Publications by authors named "Aron Frederik Popov"

186 Publications

Response to letter to the editor: "Toward the more justified strategy in off-pump coronary bypass grafting for patients with severely reduced left ventricular function" by Fukonaga et al.

J Card Surg 2021 Apr 2. Epub 2021 Apr 2.

Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Ludwigsburg, Germany.

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http://dx.doi.org/10.1111/jocs.15537DOI Listing
April 2021

Off-pump coronary artery bypass grafting for patients with severely reduced ventricular function-A justified strategy?

J Card Surg 2021 Feb 5. Epub 2021 Feb 5.

Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany.

Background And Aim: Low ejection fraction (EF) has been identified as a main risk factor for perioperative complications and mortality after coronary artery bypass grafting (CABG). The purpose of this study was to compare the efficacy and early as well as midterm outcomes of off-pump CABG (OPCAB) and conventional CABG (ONCAB) surgery in patients with reduced EF.

Methods: We performed a retrospective review of patient demographics, preoperative risk factors, operative and postoperative outcomes of patients with left ventricular EF (LV-EF) ≤35%, who underwent CABG at our institution between January 2015 and December 2017. Propensity score and multivariate logistic regression analysis were used to compare risk adjusted outcomes between groups.

Results: Overall, 111 consecutive CABG-patients with LV-EF ≤ 35% underwent either ONCAB (46 patients, 41.4%) or OPCAB surgery (65 patients, 58.6%). There was no difference in early mortality (5% vs. 7.5%, p = .64) between groups. After propensity score matching, OPCAB-patients required significantly less re-sternotomies for bleeding (20% vs. 2.5%, p = .03) and consequently received significantly less blood transfusions (57.5% vs. 32.5%, p = .03). Fewer OPCAB-patients experienced low cardiac output syndrome (22.5% vs. 42.5%, p = .06) and suffered from postoperative delirium (22.5% vs. 42.5%, p = .06). There were no differences in completeness of revascularization between groups (median 1 (1.0-1.33; 1.0-1.33) OPCAB versus median 1 (1-1.33; 0.67-2) ONCAB, p = .95). Survival after 6 months, one year and three years was similar for ONCAB- and OPCAB-patients (ONCAB 92.3%, 89.4%, and 89.4% vs. OPCAB 89.8%, 85.7%, and 82.1%; p = .403). More ONCAB-patients needed a coronary re-intervention during follow-up (8.6% vs. 2.3%, p = .402).

Conclusion: OPCAB-surgery is a safe and effective option for patients with reduced EF. Furthermore, it does not come at the expense of less complete revascularization or increased coronary re-intervention during early follow-up.
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http://dx.doi.org/10.1111/jocs.15259DOI Listing
February 2021

Expert Consensus Paper: Lateral Thoracotomy for Centrifugal Ventricular Assist Device Implant.

Ann Thorac Surg 2020 Dec 9. Epub 2020 Dec 9.

Department of Cardiothoracic Surgery, Newark Beth Israel Medical Center, USA.

Background: The increasing prevalence of heart failure has led to the expanded use of left ventricle assist devices (VADs) for end-stage heart failure patients worldwide. Technological improvements witnessed the development of miniaturized VADs and their implantation through less traumatic "non-full sternotomy approaches" using a lateral thoracotomy (LT). Although adoption of the LT approach is steadily growing, there remains a lack of consensus regarding patient selection, details of the surgical technique, and perioperative management. Furthermore, the current literature does not offer prospective randomized studies or evidence-based guidelines for LT-VAD implantation.

Methods: A worldwide group of LT-VAD experts was convened to openly discuss these key topics. After a PubMed search and review with all authors, a consensus was reached and an expert consensus paper on LT-VAD implantation was developed.

Results: This document aims to guide clinicians in the selection of patients suitable for LT approaches and preoperative optimization. Details of operative techniques are described, with an overview of hemisternotomy and bilateral thoracotomy approaches. A review of the best surgical practices for placement of the pump, inflow cannula and outflow graft provides advice on the best surgical strategies to avoid device malpositioning while optimizing VAD function. Experts´ opinions on cardiopulmonary bypass, postoperative management, and approaches for pump exchange and explant are presented. This paper also emphasizes the critical need for multidisciplinary teams and specified training.

Conclusions: This expert consensus paper provides a compact guide to LT for VAD implantation, from patient selection through intraoperative tips and postoperative management.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.063DOI Listing
December 2020

Left ventricular unloading with transaortic Impella 2.5 implantation in a pediatric patient supported by extracorporeal life support.

Artif Organs 2020 Nov 13. Epub 2020 Nov 13.

Department of Cardiovascular and Thoracic Surgery, University Hospital Tübingen, Tübingen, Germany.

We report the case of a 12-year old female patient with Friedreich's ataxia and diabetes mellitus. Due to a progressive multiorgan failure, a veno-arterial extracorporeal membrane oxygenation was implanted through the axillary vessels. However, due to a lack of ejection and severe dilatation of the left ventricle, an Impella 2.5 was implanted. Due to the small diameter of the femoral arteries, we performed a trans-aortic implantation through a median sternotomy via a Dacron tube graft. We report on the procedure and perioperative outcome.
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http://dx.doi.org/10.1111/aor.13862DOI Listing
November 2020

ECMO implantation training: Needle penetration in 3D printable materials and porcine aorta.

Perfusion 2020 Nov 11:267659120967194. Epub 2020 Nov 11.

Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Tübingen, Germany.

Aim: Patients with cardiogenic shock or ARDS, for example, in COVID-19/SARS-CoV-2, may require extracorporeal membrane oxygenation (ECMO). An ECLS/ECMO model simulating challenging vascular anatomy is desirable for cannula insertion training purposes. We assessed the ability of various 3D-printable materials to mimic the penetration properties of human tissue by using porcine aortae.

Methods: A test bench for needle penetration and piercing in sampled porcine aorta and preselected 3D-printable polymers was assembled. The 3D-printable materials had Shore A hardness of 10, 20, and 50. 17G Vygon 1.0 × 1.4 mm × 70 mm needles were used for penetration tests.

Results: For the porcine tissue and Shore A 10, Shore A 20, and Shore A 50 polymers, penetration forces of 0.9036 N, 0.9725 N, 1.0386 N, and 1.254 N were needed, respectively. For piercing through the porcine tissue and Shore A 10, Shore A 20, and Shore A 50 polymers, forces of 0.8399 N, 1.244 N, 1.475 N, and 1.482 N were needed, respectively. ANOVA showed different variances among the groups, and pairwise two-tailed -tests showed significantly different needle penetration and piercing forces, except for penetration of Shore A 10 and 20 polymers (p = 0.234 and p = 0.0857). Significantly higher forces were required for all other materials.

Conclusion: Shore A 10 and 20 polymers have similar needle penetration properties compared to the porcine tissue. Significantly more force is needed to pierce through the material fully. The most similar tested material to porcine aorta for needle penetration and piercing in ECMO-implantation is the silicon Shore A 10 polymer. This silicon could be a 3D-printable material in surgical training for ECMO-implantation.
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http://dx.doi.org/10.1177/0267659120967194DOI Listing
November 2020

The Impact of Obesity on Left Ventricular Assist Device Outcomes.

Medicina (Kaunas) 2020 Oct 23;56(11). Epub 2020 Oct 23.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, 45122 Essen, Germany.

: The understanding of high body mass index (BMI) and outcomes after Left Ventricular Assist Device (LVAD) implantation continues to evolve and the relationship has not been established yet. In this study, we investigated the effects of obesity (BMI > 30 kg/m) on post-LVAD implantation outcomes. HeartWare LVAD and Heart Mate III LVAD were implanted. The primary outcome that was measured was mortality (in-hospital and on follow-up). The secondary outcomes that were measured were major adverse events. At our institution, the West German Heart and Vascular Center (Essen, Germany), from August 2010 to January 2020, a total of 210 patients received a long-term LVAD. Patients were stratified according to BMI ≥ 30 kg/m representing the obesity threshold. The first group ( = 162) had an average BMI of 24.2 kg/m (±2.9), and the second group ( = 48) had an average BMI of 33.9 kg/m (±3.2). Baseline demographics were analysed alongside comorbidities per group. Overall mortality was not significantly different between the obese group (51.1% = 24) and the nonobese group (55.2%, = 85) ( = 0.619). The difference between the mean duration of survival of patients who expired after hospital discharge was insignificant (2.1 years ± 1.6, group 1; 2.6 years ± 1.5, group 2; = 0.29). In-hospital mortality was unvaried between the two groups: group 1: = 34 (44% out of overall group 1 deaths); group 2: = 11 (45.8% out of overall group 2 deaths) ( > 0.05). Postoperative complications were unvaried between the obese and the non-obese group (all with > 0.05). However, a significant difference was found with regards to follow-up neurological complications (18.5% vs. 37.8%, = 0.01) and LVAD thrombosis (14.7% vs. 33.3%, = 0.01), as both were higher in the obese population. Obesity does not form a barrier for LVAD implantation in terms of mortality (in-hospital and on follow up). However, a significantly higher incidence of follow-up LVAD thrombosis and neurological complications has been found in the obese group of patients.
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http://dx.doi.org/10.3390/medicina56110556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690722PMC
October 2020

Traumatic brain injury donation is not associated with poorer outcomes following orthotopic heart transplantation.

Int J Cardiol 2021 Jan 12;323:192-193. Epub 2020 Sep 12.

Department of Thoracic and Cardiovascular Surgery, University Hospital of Tübingen, Tübingen, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2020.09.015DOI Listing
January 2021

Is it Safe for Patients with Left Ventricular Assist Devices to Undergo Non-Cardiac Surgery?

Medicina (Kaunas) 2020 Aug 23;56(9). Epub 2020 Aug 23.

Department of Thoracic and Cardiovascular Surgery, University Hospital of Tübingen, 72070 Tübingen, Germany.

Since the first use of ventricular assist devices (VADs) as bridge to recovery and bridge to cardiac transplantation in the early 1990s, significant technological advances have transformed VAD implantation into a routine destination therapy. With improved survival, many patients present for cardiac surgery for conditions not directly related to their permanent mechanical circulatory support. The aim of this study was to analyze the indications and outcomes of non-cardiac surgeries (NCSs) of left ventricular assist device (LVAD) patients in tertiary center. We present a single-center experience after 151 LVAD implantations in 138 consecutive patients between 2012-2019 who had to undergo NCS during a follow-up period of 37 +/- 23.4 months on left ventricular assist device (LVAD). A total of 105 procedures was performed in 63 LVAD recipients, resulting in peri-operative mortality of 3.8%. Twenty-five (39.7%) of patients underwent multiple surgeries. We found no significant difference in cumulative survival associated with the performed surgical interventions ( = 0.469). We demonstrated good overall clinical outcomes in LVAD patients undergoing NCS. With acceptable peri-operative mortality, NCS can be safely performed in LVAD patients on long-term support.
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http://dx.doi.org/10.3390/medicina56090424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7559908PMC
August 2020

Mechanical circulatory support for cardiovascular complications in a young COVID-19 patient.

J Card Surg 2020 Nov 2;35(11):3173-3175. Epub 2020 Aug 2.

Department of Cardiothoracic and Vascular Surgery, University of Tuebingen, Eberhard-Karls-University Tübingen, Tübingen, Germany.

Background: The current coronavirus (COVID-19) pandemic is associated with severe pulmonary and cardiovascular complications.

Case Presentation: This report describes a young patient with COVID-19 without any comorbidity presenting with severe cardiovascular complications, manifesting with pulmonary embolism, embolic stroke, and right heart failure.

Conclusion: Management with short-term mechanical circulatory support, including different cannulation strategies, resulted in a successful outcome despite his critical cardiovascular status.
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http://dx.doi.org/10.1111/jocs.14916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436693PMC
November 2020

Outcomes with Ventricular Assist Device Therapy for Advanced Heart Failure in North Macedonia: First Annual Report

Heart Surg Forum 2020 06 26;23(4):E441-E446. Epub 2020 Jun 26.

Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia

Introduction: Mechanical circulatory support by a continuous-flow ventricular assist device (VAD) improves survival and quality of life in selected patients with advanced heart failure. Developing countries have been struggling to construct a contemporary and effective health care system to manage advanced heart failure. This observation represents the first annual report on clinical outcomes with VAD for patients with advanced heart failure in the Republic of North Macedonia.

Methods: Data from all patients with VAD implantations between November 2018 and December 2019 were collected. The etiology of the heart failure was dilated cardiomyopathy in 4 patients (57%), ischemic cardiomyopathy in 2 (28%), and hypertrophic cardiomyopathy in 1 (14%). The primary outcome was survival; secondary outcomes included adverse events defined according to the Interagency Registry for Mechanically Assisted Circulatory Support.

Results: A total of 7 patients (85% males, median age 56 years) received a VAD; 5 of them received left VAD, and the remaining 2 received biventricular VAD. There were no deaths. Observed morbidity during a mean follow-up of 216 days included 3 bleeding events in 1 patient, 2 patients with superficial driveline infection, and 1 minor stroke and a pump thrombosis, which were treated with VAD exchange. Significant improvement in quality of life, as assessed by the Kansas City Cardiomyopathy Questionnaire and the Functional Independence Measure™ instrument, was seen with all patients.

Conclusions: Our results demonstrate a successful initiation of the VAD program in the Republic of North Macedonia. Proper training of a dedicated HF team supports the reproducibility of this treatment in developing countries.
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http://dx.doi.org/10.1532/hsf.3025DOI Listing
June 2020

Video assisted thoracoscopic sympathectomy for intractable recurrent VT after minimal-invasive LVAD implantation.

J Card Surg 2020 Jul 21;35(7):1708-1710. Epub 2020 May 21.

Department of Thoracic and Cardiovascular Surgery, University Medical Center Tübingen, Eberhard Karls Universität Tübingen, Tübingen, Germany.

Background: Recurrent ventricular tachycardia (VT) can occur after left ventricular assist device (LVAD) implantation. In this case, medical treatment might be insufficient. We report a case of a left-sided thoracoscopic sympathectomy as a feasible treatment escalation in intractable VT.

Case Report: A 72-year-old patient underwent an internal cardioverter defibrillator (ICD) implantation as primary prophylaxis for VTs in the setting of staged heart failure therapy. Afterwards, due to a progressive dilative cardiomyopathy he underwent a minimal-invasive LVAD implantation (HeartWare, Medtronic). After an uneventful minimal-invasive LVAD-implantation the patient was discharged to a rehabilitation program. However, after 7 weeks he developed recurrent VTs which were successfully terminated by ICD shocks deliveries leading to severe discomfort and frequent hospitalizations. Eventually, the patient was admitted with an electrical VT storm. Successful endocardial catheter ablation of all inducible VTs were performed combined with multiple rearrangements of his oral antiarrhythmic medication. However, all these treatments could not suppress further occurrence of VTs. After an interdisciplinary discussion the patient agreed to a left-sided video-assisted thoracoscopic sympathectomy. After a follow up of 150 days the patient was free from VTs apart from one short event.

Conclusion: We believe video-assisted thoracoscopic sympathectomy might be a surgical treatment option in patients with intractable recurrent VTs after catheter ablation of VT reentrant substrate even after minimal-invasive LVAD implantation.
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http://dx.doi.org/10.1111/jocs.14639DOI Listing
July 2020

Accidental finding of large aortic thrombus formation.

Eur J Cardiothorac Surg 2020 08;58(2):398

Department of Thoracic and Cardiovascular Surgery, University Hospital of Tübingen, Tübingen, Germany.

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http://dx.doi.org/10.1093/ejcts/ezaa088DOI Listing
August 2020

Favorable 90-Day Mortality in Obese Caucasian Patients with Septic Shock According to the Sepsis-3 Definition.

J Clin Med 2019 Dec 24;9(1). Epub 2019 Dec 24.

Department of Anesthesiology, University Medical Center, Georg August University, D-37075 Goettingen, Germany.

Septic shock is a frequent life-threatening condition and a leading cause of mortality in intensive care units (ICUs). Previous investigations have reported a potentially protective effect of obesity in septic shock patients. However, prior results have been inconsistent, focused on short-term in-hospital mortality and inadequately adjusted for confounders, and they have rarely applied the currently valid Sepsis-3 definition criteria for septic shock. This investigation examined the effect of obesity on 90-day mortality in patients with septic shock selected from a prospectively enrolled cohort of septic patients. A total of 352 patients who met the Sepsis-3 criteria for septic shock were enrolled in this study. Body-mass index (BMI) was used to divide the cohort into 24% obese (BMI ≥ 30 kg/m) and 76% non-obese (BMI < 30 kg/m) patients. Kaplan-Meier survival analysis revealed a significantly lower 90-day mortality (31% vs. 43%; = 0.0436) in obese patients compared to non-obese patients. Additional analyses of baseline characteristics, disease severity, and microbiological findings outlined further statistically significant differences among the groups. Multivariate Cox regression analysis estimated a significant protective effect of obesity on 90-day mortality after adjustment for confounders. An understanding of the underlying physiologic mechanisms may improve therapeutic strategies and patient prognosis.
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http://dx.doi.org/10.3390/jcm9010046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019854PMC
December 2019

Aortic Valve Neocuspidization with Glutaraldehyde-Treated Autologous Pericardium (Ozaki Procedure) - A Promising Surgical Technique.

Braz J Cardiovasc Surg 2019 12 1;34(5):610-614. Epub 2019 Dec 1.

Division of Cardiovascular Surgery, Pronto-Socorro Cardiológico de Pernambuco - Prof. Luiz Tavares, PROCAPE, Recife, Brazil.

In cases of aortic valve disease, prosthetic valves have been increasingly used for valve replacement, however, there are inherent problems with prostheses, and their quality in the so-called Third World countries is lower in comparison to new-generation models, which leads to shorter durability. Recently, transcatheter aortic valve replacement has been explored as a less invasive option for patients with high-risk surgical profile. In this scenario, aortic valve neocuspidization (AVNeo) has emerged as another option, which can be applied to a wide spectrum of aortic valve diseases. Despite the promising results, this procedure is not widely spread among cardiac surgeons yet. Spurred on by the last publications, we went on to write an overview of the current practice of state-of-the-art AVNeo and its results.
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http://dx.doi.org/10.21470/1678-9741-2019-0304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6852454PMC
December 2019

Targeted CT-guided punction of an intrapericardial abscess in HeartWare left ventricular patient. New diagnostic tool to highlight patients on the heart transplant waiting list.

J Card Surg 2019 Nov 3;34(11):1361-1362. Epub 2019 Sep 3.

Division of Thoracic and Cardiovascular Surgery, Johan Wolfgang Goethe University Frankfurt am Main, Frankfurt, Germany.

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http://dx.doi.org/10.1111/jocs.14239DOI Listing
November 2019

Reprogramming of Urine-Derived Renal Epithelial Cells into iPSCs Using srRNA and Consecutive Differentiation into Beating Cardiomyocytes.

Mol Ther Nucleic Acids 2019 Sep 31;17:907-921. Epub 2019 Jul 31.

Department of Thoracic and Cardiovascular Surgery, University Hospital Tübingen, Calwerstraße 7/1, 72076 Tübingen, Germany. Electronic address:

The generation of induced pluripotent stem cells (iPSCs) from patient's somatic cells and the subsequent differentiation into desired cell types opens up numerous possibilities in regenerative medicine and tissue engineering. Adult cardiomyocytes have limited self-renewal capacity; thus, the efficient, safe, and clinically applicable generation of autologous cardiomyocytes is of great interest for the treatment of damaged myocardium. In this study, footprint-free iPSCs were successfully generated from urine-derived renal epithelial cells through a single application of self-replicating RNA (srRNA). The expression of pluripotency markers and the in vitro as well as in vivo trilineage differentiation were demonstrated. Furthermore, the resulting iPSCs contained no residual srRNA, and the karyotyping analysis demonstrated no detectable anomalies. The cardiac differentiation of these iPSCs resulted in autologous contracting cardiomyocytes after 10 days. We anticipate that the use of urine as a non-invasive cell source to obtain patient cells and the use of srRNA for reprogramming into iPSCs will greatly improve the future production of clinically applicable cardiomyocytes and other cell types. This could allow the regeneration of tissues by generating sufficient quantities of autologous cells without the risk of immune rejection.
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http://dx.doi.org/10.1016/j.omtn.2019.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6723182PMC
September 2019

Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy-Current Evidence and Practice.

Thromb Haemost 2019 10 17;119(10):1590-1605. Epub 2019 Aug 17.

Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.

As the number of, and the indications for, structural heart interventions are increasing worldwide, the optimal secondary prevention to reduce device thrombosis is becoming more important. To date, most of the recommendations are empiric. The current review discusses mechanisms behind device-related thrombosis, the available evidence with regard to antithrombotic regimen after cardiac device implantation, as well as providing an algorithm for identification of risk factors for device thrombogenicity and for management of device thrombosis after implantation of patent foramen ovale and left atrial appendage occluders, MitraClips/transcatheter mitral valve replacement, pacemaker leads, and left ventricular assist devices. Of note, the topic of antithrombotic therapy and thrombogenicity of prostheses in aortic position (transcatheter aortic valve replacement, surgical, mechanical, and bioprostheses) is not part of the present article and is discussed in detail in other contemporary focused articles.
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http://dx.doi.org/10.1055/s-0039-1694751DOI Listing
October 2019

Minimally invasive embolectomy of HeartWare left ventricular assist device outflow graft.

J Thorac Dis 2019 Apr;11(Suppl 6):S957-S959

Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.

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http://dx.doi.org/10.21037/jtd.2019.03.82DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535482PMC
April 2019

The role of extracorporeal life support in the management with severe idiopathic pulmonary artery hypertension undergoing lung transplantation: are those patients referred too late?

J Thorac Dis 2019 Apr;11(Suppl 6):S929-S937

Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Middlesex, London, UK.

Background: Idiopathic pulmonary artery hypertension (iPAH) is a relatively minor indication for lung transplantation (LTx) with comparatively poorer outcomes. Extracorporeal life support (ECLS) in various forms is increasingly being used in the management of this entity. However, the data and experience with this therapy remains limited. We evaluated the role of ECLS in the management of severe iPAH patients as a bridge to LTx as well as post LTx support.

Methods: A retrospective analysis of iPAH patients that received LTx between January 2007 and May 2014 was performed. Early- and mid-term outcomes were analyzed for this patient cohort. Also, early and mid-term outcomes after LTx were compared to the control group of patients with other diagnoses using unadjusted analysis and 1:3 propensity score matching.

Results: Of 321 LTx performed during the study period in our centre 15 patients had iPAH as a cause of end-stage lung disease. Four iPAH (27%) patients were bridged to LTx utilizing ECLS in the form of veno-arterial ECMO and extra-corporeal CO removal device, whereas 9 patients (60%) required ECLS support for primary graft dysfunction (PGD) after surgery. Patients with iPAH required more frequently on-pump LTx, both pre and post LTx ECLS, and had significantly lower pO/FiO ratio at 24, 48 and 72 hours after LTx. Also iPAH patients had significantly longer ICU and hospital stay. Whereas the incidence of postoperative bronchiolitis obliterans syndrome (BOS) and rejection was comparable to the control group, overall cumulative survival with up to 6 years follow-up was significantly poorer in the iPAH group. After propensity score matching, the results in terms of postoperative outcomes remained as in the unadjusted analysis.

Conclusions: ECLS is an essential tool in the armamentarium of any lung transplant program treating iPAH with a potential of bridge patients to transplantation and to overcome graft dysfunction after LTx. Despite utilization of ECLS in the management of iPAH, the outcomes in terms of primary graft failure and survival remain poor compared to patients with other diagnoses.
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http://dx.doi.org/10.21037/jtd.2019.04.58DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535489PMC
April 2019

Results of concomitant groin-free percutaneous temporary RVAD support using a centrifugal pump with a double-lumen jugular venous cannula in LVAD patients.

J Thorac Dis 2019 Apr;11(Suppl 6):S913-S920

Department of Cardiac Surgery, University Hospital of Heidelberg, Heidelberg, Germany.

Background: Modern left ventricular assist devices (LVAD) have evolved to become standard of care in severe heart failure (HF) patients. Right HF (RHF) is a major complication responsible for early mortality. Several techniques for temporary right ventricular assist device (t-RVAD) have been described before, baring relevant disadvantages such as limited mobilization or the need for re-thoracotomy. We describe the results of an alternative technique for t-RVAD using the Tandem Heart™ with ProtekDuo™ cannula.

Methods: An institutional retrospective single centre outcome analysis was performed including all permanent LVAD recipients with concomitant groin-free t-RVAD support.

Results: Between October 2015 and September 2017, 11 patients (10 male, 90.9%) were included. Preoperative NYHA class was 3.8±0.75 and INTERMACS class 3.5±1.5. Four (36.4%) patients were already on mechanical circulatory support (MCS) at time of implantation with 4 (36.4%) patients already on inotropic support. All LVAD implantations were performed on-pump and 3 cases (27.3%) were re-do cases. Mean t-RVAD duration was 16.8±9.5 days. Ten patients (90.9%) could be weaned from temporary RVAD support, 1 patient deceased on support. Mean ICU stay was 23.8±16.5 days, while 30-day survival was 72.7%. Follow-up was complete with 214.7±283 days. Three patients (27.3%) died following multi-organ failure (MOF), 1 patient (9.1%) following intracranial bleed 12 days after t-RVAD explantation. No severe t-RVAD associated complications were observed.

Conclusions: Our technique allows for safe groin-free t-RVAD providing all advantages of percutaneous implantation including complete mobilization and bedside explantation without any need for operation.
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http://dx.doi.org/10.21037/jtd.2018.11.121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535488PMC
April 2019

Preface for the special issue "".

J Thorac Dis 2019 Apr;11(Suppl 6):S851-S852

Department of Thoracic, Cardiac and Vascular Surgery, University Hospital Tuebingen, Tuebingen, Germany.

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http://dx.doi.org/10.21037/jtd.2019.03.53DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535487PMC
April 2019

Lack of an Association between the Functional Polymorphism TREM-1 rs2234237 and the Clinical Course of Sepsis among Critically Ill Caucasian Patients-A Monocentric Prospective Genetic Association Study.

J Clin Med 2019 Mar 3;8(3). Epub 2019 Mar 3.

Department of Anesthesiology, University Medical Center, Georg August University, D-37075 Goettingen, Germany.

Sepsis is a life-threatening condition and a significant challenge for those working in intensive care, where it remains one of the leading causes of mortality. According to the sepsis-3 definition, sepsis is characterized by dysregulation of the host response to infection. The TREM-1 gene codes for the triggering receptor expressed on myeloid cells 1, which is part of the pro-inflammatory response of the immune system. This study aimed to determine whether the functional TREM-1 rs2234237 single nucleotide polymorphism was associated with mortality in a cohort of 649 Caucasian patients with sepsis. The 90-day mortality rate was the primary outcome, and disease severity and microbiological findings were analyzed as secondary endpoints. TREM-1 rs2234237 TT homozygous patients were compared to A-allele carriers for this purpose. Kaplan⁻Meier survival analysis revealed no association between the clinically relevant TREM-1 rs2234237 single nucleotide polymorphism and the 90-day or 28-day survival rate in this group of septic patients. In addition, the performed analyses of disease severity and the microbiological findings did not show significant differences between the TREM-1 rs2234237 genotypes. The TREM-1 rs2234237 genotype was not significantly associated with sepsis mortality and sepsis disease severity. Therefore, it was not a valuable prognostic marker for the survival of septic patients in the studied cohort.
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http://dx.doi.org/10.3390/jcm8030301DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6463065PMC
March 2019

CTLA-4 Genetic Variants Predict Survival in Patients with Sepsis.

J Clin Med 2019 Jan 10;8(1). Epub 2019 Jan 10.

Department of Anesthesiology, University Medical Center, Georg August University, D-37075 Goettingen, Germany.

Cytotoxic T lymphocyte-associated protein 4 (CTLA-4) is a coinhibitory checkpoint protein expressed on the surface of T cells. A recent study by our working group revealed that the rs231775 single nucleotide polymorphism (SNP) in the CTLA-4 gene was associated with the survival of patients with sepsis and served as an independent prognostic variable. To further investigate the impact of CTLA-4 genetic variants on sepsis survival, we examined the effect of two functional SNPs, CTLA-4 rs733618 and CTLA-4 rs3087243, and inferred haplotypes, on the survival of 644 prospectively enrolled septic patients. Kaplan⁻Meier survival analysis revealed significantly lower 90-day mortality for rs3087243 G allele carriers ( = 502) than for AA-homozygous ( = 142) patients (27.3% vs. 40.8%, = 0.0024). Likewise, lower 90-day mortality was observed for TAA haplotype-negative patients ( = 197; compound rs733618 T/rs231775 A/rs3087243 A) than for patients carrying the TAA haplotype ( = 447; 24.4% vs. 32.9%, = 0.0265). Carrying the rs3087243 G allele hazard ratio (HR): 0.667; 95% confidence interval (CI): 0.489⁻0.909; = 0.0103) or not carrying the TAA haplotype (HR: 0.685; 95% CI: 0.491⁻0.956; = 0.0262) remained significant covariates for 90-day survival in the multivariate Cox regression analysis and thus served as independent prognostic variables. In conclusion, our findings underscore the significance of CTLA-4 genetic variants as predictors of survival of patients with sepsis.
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http://dx.doi.org/10.3390/jcm8010070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352177PMC
January 2019

It keeps on turning: Effects of prolonged long-term left ventricular assist device support as a bridge to heart transplantation.

Int J Artif Organs 2019 Feb 24;42(2):65-71. Epub 2018 Dec 24.

1 Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, Middlesex, UK.

Objectives:: Increasing incidence of end-stage heart failure has moved the therapy with left ventricular assist devices to the forefront of surgical treatment. Moreover, continuous sophistication in this technology has resulted in increasing proportion of patients on prolonged support. Early and late complications after left ventricular assist device as a bridge to transplantation and present factors associated with long-term support and long-term outcomes of patients supported for at least 1 year were compared.

Methods:: A total of 163 consecutive patients who underwent left ventricular assist device implantation as bridge to transplantation were included. A total of 79 patients were supported for at least 1 year (long-term support), whereas 84 patients were supported for less than 1 year (short-term group).

Results:: Factors associated with a successful long-term support were male gender (p < 0.001), cessation of smoking at least 6 months prior to surgery (p = 0.045), previous implantation of implantable cardioverter defibrillator (p = 0.001) and rapid postoperative extubation (p = 0.018). Regarding echocardiographic parameters, higher left ventricular mass (p = 0.013) and larger left ventricular-end systolic (p = 0.008) and diastolic (p = 0.005) diameters prior to left ventricular assist device implantation were associated with long-term support. Short-term group showed higher mortality and higher proportion of patients who underwent device exchange due to device failure, and left ventricular assist device explantation for myocardial recovery was less frequent in the long-term support (p < 0.001). In addition, patients from the long-term support had significantly higher incidence of higher-grade aortic regurgitation (p = 0.005).

Conclusion:: Prolonged left ventricular assist device support as bridge to transplantation is associated with lower mortality and lower incidence of device failure requiring device exchange. However, long-term support reduces the chance of device explantation for myocardial recovery and increases the incidence of higher-grade aortic regurgitation in the follow-up.
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http://dx.doi.org/10.1177/0391398818815471DOI Listing
February 2019

Porcine-derived biomaterials in tissue engineering and reconstructive surgery: Considerations and alternatives in Muslim patients.

J Tissue Eng Regen Med 2019 02 4;13(2):253-260. Epub 2019 Jan 4.

Department of Plastic Surgery, Hand Surgery and Burn Center, Faculty of Medicine, RWTH University Hospital, Aachen, Germany.

During the last three decades, tissue engineering and reconstructive surgery have become standard therapeutic options in the world of medicine. Several biomaterials, either alone or in combination with cultured cellular products, have been introduced to compensate for the scarcity of autologous donor tissue or to improve healing in a variety of surgical specialties, for example, abdominal/visceral surgery, plastic surgery, and cardiovascular surgery. Many of these biomaterials are of porcine origin. It is well known that Islam has prohibited the consumption of porcine or any of its products. With Muslims accounting for 23% (1.6 billion) of the global population, a thorough review of the implications of porcine-derived tissue-engineered products in surgery seems necessary. In life-threatening conditions as well as severe diseases, the use of porcine-derived products is permissible if similar non-porcine-derived materials are not available. In this case, the use of porcine-derived products represents a necessity and is allowed. Therefore, this distinction between sole need and necessity has great importance not only for the medical community but also for researchers in biotechnology and industry who may consider alternatives to porcine-derived materials.
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http://dx.doi.org/10.1002/term.2788DOI Listing
February 2019

Anaemia requiring red blood cell transfusion is associated with unfavourable 90-day survival in surgical patients with sepsis.

BMC Res Notes 2018 Dec 11;11(1):879. Epub 2018 Dec 11.

Department of Anesthesiology, University Medical Center, Georg August University, Goettingen, Germany.

Objective: The mortality associated with sepsis remains unacceptably high, despite modern high-quality intensive care. Based on the results from previous studies, anaemia and its management in patients with sepsis appear to impact outcomes; however, the transfusion policy is still being debated, and the ideal approach may be extremely specific to the individual. This study aimed to investigate the long-term impact of anaemia requiring red blood cell (RBC) transfusion on mortality and disease severity in patients with sepsis. We studied a general surgical intensive care unit (ICU) population, excluding cardiac surgery patients. 435 patients were enrolled in this observational study between 2012 and 2016.

Results: Patients who received RBC transfusion between 28 days before and 28 days after the development of sepsis (n = 302) exhibited a significantly higher 90-day mortality rate (34.1% vs 19.6%; P = 0.004, Kaplan-Meier analysis). This association remained significant after adjusting for confounders in the multivariate Cox regression analysis (hazard ratio 1.68; 95% confidence interval 1.03-2.73; P = 0.035). Patients who received transfusions also showed significantly higher morbidity scores, such as SOFA scores, and ICU lengths of stay compared to patients without transfusions (n = 133). Our results indicate that anaemia and RBC transfusion are associated with unfavourable outcomes in patients with sepsis.
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http://dx.doi.org/10.1186/s13104-018-3988-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6290543PMC
December 2018

Minimally Invasive Left Ventricular Assist Device Implantation: A Comparative Study.

Artif Organs 2018 Dec 15;42(12):1125-1131. Epub 2018 Nov 15.

Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Harefield, Uxbridge, UK.

Left ventricular assist device (LVAD) is now a routine therapy for advanced heart failure. Minimally invasive approach via thoracotomy for LVAD implantation is getting popular due to its potential advantage over the conventional sternotomy approach in terms of reduced risk at re-operation due to sternal sparing. We compared the approaches (thoracotomy and sternotomy) to determine the superiority. Minimally invasive approach involved fitting of the LVAD inflow cannula into left ventricle apex via left anterior thoracotomy and anastomosis of outflow graft to ascending aorta via right anterior thoracotomy. In the sternotomy approach, both the procedures were performed via sternotomy. Outcomes in patients after LVAD implantation were compared depending on these approaches for the surgery. Two hundred and five continuous flow LVAD implantations performed between July 2006 and June 2015 at a single center were divided based on surgical approach, that is, sternotomy (n = 180) and thoracotomy (n = 25) groups. There was no significant difference between the groups in relation to patient demographics, preoperative hemodynamic parameters, laboratory markers, or risk factors. There was no significant difference between the groups in terms of postoperative hemodynamic parameters, laboratory markers, bleeding and requirement of blood products, intensive care unit, and hospital stay or complications of LVAD surgery. There were no significant differences in terms of long-term survival (Log-Rank P = 0.953), however, thoracotomy, compared to sternotomy approach, incurred significantly less requirement of temporary right ventricular assist (4 vs. 19.4%, P = 0.041). Minimally invasive bilateral thoracotomy approach for LVAD implantation in addition to benefits of sternal sparing avoids dilatation of right ventricle and reduces chances of right ventricular failure requiring temporary right ventricular assist.
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http://dx.doi.org/10.1111/aor.13269DOI Listing
December 2018

The CTLA-4 rs231775 GG genotype is associated with favorable 90-day survival in Caucasian patients with sepsis.

Sci Rep 2018 10 11;8(1):15140. Epub 2018 Oct 11.

Department of Anesthesiology, University Medical Center, Georg August University, Robert-Koch-Str. 40, D-37075, Goettingen, Germany.

Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) is a surface protein on T cells, that has an inhibitory effect on the host immune reaction and prevents overreaction of the immune system. Because the functional single-nucleotide polymorphism (SNP) rs231775 of the CTLA-4 gene is associated with autoimmune diseases and because of the critical role of the immune reaction in sepsis, we intended to examine the effect of this polymorphism on survival in patients with sepsis. 644 septic adult Caucasian patients were prospectively enrolled in this study. Patients were followed up for 90 days. Mortality risk within this period was defined as primary outcome parameter. Kaplan-Meier survival analysis revealed a significantly lower 90-day mortality risk among GG homozygous patients (n = 101) than among A allele carriers (n = 543; 22% and 32%, respectively; p = 0.03565). Furthermore, the CTLA-4 rs231775 GG genotype remained a significant covariate for 90-day mortality risk after controlling for confounders in the multivariate Cox regression analysis (hazard ratio: 0.624; 95% CI: 0.399-0.975; p = 0.03858). In conclusion, our study provides the first evidence for CTLA-4 rs231775 as a prognostic variable for the survival of patients with sepsis and emphasizes the need for further research to reveal potential functional associations between CTLA-4 and the immune pathophysiology of sepsis.
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http://dx.doi.org/10.1038/s41598-018-33246-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6181961PMC
October 2018

Comparison of temporary ventricular assist devices and extracorporeal life support in post-cardiotomy cardiogenic shock.

Interact Cardiovasc Thorac Surg 2018 12;27(6):863-869

Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, London, UK.

Objectives: Post-cardiotomy cardiogenic shock (PCCS) results in substantial morbidity and mortality, whereas refractory cases require mechanical circulatory support (MCS). The aim of the study was to compare extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) utilized in the management of PCCS.

Methods: In total, 56 consecutive patients who developed PCCS from 2005 to 2014 required MCS as a bridge to decision-24 were supported with a VAD and 32 with an ECMO. Groups were compared with respect to pre- and intraoperative characteristics and early and long-term outcomes to evaluate the impact of the type of MCS on complications and survival. Data are mean ± standard deviation and median with quartiles.

Results: EuroSCORE II was significantly higher in the VAD group than in the ECMO group (28 ± 20 vs 13 ± 16, P = 0.020) corresponding to significantly higher New York Heart Association (P = 0.031) class and Canadian Cardiovascular Society class (P = 0.040) in the cohort. The median duration of support was 10 (4-23) and 7 (4-10) days in the VAD and ECMO groups, respectively. There were no significant differences in ITU (P = 0.262), hospital stay (P = 0.193) and incidences of most postoperative complications. A significantly higher proportion of patients was successfully weaned/upgraded in the VAD group [13 (54%) vs 4 (13%), P = 0.048] with a trend towards higher discharge rate [9 (38%) vs 5 (16%), P = 0.061]. Overall cumulative survival in early follow-up [Breslow (Generalized Wilcoxon) P = 0.017] and long-term follow-up [Log-rank (Mantel-Cox) p = 0.015] was significantly better in the VAD group.

Conclusions: VAD and ECMO represent essential tools to support patients with PCCS. Our preliminary results might indicate some benefits of using VAD in this group of patients; however, this evidence should be further assessed in larger multicentre trials.
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http://dx.doi.org/10.1093/icvts/ivy185DOI Listing
December 2018