86% vs. 32%, p=0.01). Mean systolic arterial pressure was similar (94.3±12.6 mmHg versus 92.9±10.5 mmHg, p=0.65), but mean heart rate was significantly higher in the conventional sedation group, when compared to the isoflurane group (85.2±20.5 / min vs. 74.7±15.0 /min; p=0.02). Catecholamine doses, VA-ECMO blood and gas flow, ventilation time (304±143 h vs. 398±272 h, p=0.16), bleeding complications BARC3a or higher (59.3% vs. 65.3%, p=0.76) and 30-day mortality (59.2% vs. 63.4%, p=0.80) were similar in both groups.
Conclusions
Volatile sedation with isoflurane is feasible in patients with cardiogenic shock and VA-ECMO treatment and was not associated with higher catecholamine dosage or ECMO flow rate compared to IV sedation.
Mortality and bleeding
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- C Scherer
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - D Kupka
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - T Stocker
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - D Joskowiak
- Ludwig-Maximilians University, Department of Cardiac Surgery, Munich, Germany
| | - H Scheuplein
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - C Schoenegger
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - C Stremmel
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - E Luesebrink
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - K Stark
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - M Orban
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - S Peterss
- Ludwig-Maximilians University, Department of Cardiac Surgery, Munich, Germany
| | - J Hausleiter
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - C Hagl
- Ludwig-Maximilians University, Department of Cardiac Surgery, Munich, Germany
| | - S Massberg
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - M Orban
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
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Abstract
Abstract
Background
Atrial Fibrillation (AF) is common and is caused and predisposed to by a complex pathophysiology. Aging is among the most important risk factors for AF. Yet, some individuals develop AF in early years, whereas elderly individuals may remain free of AF. Aside from measurable concomitant risks, we hypothesized that a pathophysiologically relevant biological age exists, which outweighs a patient's calendar age. Telomere length is a measurable marker of age, which might reflect biological age. AF and telomere length have previously been associated, but results remained controversial. Here, we tested the relation between AF and telomere length in a well-characterized and so far largest cohort.
Methods
Since 2005, we enrolled 2475 patients with AF from the prospective AFLMU cohort, preferentially if they developed AF before age 65 years, and 3077 control individuals free of AF from the community-based KORA Study between 2006–08. All participants received a detailed clinical characterization, an electrocardiogram, and a blood draw for biomarker analyses. In all participants, we determined telomere length using a qPCR-based method. In a 384 well format, we employed a multiplex TaqMan assay to determine both telomere length and the single copy gene 36B4. Telomere length was expressed by the delta-CT method and was reformatted to have lower CT values indicate shorter telomere length. We compared telomere length between cases and controls using multi-variably corrected logistic regression models.
Results
Our cohort's mean age was 58 years in AFLMU and 56 years in KORA F4. Men were enrolled more commonly, with 72.3% in AFLMU and 51.7% in KORA F4. For consistency with available information, we confirmed that telomere length is continuously decreasing with age and that men have shorter telomere length compared to women. As a main result we found that AF patients have significantly shorter telomere length compared to controls (controls: telomere length 13,10 [12.60, 13.63] versus AF: 9.81 [5.98, 13.1], p<0,001). This relation remained significant following multi-variable adjustment for sex, body mass index, hypertension, and diabetes. The odds ratio per unit longer telomer length was 0.77 [95% confidence interval 0.74–0.77], p<0.001. We also calculated a propensity-score matched model of cases with and without AF confirming our main results (controls: telomere length 13.21 [11.65, 13.67] versus AF: 9.03 [5.35, 12.54], p<0.001). The multi-variable adjusted model revealed an odds ratio of 0,75 [95% confidence interval 0.73–0.76], p<0.001.
Conclusion
AF is significantly associated with telomere length in one of the largest cohorts to date. Assessment of telomere length may adjudicate patients with AF due to premature biological aging. The underlying reasons for such premature aging remain to be identified.
Funding Acknowledgement
Type of funding source: Public grant(s) – EU funding. Main funding source(s): European Commission - Horizon 2020
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Affiliation(s)
- M Sinner
- University Hospital of Munich, Department of Medicine I, Munich, Germany
| | - D Kupka
- University Hospital of Munich, Department of Medicine I, Munich, Germany
| | - W Wilfert
- University Hospital of Munich, Institute of Laboratory Medicine, Munich, Germany
| | - M Waldenberger
- Helmholtz Center of Munich, Institute of Epidemiology, Neuherberg, Germany
| | - A Peters
- Helmholtz Center of Munich, Institute of Epidemiology, Neuherberg, Germany
| | - L Holdt
- University Hospital of Munich, Institute of Laboratory Medicine, Munich, Germany
| | - S Kaab
- University Hospital of Munich, Department of Medicine I, Munich, Germany
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14
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Schrage B, Becher PM, Bernhardt A, Bezerra H, Blankenberg S, Brunner S, Colson P, Cudemus Deseda G, Dabboura S, Eckner D, Eden M, Eitel I, Frank D, Frey N, Funamoto M, Goßling A, Graf T, Hagl C, Kirchhof P, Kupka D, Landmesser U, Lipinski J, Lopes M, Majunke N, Maniuc O, McGrath D, Möbius-Winkler S, Morrow DA, Mourad M, Noel C, Nordbeck P, Orban M, Pappalardo F, Patel SM, Pauschinger M, Pazzanese V, Reichenspurner H, Sandri M, Schulze PC, H G Schwinger R, Sinning JM, Aksoy A, Skurk C, Szczanowicz L, Thiele H, Tietz F, Varshney A, Wechsler L, Westermann D. Left Ventricular Unloading Is Associated With Lower Mortality in Patients With Cardiogenic Shock Treated With Venoarterial Extracorporeal Membrane Oxygenation: Results From an International, Multicenter Cohort Study. Circulation 2020; 142:2095-2106. [PMID: 33032450 PMCID: PMC7688081 DOI: 10.1161/circulationaha.120.048792] [Citation(s) in RCA: 243] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to treat cardiogenic shock. However, VA-ECMO might hamper myocardial recovery. The Impella unloads the left ventricle. This study aimed to evaluate whether left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO was associated with lower mortality. METHODS Data from 686 consecutive patients with cardiogenic shock treated with VA-ECMO with or without left ventricular unloading using an Impella at 16 tertiary care centers in 4 countries were collected. The association between left ventricular unloading and 30-day mortality was assessed by Cox regression models in a 1:1 propensity score-matched cohort. RESULTS Left ventricular unloading was used in 337 of the 686 patients (49%). After matching, 255 patients with left ventricular unloading were compared with 255 patients without left ventricular unloading. In the matched cohort, left ventricular unloading was associated with lower 30-day mortality (hazard ratio, 0.79 [95% CI, 0.63-0.98]; P=0.03) without differences in various subgroups. Complications occurred more frequently in patients with left ventricular unloading: severe bleeding in 98 (38.4%) versus 45 (17.9%), access site-related ischemia in 55 (21.6%) versus 31 (12.3%), abdominal compartment in 23 (9.4%) versus 9 (3.7%), and renal replacement therapy in 148 (58.5%) versus 99 (39.1%). CONCLUSIONS In this international, multicenter cohort study, left ventricular unloading was associated with lower mortality in patients with cardiogenic shock treated with VA-ECMO, despite higher complication rates. These findings support use of left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO and call for further validation, ideally in a randomized, controlled trial.
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Affiliation(s)
- Benedikt Schrage
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
| | - Peter Moritz Becher
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
| | - Alexander Bernhardt
- Cardiothoracic Surgery (A.B., H.R.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
| | - Hiram Bezerra
- Tampa General Hospital, University of South Florida (H.B.)
| | - Stefan Blankenberg
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
| | - Stefan Brunner
- Medizinische Klinik und Poliklinik I (S. Brunner, D.K., M.O.), LMU Klinikum, Munich, Germany
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, France (P.C., M.M.)
| | - Gaston Cudemus Deseda
- Division of Anesthesia, Critical Care and Pain Medicine (G.C.D.), Massachusetts General Hospital, Boston
| | - Salim Dabboura
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany
| | - Dennis Eckner
- Department of Cardiology, Paracelsus Medical University Nürnberg, Germany (D.E., M.P.)
| | - Matthias Eden
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany(M.E., D.F., N.F., C.N.)
| | - Ingo Eitel
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany (I.E., T.G.)
| | - Derk Frank
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany(M.E., D.F., N.F., C.N.)
| | - Norbert Frey
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany(M.E., D.F., N.F., C.N.)
| | - Masaki Funamoto
- Division of Cardiac Surgery (M.F., D.M.), Massachusetts General Hospital, Boston
| | - Alina Goßling
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany
| | - Tobias Graf
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany (I.E., T.G.)
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik (C.H.), LMU Klinikum, Munich, Germany
| | - Paulus Kirchhof
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Institute of Cardiovascular Sciences, University of Birmingham and University Hospitals Birmingham and Sandwell and West Birmingham National Health ServiceTrusts, United Kingdom (P.K.)
| | - Danny Kupka
- Departments of Cardiology (B.S., P.M.B., S. Blankenberg, S.D., A.G., P.K., D.W.), University Heart and Vascular Center Hamburg, Germany.,Medizinische Klinik und Poliklinik I (S. Brunner, D.K., M.O.), LMU Klinikum, Munich, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin, Charité Universitätsmedizin Berlin, Germany (U.L., C.S.).,Franklin/German Centre for Cardiovascular Research (DZHK), partner site Berlin/Institute of Health (BIH), Germany (U.L., C.S.)
| | - Jerry Lipinski
- Department of Internal Medicine, University of California, San Diego (J.L.)
| | - Mathew Lopes
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L., D.A.M., A.V.)
| | - Nicolas Majunke
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - Octavian Maniuc
- Medizinische Klinik und Poliklinik I (S. Brunner, D.K., M.O.), LMU Klinikum, Munich, Germany.,Department of Internal Medicine I, University Hospital Würzburg, Germany (O.M., P.N.)
| | - Daniel McGrath
- Division of Cardiac Surgery (M.F., D.M.), Massachusetts General Hospital, Boston
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, University Hospital Jena, Germany (S.M.-W., P.C.S.)
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L., D.A.M., A.V.)
| | - Marc Mourad
- Department of Anesthesiology and Critical Care Medicine, CHU Montpellier, University Montpellier, France (P.C., M.M.)
| | - Curt Noel
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.).,Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany(M.E., D.F., N.F., C.N.)
| | - Peter Nordbeck
- Department of Internal Medicine I, University Hospital Würzburg, Germany (O.M., P.N.)
| | | | - Federico Pappalardo
- Advanced Heart Failure and Mechanical Circulatory Support Program, Vita Salute University, Milan, Italy (F.P., V.P.).,Department of Anesthesia and Intensive Care, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) ISMETT (Istituto Mediterraneo trapianti e terapie avanzate), UPMC (University of Pittsburgh Medical Center)Italy, Palermo, Italy (F.P.)
| | - Sandeep M Patel
- Department of Interventional Cardiology, St. Rita's Medical Center, Lima, OH (S.M.P.)
| | - Matthias Pauschinger
- Department of Cardiology, Paracelsus Medical University Nürnberg, Germany (D.E., M.P.)
| | - Vittorio Pazzanese
- Advanced Heart Failure and Mechanical Circulatory Support Program, Vita Salute University, Milan, Italy (F.P., V.P.)
| | - Hermann Reichenspurner
- Cardiothoracic Surgery (A.B., H.R.), University Heart and Vascular Center Hamburg, Germany
| | - Marcus Sandri
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - P Christian Schulze
- Department of Internal Medicine I, University Hospital Jena, Germany (S.M.-W., P.C.S.)
| | | | - Jan-Malte Sinning
- University Heart Center Bonn, Department of Cardiology, Germany (J.-M.S., A.A.)
| | - Adem Aksoy
- University Heart Center Bonn, Department of Cardiology, Germany (J.-M.S., A.A.)
| | - Carsten Skurk
- Department of Cardiology, Campus Benjamin, Charité Universitätsmedizin Berlin, Germany (U.L., C.S.).,Franklin/German Centre for Cardiovascular Research (DZHK), partner site Berlin/Institute of Health (BIH), Germany (U.L., C.S.)
| | - Lukasz Szczanowicz
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - Holger Thiele
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - Franziska Tietz
- Department of Internal Medicine and Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (N.M., M.S., L.S., H.T., F.T.)
| | - Anubodh Varshney
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.L., D.A.M., A.V.)
| | - Lukas Wechsler
- Medizinische Klinik II, Klinikum Weiden, Germany (R.H.G.S., L.W.)
| | - Dirk Westermann
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany (B.S., P.M.B., A.B., S. Blankenberg, S.D., M.E., I.E., D.F., N.F., T.G., P.K., C.N., D.W.)
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15
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Lüsebrink E, Stremmel C, Stark K, Joskowiak D, Czermak T, Born F, Kupka D, Scherer C, Orban M, Petzold T, von Samson-Himmelstjerna P, Kääb S, Hagl C, Massberg S, Peterss S, Orban M. Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation. J Clin Med 2020; 9:jcm9040992. [PMID: 32252267 PMCID: PMC7230450 DOI: 10.3390/jcm9040992] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.
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Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christopher Stremmel
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Konstantin Stark
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Thomas Czermak
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Frank Born
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Danny Kupka
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Clemens Scherer
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Tobias Petzold
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Patrick von Samson-Himmelstjerna
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Stefan Kääb
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
- Correspondence: or ; Tel.: +49-(0)-4400-75221
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16
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Orban M, Orban MW, Braun D, Deseive S, Kupka D, Stocker TJ, Bagaev E, Karam N, Hagl C, Massberg S, Nabauer M, Hausleiter J. Clinical impact of elevated tricuspid valve inflow gradients after transcatheter edge-to-edge tricuspid valve repair. EUROINTERVENTION 2019; 15:e1057-e1064. [PMID: 31498114 DOI: 10.4244/eij-d-19-00237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to compare the outcome of patients with a post-procedural tricuspid valve gradient (TVG) of >3 mmHg vs ≤3 mmHg after transcatheter edge-to-edge tricuspid valve repair (TTVR). METHODS AND RESULTS Between March 2016 and October 2018 we treated 145 patients with severe tricuspid regurgitation (TR) with TTVR by placing 2.2±0.7 clips per patient. Device success (TR reduction ≥1° to at least moderate) was achieved in 125 patients (86.2%). TTVR resulted in an elevated TVG >3 mmHg in 25 (17.2%) patients. Device success (84% vs 86.7%, p=0.9), number of clips implanted (2.3±0.7 vs 2.2±0.7, p=0.33), clinical improvement including NYHA class (III/IV 24% vs 28%, p=0.92) and increase in six-minute walking test at one month (67 m [IQR 5-103 m] vs 56 m [IQR 8-97 m], p=0.93), mortality (HR 1.07, 95% CI: 0.43-2.65, plogrank=0.88) and the combined endpoint mortality and hospitalisation for heart failure at one year (HR 1.07, 95% CI: 0.46-2.48, plogrank=0.88) were similar between patients with a TVG >3 mmHg versus patients with a TVG ≤3 mmHg. CONCLUSIONS A small cohort of patients demonstrated an elevated TVG higher than 3 mmHg at discharge. This elevation had no impact on clinical improvement, mortality or hospitalisation for heart failure.
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Affiliation(s)
- Martin Orban
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
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17
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Orban M, Trenk D, Geisler T, Rieber J, Hadamitzky M, Gross L, Orban M, Kupka D, Baylacher M, Müller S, Huber K, Koltowski L, Huczek Z, Heyn J, Jacobshagen C, Aradi D, Massberg S, Sibbing D, Hein R. Smoking and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients: a substudy from the randomized TROPICAL-ACS trial. European Heart Journal - Cardiovascular Pharmacotherapy 2019; 6:372-381. [DOI: 10.1093/ehjcvp/pvz084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/24/2019] [Accepted: 12/13/2019] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
Prior analyses disclosed variations in antiplatelet drug response and clinical outcomes between smokers and non-smokers, thus the safety and efficacy of any dual antiplatelet therapy (DAPT) de-escalation strategy may differ in relation to smoking status. Hence, we assessed the impact of smoking on clinical outcomes and adenosine diphosphate-induced platelet aggregation following guided de-escalation of DAPT in invasively managed acute coronary syndrome (ACS) patients.
Methods and results
The multicentre TROPICAL-ACS trial randomized 2610 biomarker-positive ACS patients 1:1 to standard treatment with prasugrel for 12 months (control group) or a platelet function testing guided de-escalation of DAPT. Current smokers (n = 1182) showed comparable event rates between study groups [6.6% vs. 6.6%; hazard ratio (HR) 1.0, 95% confidence interval (CI) 0.64–1.56, P > 0.99]. In non-smokers (n = 1428), a guided DAPT de-escalation was associated with a lower 1-year incidence of the primary endpoint [cardiovascular death, myocardial infarction, stroke, or bleeding ≥ Grade 2 according to Bleeding Academic Research Consortium (BARC) criteria] compared with control group patients (7.9% vs. 11.0%; HR 0.71, 95% CI 0.50–0.99, P = 0.048). This reduction was mainly driven by a lower rate of BARC ≥ Grade 2 bleedings (5.2% vs. 7.7%; HR 0.68, 95% CI 0.45–1.03, P = 0.066). There was no significant interaction of smoking status with treatment effects of guided DAPT de-escalation (Pint = 0.23). Adenosine diphosphate-induced platelet aggregation values were higher in current smokers [median 28 U, interquartile range (IQR: 20–40)] vs. non-smoker [median 24 U (16–25), P < 0.0001] in the control group and in current smokers [median 42 U, IQR (27–68)] vs. non-smoker [median 37 U, IQR (25–55), P < 0.001] in the monitoring group.
Conclusion
Guided DAPT de-escalation appears to be equally safe and effective in smokers and non-smokers. Regardless of smoking status and especially for those patients deemed unsuitable for 1 year of potent platelet inhibition this DAPT strategy might be used as an alternative antiplatelet treatment regimen.
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Affiliation(s)
- Martin Orban
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, University Heart Centre Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Disease, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Johannes Rieber
- Department of Cardiology and Intensive Care Medicine, Heart Centre Bogenhausen, Englschalkinger Straße 77, 81925 München, Germany
| | - Martin Hadamitzky
- Department of Radiology, German Heart Center of Munich, Lazarettstraße 36, 80636 München, Germany
| | - Lisa Gross
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Mathias Orban
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Danny Kupka
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Monika Baylacher
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Susan Müller
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Kurt Huber
- 3 Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud Private University, Medical School, Montleartstrasse 35-37, 1160 Vienna, Austria
| | - Lukasz Koltowski
- 1 Department of Cardiology, Medical University of Warsaw, Żwirki i Wigury 61, 02-091 Warszawa, Poland
| | - Zenon Huczek
- 1 Department of Cardiology, Medical University of Warsaw, Żwirki i Wigury 61, 02-091 Warszawa, Poland
| | - Jens Heyn
- Department of Anesthesiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
| | - Claudius Jacobshagen
- Department of Cardiology and Pneumology, Heart Centre/Georg-August-University Göttingen, 37073 Göttingen, Germany
| | - Dániel Aradi
- Department of Cardiology, Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University, Gyógy tér 2 8230 Balatonfüred, Budapest, Hungary
| | - Steffen Massberg
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Ralph Hein
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
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18
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Orban M, Orban MW, Braun D, Deseive S, Kupka D, Stocker T, Stark K, Massberg S, Nabauer M, Hausleiter J. P4717Clinical impact of elevated tricuspid valve gradient after transcatheter tricuspid valve repair. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.1097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Transcatheter edge-to-edge tricuspid valve repair (TTVR) is a novel treatment approach in heart failure patients with moderate-to-severe tricuspid regurgitation (TR) at prohibitive surgical risk.
Aim
The aim of this study was to investigate the mean tricuspid valve gradient (TVG) over time and compare patient characteristics and outcome of patients with a post-procedure TVG of >3 mmHg vs. ≤3 mmHg.
Methods
All patients who were treated between between March 2016 and October 2018 with TTVR were included in this analysis. Trans-thoracic echocardiographic assessment of TVG was performed pre-procedurally, pre-discharge, after 1, 6, and 12 month.
Results
We treated 145 consecutive patients with moderate-to-severe secondary TR with TTVR. Patients were treated with TTVR for severe TR alone (70 patients) or in combination with mitral valve repair for concomitant severe mitral regurgitation and severe or moderate-severe TR with significant annulus dilatation (75 patients). One clip was implanted in 17 (11.7%), 2 clips in 83 (57.2%), 3 clips in 40 (27.6%) and 4 clips in 4 patients (2.8%). Reduction of at least 1 degree of TR was achieved in 136 Patients (93.8%). The median baseline TVG of all patients was 1 mmHg [Inter Quarter Range, IQR 1.0–1.4 mmHg]. The median TVG – measured at post-procedural trans-thoracic echocardiogram pre-discharge – increased to 2 mmHg [IQR, 1.6–3.0 mmHg] and remained constant up to 12 month (2.0 mmHg [IQR 1.0–2.0 mmHg).
Of these, twenty-five patients showed an elevated TVG >3 mmHg post-procedurally. Patients with TVG >3 mmHg were younger (73.1±11.0 vs. 77.5±9.2 years, p=0.038) and presented with lower levels of pro-BNP at baseline (median 2276 ng/l [IQR, 906–5150] vs. 4182 ng/l [2310–8629], p=0.008) compared to patients with TVG ≤3mmHg. All other baseline characteristics were balanced. There were no differences in procedural success (TR reduction of ≥1 grade in 96% vs. 93.3%, p=0.946) and number of clips implanted (p=0.697). At one month follow-up there were no differences in NYHA class (NYHA class ≥3 in 24% vs. 30.8%, p=0.559), quality of life measured with the Minnesota Living With Heart Failure questionnaire (32.0±22.9 vs. 31.1±16.3, p=0.833), 6 minute walking distance (255.5±140.6 vs. 250.5±111.7 metre, p=0.872). The clinical endpoints 1-year mortality (HR 1.07; 95% CI [0.43–2.65], p=0.88) and the combined endpoint mortality and hospitalization for heart failure at one year (HR 1.07; 95% CI [0.46 to 2.48], p=0.88, see Figure) did not differ between patients with a TVG >3 mmHg vs. patients with a TVG ≤3mmHg.
Figure 1
Conclusion
TTVR results in a small increase in the tricuspid valve gradient, which remains constant up to one year. A small cohort of patients shows an elevated TVG higher than 3 mmHg after the procedure. This elevation has no impact on NYHA class at 1 month and the clinical endpoints mortality and hospitalization for heart failure at 1 year.
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Affiliation(s)
- M Orban
- University Hospital of Munich, Munich, Germany
| | - M W Orban
- University Hospital of Munich, Munich, Germany
| | - D Braun
- University Hospital of Munich, Munich, Germany
| | - S Deseive
- University Hospital of Munich, Munich, Germany
| | - D Kupka
- University Hospital of Munich, Munich, Germany
| | - T Stocker
- University Hospital of Munich, Munich, Germany
| | - K Stark
- University Hospital of Munich, Munich, Germany
| | - S Massberg
- University Hospital of Munich, Munich, Germany
| | - M Nabauer
- University Hospital of Munich, Munich, Germany
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19
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Schüpke S, Hein-Rothweiler R, Mayer K, Janisch M, Sibbing D, Ndrepepa G, Hilz R, Laugwitz KL, Bernlochner I, Gschwendtner S, Kupka D, Gori T, Zeiher AM, Schunkert H, Massberg S, Kastrati A. Revacept, a Novel Inhibitor of Platelet Adhesion, in Patients Undergoing Elective PCI-Design and Rationale of the Randomized ISAR-PLASTER Trial. Thromb Haemost 2019; 119:1539-1545. [PMID: 31226721 DOI: 10.1055/s-0039-1692423] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Despite dual antiplatelet therapy patients undergoing percutaneous coronary intervention (PCI) continue to experience periprocedural ischemic events. In addition, all currently used antithrombotic drugs increase the bleeding risk. Thus, there is an unmet clinical need for antithrombotic strategies with improved efficacy and no increase in bleeding. Revacept is a novel, lesion-directed antithrombotic drug that does not interfere with the function of circulating platelets. This dimeric fusion protein of the extracellular domain of glycoprotein VI (the major platelet collagen receptor) and the human Fc-fragment inhibits collagen-mediated platelet adhesion and subsequent aggregation at the site of vascular injury. The randomized, double-blinded, phase II ISAR-PLASTER trial is based on extensive preclinical evaluation of Revacept and a favorable first-in-man trial. A total of 332 patients with stable coronary artery disease undergoing elective PCI will be randomized to either Revacept 160 mg, Revacept 80 mg, or placebo administered as single intravenous infusion directly before the intervention, on top of standard dual antiplatelet therapy and either heparin or bivalirudin, based on local practice and current guidelines. The primary endpoint is the composite of death or myocardial injury (defined as increase in high sensitivity troponin T ≥ 5 times the upper limit of normal) at 48 hours. The safety endpoint is bleeding of class 2 or higher according to the Bleeding Academic Research Consortium at 30 days. This phase II randomized, double blind trial will assess for the first time the efficacy and safety of Revacept-a lesion-directed inhibitor of platelet adhesion-in patients undergoing elective PCI.
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Affiliation(s)
- Stefanie Schüpke
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Ralph Hein-Rothweiler
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Katharina Mayer
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität, Munich, Germany
| | - Marion Janisch
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität, Munich, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität, Munich, Germany
| | - Raphaela Hilz
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität, Munich, Germany
| | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany
| | - Isabell Bernlochner
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany
| | - Sarah Gschwendtner
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Danny Kupka
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Tommaso Gori
- Zentrum für Kardiologie, University Hospital Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany
| | - Andreas M Zeiher
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Germany
- Cardiology Division, Department of Medicine III, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Steffen Massberg
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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20
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Gross L, Kupka D, Trenk D, Geisler T, Hadamitzky M, Löw A, Orban M, Huber K, Kiss RG, Merkely B, Huczek Z, Beuthner BE, Hein-Rothweiler R, Baylacher M, Rizas K, Massberg S, Aradi D, Sibbing D, Jacobshagen C. Gender and Outcomes following Guided De-Escalation of Antiplatelet Treatment in Acute Coronary Syndrome Patients: The TROPICAL-ACS Gender Substudy. Thromb Haemost 2019; 119:1527-1538. [PMID: 31226717 DOI: 10.1055/s-0039-1692441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This prespecified analysis of the TROPICAL-ACS trial aimed to assess the impact of gender on clinical outcomes and platelet reactivity (PR) following guided de-escalation of dual antiplatelet treatment (DAPT) in acute coronary syndrome (ACS) patients. BACKGROUND Guided de-escalation of DAPT was recently identified as an effective alternative treatment strategy in ACS. METHODS We used Cox proportional hazards models and linear regression analysis to assess the interaction of gender with clinical endpoints and PR. RESULTS In both male (n = 2,052) and female (n = 558) patients, the 1-year incidence of the primary endpoint did not differ in guided de-escalation versus control group patients (male: 7.0% vs. 9.0%; hazard ratio [HR], 0.78, 95% confidence interval [CI], 0.57-1.06, p = 0.11; female: 8.4% vs. 9.2%; HR, 0.92, 95% CI, 0.53-1.62, p = 0.76, p int = 0.60). The 1-year incidence of combined ischemic events (male: 2.5% vs. 3.3%; HR, 0.76, 95% CI, 0.46-1.26, p = 0.29; female: 2.2% vs. 2.8%; HR, 0.78,95% CI, 0.27-2.25, p = 0.65, p int = 0.96) as well as Bleeding Academic Research Consortium ≥ 2 bleeding (male: 4.6% vs. 6.0%; HR, 0.77, 95% CI, 0.52-1.12, p = 0.17; female: 6.2% vs. 6.4%; HR, 0.99, 95% CI, 0.51-1.92, p = 0.97, p int = 0.51) was similar in the guided de-escalation versus control group for both male and female patients. Interaction testing revealed no significant impact of gender on PR levels (prasugrel or clopidogrel) across treatment groups (p int = 0.72). CONCLUSION Guided de-escalation of DAPT appears to be equally safe and effective in women and men. Especially in patients with increased bleeding risk and independent from gender, a guided DAPT de-escalation strategy may be used as an alternative treatment strategy. CLINICAL TRIAL REGISTRATION URL: https//www.clinicaltrials.gov. Unique Identifier: NCT: 01959451.
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Affiliation(s)
- Lisa Gross
- Department of Cardiology, LMU München, Munich, Germany
| | - Danny Kupka
- Department of Cardiology, LMU München, Munich, Germany
| | - Dietmar Trenk
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Tobias Geisler
- Department of Cardiology, University Hospital of Tuebingen, Tübingen, Germany
| | - Martin Hadamitzky
- Department of Radiology, German Heart Center of Munich, Munich, Germany
| | - Anja Löw
- Department of Cardiology, LMU München, Munich, Germany
| | - Martin Orban
- Department of Cardiology, LMU München, Munich, Germany
| | - Kurt Huber
- Wilhelminen Hospital, 3rd Medical Department for Cardiology and Emergency Medicine, and Sigmund Freud University, Medical School, Vienna, Austria
| | | | - Bela Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Bo Eric Beuthner
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
| | | | | | | | - Steffen Massberg
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Daniel Aradi
- Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Dirk Sibbing
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Claudius Jacobshagen
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
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21
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Kupka D, Sibbing D. De-Escalation of P2Y12 Receptor Inhibitor Therapy after Acute Coronary Syndromes in Patients Undergoing Percutaneous Coronary Intervention. Korean Circ J 2018; 48:863-872. [PMID: 30238704 PMCID: PMC6158449 DOI: 10.4070/kcj.2018.0255] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/12/2018] [Indexed: 01/02/2023] Open
Abstract
Dual antiplatelet therapy (DAPT) - a combination of a P2Y₁₂ receptor inhibitor and aspirin - has revolutionized antithrombotic treatment. Potent P2Y₁₂ inhibitors such as prasugrel and ticagrelor exhibit a strong and more consistent platelet inhibition when compared to clopidogrel. Therefore, ticagrelor and prasugrel significantly reduce ischemic events, but at an expense of an increased bleeding risk in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). These observations have engaged intensive clinical research in alternative DAPT regimens to achieve sufficient platelet inhibition with an acceptable bleeding risk. Our review focusses on P2Y₁₂ receptor therapy de-escalation defined as a switch from a potent antiplatelet agent (ticagrelor or prasugrel) to clopidogrel. Recently, both unguided (platelet function testing independent) and guided (platelet function testing dependent) DAPT de-escalation strategies have been investigated in different clinical studies and both switching strategies could be possible options to prevent bleeding complications without increasing ischemic risk. In light of the still limited data currently available, future large-scale trials should accumulate more data on various DAPT de-escalation regimens with both ticagrelor and prasugrel in unguided and guided de-escalation approaches. In the current review we aim at summarizing and discussing the current evidence on this still emerging topic in the field of antiplatelet treatment.
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Affiliation(s)
- Danny Kupka
- Department of Cardiology, LMU Munich, Marchioninistraße 15, München, Germany
- DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, München, Germany.
| | - Dirk Sibbing
- Department of Cardiology, LMU Munich, Marchioninistraße 15, München, Germany
- DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, München, Germany. ,
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22
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Abstract
INTRODUCTION P2Y12 inhibitors are a critical component of dual antiplatelet therapy (DAPT), which is the superior strategy to prevent arterialthrombosis in patients with acute coronary syndromes (ACS) and undergoing stent implantation.. Areas covered: Basic science articles, clinical studies, and reviews from 1992-2017 were searched using Pubmed library to collet impactful literature. After an introduction to the purinergic receptor biology, this review summarizes current knowledge on P2Y12 receptor inhibitors. Furthermore, we describe the subsequent improvements of next-generation P2Y12 receptor inhibitors facing the ambivalent problem of bleeding events versus prevention of arterial thrombosis in a variety of clinical settings. Therefore, we summarize data from relevant preclinical and clinical trials of currently approved P2Y12 receptor inhibitors (clopidogrel, prasugrel, ticagrelor, cangrelor) and provide strategies of drug switching and management of bleeding events. Expert opinion: An enormous amount of pharmacologic and clinical data is available for the application of P2Y12 receptor inhibitors. Today prasugrel, ticagrelor and clopidogrel are the standard of care drugs during dual antiplatelet therapy for ACS patients, but have considerable rates of bleeding. Recent and future clinical trials will provide evidence for subsequent escalation and de-escalation strategies of P2Y12 receptor inhibition. These data may pave the way for an evidence-based, individualized P2Y12 receptor inhibitor therapy.
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Affiliation(s)
- Danny Kupka
- a Department of Cardiology , LMU München , Munich , Germany.,b DZHK (German Centre for Cardiovascular Research) , Munich Heart Alliance , Munich , Germany
| | - Dirk Sibbing
- a Department of Cardiology , LMU München , Munich , Germany.,b DZHK (German Centre for Cardiovascular Research) , Munich Heart Alliance , Munich , Germany
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23
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Neumann K, Castiñeiras-Vilariño M, Höckendorf U, Hannesschläger N, Lemeer S, Kupka D, Meyermann S, Lech M, Anders HJ, Kuster B, Busch DH, Gewies A, Naumann R, Groß O, Ruland J. Clec12a is an inhibitory receptor for uric acid crystals that regulates inflammation in response to cell death. Immunity 2014; 40:389-99. [PMID: 24631154 DOI: 10.1016/j.immuni.2013.12.015] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 12/24/2013] [Indexed: 12/14/2022]
Abstract
Recognition of cell death by the innate immune system triggers inflammatory responses. However, how these reactions are regulated is not well understood. Here, we identify the inhibitory C-type lectin receptor Clec12a as a specific receptor for dead cells. Both human and mouse Clec12a could physically sense uric acid crystals (monosodium urate, MSU), which are key danger signals for cell-death-induced immunity. Clec12a inhibited inflammatory responses to MSU in vitro, and Clec12a-deficient mice exhibited hyperinflammatory responses after being challenged with MSU or necrotic cells and after radiation-induced thymocyte killing in vivo. Thus, we identified a negative regulatory MSU receptor that controls noninfectious inflammation in response to cell death that has implications for autoimmunity and inflammatory disease.
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Affiliation(s)
- Konstantin Neumann
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Mercedes Castiñeiras-Vilariño
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Ulrike Höckendorf
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Nicole Hannesschläger
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Simone Lemeer
- Lehrstuhl für Proteomik und Bioanalytik, Technische Universität München, Emil Erlenmeyer Forum 5, 85354 Freising, Germany
| | - Danny Kupka
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Svenia Meyermann
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Maciej Lech
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München (LMU), 80336 München, Germany
| | - Hans-Joachim Anders
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München (LMU), 80336 München, Germany
| | - Bernhard Kuster
- Lehrstuhl für Proteomik und Bioanalytik, Technische Universität München, Emil Erlenmeyer Forum 5, 85354 Freising, Germany
| | - Dirk H Busch
- Institut für Medizinische Mikrobiologie, Immunologie und Hygiene, Technische Universität München, 81675 Munich, Germany
| | - Andreas Gewies
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Ronald Naumann
- Max Planck Institute of Molecular Cell Biology and Genetics, 01307 Dresden, Germany
| | - Olaf Groß
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany
| | - Jürgen Ruland
- Institut für Klinische Chemie und Pathobiochemie, Klinikum rechts der Isar, Technische Universität München, 81675 Munich, Germany.
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Kupka D, Wende E, Klos A, Zipfel P. Pra1 binds and inactivates effector functions of the anaphylatoxin C3a. Mol Immunol 2011. [DOI: 10.1016/j.molimm.2011.06.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kupka D, Luo S, Hippler UC, Hoffmann R, Hube B, Rupp S, Zipfel PF. Candida albicans CRASP binds anaphylatoxin C3a and inhibits C3a mediated immune effector functions. Mol Immunol 2010. [DOI: 10.1016/j.molimm.2010.05.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Skvarla J, Kupka D, Návesnáková Y, Skvarlová A. An evaluation of the outer membrane charge and softness of Thiobacillus ferrooxidans by the Ohshima's electrophoretic model of a "soft" particle. Folia Microbiol (Praha) 2002; 47:218-24. [PMID: 12094728 DOI: 10.1007/bf02817641] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The surface charge of bacterial cells plays an important role in their interfacial physiology and adhesion to substrata mediated by the electrostatic double-layer interaction. The surface charge or potential of biological cells is generally calculated from the experimentally measurable electrophoretic velocity of these cells migrating in an external electric field, applying the well-known Smoluchowski equation which is valid for "hard" particles with a sharp interface. However, bacterial cells possessing a structured outer membrane of a finite thickness (dependent on the ionic strength and pH of the surrounding liquid medium) are expected to obey Ohshima's electrophoretic mobility equation derived recently for "soft" particles. The electrophoretic mobility of Thiobacillus ferrooxidans was measured here by the fully automated technique of electrophoretic light scattering, based on the proportionality between the mobility and the Doppler shift in the frequency of light scattered by electrophoresing cells. Agreement was obtained between the experimentally determined electrophoretic mobility expressed as a function of low ionic strength (60-6000 mumol/L) at different pH values and the best-fit theoretical predictions of the "soft" particle electrophoresis theory, which is better than in the case of applying the Smoluchowski formula. The best-fit surface-charge and softness parameters predict a rather rigid and low-charge outer membrane of the bacterium examined, as compared to the parameters obtained for other bacteria in media of high ionic strength.
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Affiliation(s)
- J Skvarla
- Department of Mineralurgy and Environmental Technologies, Technical University, 04 384 Kosice, Slovakia.
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