Publications by authors named "Christophe Vandenbriele"

43 Publications

Interaction between flucloxacillin and azoles: is isavuconazole next?

Mycoses 2021 Sep 23. Epub 2021 Sep 23.

Department of Pharmaceutical and Pharmacological Sciences, KU Leuven and Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.

Background: Isavuconazole is a triazole antifungal drug, approved for the treatment of invasive aspergillosis and mucormycosis. It has been previously reported that an interaction between flucloxacillin and voriconazole may lead to subtherapeutic voriconazole exposure, when used concomitantly. Since isavuconazole is also metabolized via cytochrome P450 enzymes, the same interaction may be expected.

Objectives: We aim to document exposure to isavuconazole in patients concomitantly treated with flucloxacillin.

Patients: We report two patients treated with both isavuconazole and flucloxacillin, in whom we determined isavuconazole concentrations.

Results: Low isavuconazole trough concentrations (< 1 mg/L) were observed in two patients under concomitant treatment with flucloxacillin.

Conclusions: In combination with flucloxacillin, low isavuconazole concentrations were observed but an adequate isavuconazole exposure may be reached with dose augmentation. Therapeutic drug monitoring of isavuconazole is recommended to ensure an adequate exposure.
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http://dx.doi.org/10.1111/myc.13373DOI Listing
September 2021

Antithrombotic Treatment After Surgical and Transcatheter Heart Valve Repair and Replacement.

Front Cardiovasc Med 2021 5;8:702780. Epub 2021 Aug 5.

Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.

New antithrombotic drugs have been developed, new valve types have been designed and minimally invasive transcatheter techniques have emerged, making the choice of antithrombotic therapy after surgical or transcatheter heart valve repair and replacement increasingly complex. Moreover, due to a lack of large randomized controlled trials many recommendations for antithrombotic therapy are based on expert opinion, reflected by divergent recommendations in current guidelines. Therefore, decision-making in clinical practice regarding antithrombotic therapy for prosthetic heart valves is difficult, potentially resulting in sub-optimal patient treatment. This article compares the 2017 ESC/EACTS and 2020 ACC/AHA guidelines on the management of valvular heart disease and summarizes the available evidence. Finally, we established a convenient consensus on antithrombotic therapy after valve interventions based on over 800 annual cases of surgical and transcatheter heart valve repair and replacement and a multidisciplinary team discussion between the department of cardiovascular diseases and cardiac surgery of the University Hospitals Leuven, Belgium.
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http://dx.doi.org/10.3389/fcvm.2021.702780DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8375148PMC
August 2021

Regional differences in presentation characteristics, use of treatments and outcome of patients with cardiogenic shock: Results from multicenter, international registry.

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021 Aug 19. Epub 2021 Aug 19.

University Heart and Vasculature Centre, Hamburg, Germany.

Background: Concurrent evidence about cardiogenic shock (CS) characteristics, treatment and outcome does not represent a global spectrum of patients and is therefore limited. The aim of this study was to investigate these regional differences.

Methods: To investigate regional differences in presentation characteristics, treatments and outcomes of patients treated with all types of cardiogenic shock (CS) in a single calendar year on a multi-national level. Consecutive patients from 19 tertiary care hospitals in 13 countries with CS who were treated between January 1, 2018 and December 31, 2018 were enrolled in this study.

Results: In total, 699 cardiogenic shock patients were included in this study. Of these patients, 440 patients (63%) were treated in European hospitals and 259 (37%) were treated in Non-European hospitals. Female patients (P<0.01) and patients with a previous myocardial infarction (P=0.02) were more likely to present at Non-European hospitals; whereas older patients (P=0.01) and patients with cardiogenic shock due to acute heart failure (P<0.01) were more likely to present at European hospitals. Vasopressor use was more likely in Non-European hospitals (P=0.04), whereas use of mechanical circulatory support (MCS) was more likely in European hospitals (P<0.01). Despite adjustment for relevant confounders, 30-day in-hospital mortality risk was comparably high in CS patients treated in European vs. Non-European hospitals (hazard ratio 1.08, 95% CI 0.84-1.39, P=0.56).

Conclusion: Despite marked heterogeneity in characteristics and treatment of CS patients, including fewer use of MCS but more frequent use of vasopressors in Non-European hospitals, 30-day in-hospital mortality did not differ between regions.
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http://dx.doi.org/10.5507/bp.2021.046DOI Listing
August 2021

Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review.

Thromb J 2021 Aug 11;19(1):54. Epub 2021 Aug 11.

Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.

Objectives: We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications.

Methods: An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles.

Findings: TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma.

Conclusions: TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.
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http://dx.doi.org/10.1186/s12959-021-00303-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356407PMC
August 2021

Ultrasound Diagnosis of Cardiac Arrest in an 81-Year-Old Postoperative Patient.

Chest 2021 Aug;160(2):e233-e236

Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Department of Cardiac Intensive Care, University Hospitals Leuven, Leuven, Belgium.

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http://dx.doi.org/10.1016/j.chest.2020.07.105DOI Listing
August 2021

A Large Retrospective Assessment of Voriconazole Exposure in Patients Treated with Extracorporeal Membrane Oxygenation.

Microorganisms 2021 Jul 20;9(7). Epub 2021 Jul 20.

Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium.

Background: Voriconazole is one of the first-line therapies for invasive pulmonary aspergillosis. Drug concentrations might be significantly influenced by the use of extracorporeal membrane oxygenation (ECMO). We aimed to assess the effect of ECMO on voriconazole exposure in a large patient population.

Methods: Critically ill patients from eight centers in four countries treated with voriconazole during ECMO support were included in this retrospective study. Voriconazole concentrations were collected in a period on ECMO and before/after ECMO treatment. Multivariate analyses were performed to evaluate the effect of ECMO on voriconazole exposure and to assess the impact of possible saturation of the circuit's binding sites over time.

Results: Sixty-nine patients and 337 samples (190 during and 147 before/after ECMO) were analyzed. Subtherapeutic concentrations (<2 mg/L) were observed in 56% of the samples during ECMO and 39% without ECMO ( = 0.80). The median trough concentration, for a similar daily dose, was 2.4 (1.2-4.7) mg/L under ECMO and 2.5 (1.4-3.9) mg/L without ECMO ( = 0.58). Extensive inter-and intrasubject variability were observed. Neither ECMO nor squared day of ECMO (saturation) were retained as significant covariates on voriconazole exposure.

Conclusions: No significant ECMO-effect was observed on voriconazole exposure. A large proportion of patients had voriconazole subtherapeutic concentrations.
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http://dx.doi.org/10.3390/microorganisms9071543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8303158PMC
July 2021

Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices.

Eur Heart J Acute Cardiovasc Care 2021 Jun;10(5):570-583

Department of Adult Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, Sydney Street, SW3 6NP London, UK.

There has been a significant increase in the use of short-term percutaneous ventricular assist devices (pVADs) as acute circulatory support in cardiogenic shock and to provide haemodynamic support during interventional procedures, including high-risk percutaneous coronary interventions. Although frequently considered together, pVADs differ in their haemodynamic effects, management, indications, insertion techniques, and monitoring requirements. This consensus document summarizes the views of an expert panel by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Association for Acute Cardiovascular Care (ACVC) and appraises the value of short-term pVAD. It reviews the pathophysiological context and possible indications for pVAD in different clinical settings and provides guidance regarding the management of pVAD based on existing evidence and best current practice.
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http://dx.doi.org/10.1093/ehjacc/zuab015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245145PMC
June 2021

Joint EAPCI/ACVC expert consensus document on percutaneous ventricular assist devices.

EuroIntervention 2021 Jul 20;17(4):e274-e286. Epub 2021 Jul 20.

Interventional Cardiology Unit San Raffaele Scientific Institute - Milan, Italy.

There has been a significant increase in the use of short-term percutaneous ventricular assist devices (pVADs) as acute circulatory support in cardiogenic shock and to provide haemodynamic support during interventional procedures, including high-risk percutaneous coronary interventions. Although frequently considered together, pVADs differ in their haemodynamic effects, management, indications, insertion techniques, and monitoring requirements. This consensus document summarizes the views of an expert panel by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and the Association for Acute Cardiovascular Care (ACVC) and appraises the value of short-term pVAD. It reviews the pathophysiological context and possible indications for pVAD in different clinical settings and provides guidance regarding the management of pVAD based on existing evidence and best current practice.
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http://dx.doi.org/10.4244/EIJY21M05_01DOI Listing
July 2021

Managing Harlequin Syndrome in VA-ECMO - do not forget the right ventricle.

Perfusion 2021 May 31:2676591211020895. Epub 2021 May 31.

Department of Adult Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK.

Harlequin Syndrome (also known as North-South Syndrome) is a complication of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) that can occur when left ventricular function starts to recover. While most commonly due to continued impaired gas exchange in the lungs, we present a case caused by right ventricular dysfunction, successfully managed by conversion of the ECMO circuit to a veno-veno-arterial (VV-A) configuration.
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http://dx.doi.org/10.1177/02676591211020895DOI Listing
May 2021

Screening for venous thromboembolism in patients with COVID-19.

J Thromb Thrombolysis 2021 May 21. Epub 2021 May 21.

Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.

Pulmonary thromboembolism and deep venous thrombosis occur frequently in hospitalised patients with COVID-19, the prevalence increases on the intensive care unit (ICU) and is very high in patients on extracorporeal membrane oxygenation (ECMO). We undertook a literature review to assess the usefulness of screening for peripheral venous thrombosis or pulmonary thrombosis in patients admitted with COVID-19. Outside of the ICU setting, D-dimer elevation on presentation or marked increase from baseline should alert the need for doppler ultrasound scan of the lower limbs. In the ICU setting, consideration should be given to routine screening with doppler ultrasound, given the high prevalence of thrombosis in this cohort despite standard anticoagulant thromboprophylaxis. However, absence of lower limb thrombosis on ultrasound does not exclude pulmonary venous thrombosis. Screening with CT pulmonary angiography (CTPA) is not justified in patients on the general wards, unless there are clinical features and/or marked elevations in markers of COVID-19-associated coagulopathy. However, the risk of pulmonary embolism or pulmonary thrombosis in ICU patients is very high, especially in patients on ECMO, where studies that employed routine screening for thrombosis with CT scanning have uncovered up to 100% incidence of pulmonary thrombosis despite standard anticoagulant thromboprophylaxis. Therefore, in patients at low bleeding risk and high clinical suspicion of venous thromboembolism, therapeutic anticoagulation should be considered even before screening, Our review highlights the need for increased vigilance for VTE, with a low threshold for doppler ultrasound and CTPA in high risk in-patient cohorts, where clinical features and D-dimer levels may not accurately reflect the occurrence of pulmonary thromboembolism.
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http://dx.doi.org/10.1007/s11239-021-02474-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137803PMC
May 2021

Optimal Tests to Minimise Bleeding and Ischaemic Complications in Patients on Extracorporeal Membrane Oxygenation.

Thromb Haemost 2021 May 13. Epub 2021 May 13.

Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom.

Patients supported with extracorporeal membrane oxygenation (ECMO) experience a very high frequency of bleeding and ischaemic complications, including stroke and systemic embolism. These patients require systemic anticoagulation, mainly with unfractionated heparin (UFH) to prevent clotting of the circuit and reduce the risk of arterial or venous thrombosis. Monitoring of UFH can be very challenging. While most centres routinely monitor the activated clotting time and activated partial thromboplastin time (aPTT) to assess UFH, measurement of anti-factor Xa (anti-Xa) level best correlates with heparin dose, and appears to be predictive of circuit thrombosis, although aPTT may be a better predictor of bleeding. Although monitoring of prothrombin time, platelet count and fibrinogen is routinely undertaken to assess haemostasis, there is no clear guidance available regarding the optimal test.Additional tests, including antithrombin level and thromboelastography, can be used for risk stratification of patients to try and predict the risks of thrombosis and bleeding. Each has their specific role, strengths and limitations. Increased thrombin generation may have a role in predicting thrombosis. Acquired von Willebrand syndrome is frequent with ECMO, contributing to bleeding risk and can be detected by assessing the von Willebrand factor activity-to-antigen ratio, while the platelet function analyser can be used in urgent situations to detect this, with a high negative predictive value. Tests of platelet aggregation can aid in the prediction of bleeding.To personalise management, a selection of complementary tests to collectively assess heparin-effect, coagulation, platelet function and platelet aggregation is proposed, to optimise clinical outcomes in these high-risk patients.
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http://dx.doi.org/10.1055/a-1508-8230DOI Listing
May 2021

Venous Thromboembolism in Patients Discharged after COVID-19 Hospitalization.

Semin Thromb Hemost 2021 Jun 23;47(4):362-371. Epub 2021 Apr 23.

Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.

Background:  Venous thromboembolism (VTE) is a frequent complication of COVID-19, so that the importance of adequate in-hospital thromboprophylaxis in patients hospitalized with COVID-19 is well established. However, the incidence of VTE after discharge and whether postdischarge thromboprophylaxis is beneficial and safe are unclear. In this prospective observational single-center study, we report the incidence of VTE 6 weeks after hospitalization and the use of postdischarge thromboprophylaxis.

Methods:  Patients hospitalized with confirmed COVID-19 were invited to a multidisciplinary follow-up clinic 6 weeks after discharge. D-dimer and C-reactive protein were measured, and all patients were screened for deep vein thrombosis with venous duplex-ultrasound. Additionally, selected high-risk patients received computed tomography pulmonary angiogram or ventilation-perfusion (V/Q) scan to screen for incidental pulmonary embolism.

Results:  Of 485 consecutive patients hospitalized from March through June 2020, 146 patients were analyzed, of which 39% had been admitted to the intensive care unit (ICU). Postdischarge thromboprophylaxis was prescribed in 28% of patients, but was used more frequently after ICU stay (61%) and in patients with higher maximal D-dimer and C-reactive protein levels during hospitalization. Six weeks after discharge, elevated D-dimer values were present in 32% of ward and 42% of ICU patients. Only one asymptomatic deep vein thrombosis (0.7%) and one symptomatic pulmonary embolism (0.7%) were diagnosed with systematic screening. No bleedings were reported.

Conclusion:  In patients who had been hospitalized with COVID-19, systematic screening for VTE 6 weeks after discharge revealed a low incidence of VTE. A strategy of selectively providing postdischarge thromboprophylaxis in high-risk patients seems safe and potentially effective.
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http://dx.doi.org/10.1055/s-0041-1727284DOI Listing
June 2021

Transplantation of donor hearts after circulatory death using normothermic regional perfusion and cold storage preservation.

Eur J Cardiothorac Surg 2021 Mar 30. Epub 2021 Mar 30.

Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.

Objectives: Hearts donated after circulatory determination of death are usually preserved with normothermic machine perfusion prior to transplantation. This type of preservation is costly, requires bench time adding to warm ischaemia, and does not provide a reliable evaluation of the unloaded donor heart. We report on 4 successful donation after circulatory death (category III) hearts transplanted after thoraco-abdominal normothermic regional perfusion (NRP) and static cold storage.

Methods: After life sustaining therapy was withdrawn and death was declared, perfusion to thoraco-abdominal organs was restored using extracorporeal circulation via cannulas in the femoral artery and vein and clamping of supra-aortic vessels. After weaning from extracorporeal circulation, cardiac function was assessed. Once approved, the heart was retrieved and stored using classic static cold storage. Data are expressed as median [min-max].

Results: Donor and recipient ages were 44 years [12-60] (n = 4) and 53 years [14-64] (n = 4), respectively. Time from the withdrawal of life sustaining therapy to start of NRP was 22 min [18-31]. Cold storage time was 72 min [35-129]. Thirty-day survival was 100% with a left ventricle ejection fraction of 60% [50-60].

Conclusions: Donation after circulatory death heart transplantation using thoraco-abdominal NRP and subsequent cold storage preservation for up to 129 min was safe for 4 procedures and could be a way to expand the donor heart pool while avoiding costs of machine preservation.
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http://dx.doi.org/10.1093/ejcts/ezab139DOI Listing
March 2021

Managing Patients With Short-Term Mechanical Circulatory Support: JACC Review Topic of the Week.

J Am Coll Cardiol 2021 03;77(9):1243-1256

Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.

The use of mechanical circulatory support for patients presenting with cardiogenic shock is rapidly increasing. Currently, there is only limited and conflicting evidence available regarding the role of the Impella (a microaxial, continuous-flow, short-term, left or right ventricular assist device) in cardiogenic shock; further randomized trials are needed. Patient selection, timing of implantation, and post-implantation management in the cardiac intensive care unit are crucial elements for success. Particular challenges at the bedside include the practical management of anticoagulation, evaluation of correct device position, and the approach to use in a patient with signs of insufficient hemodynamic support. Profound knowledge of these issues is required to enable the maximal potential of the device. This review provides a comprehensive overview of the short-term assist device and describes a practical approach to optimize care for patients supported with the device.
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http://dx.doi.org/10.1016/j.jacc.2020.12.054DOI Listing
March 2021

Fulminant eosinophilic myocarditis treated with steroids and mechanical unloading: a case report.

Eur Heart J Case Rep 2020 Dec 7;4(6):1-5. Epub 2020 Dec 7.

Department of Cardiovascular Diseases, Universitaire Ziekenhuizen Leuven, Herestraat 49, 300 Leuven, Belgium.

Background: Eosinophilic myocarditis is a rare form of myocardial inflammatory disease. Eosinophilic infiltration of the myocardium is often the consequence of a systemic disorder but can remain unexplained in up to a third of patients. The disease course can range from mild to fulminant myocarditis and mortality remains high for fulminant cases.

Case Summary: A 42-year-old male was admitted for cardiogenic shock. He presented in another hospital with fever, low blood pressure, diffuse electrocardiogram-abnormalities, and elevated troponin T (4.5 µg/L; reference <0.013 µg/L) levels. Coronary angiography was unremarkable. Mechanical circulatory support with the Impella CP device was initiated. Since fulminant myocarditis was suspected and magnetic resonance imaging was not feasible in urgency, an endomyocardial biopsy was performed. He transiently developed right ventricular failure after Impella implantation, requiring the re-institution of an inotropic agent. Biopsy showed eosinophilic myocarditis, even though there was no increase in the peripheral blood eosinophil count. Methylprednisone and Ramipril were initiated to which he responded well. No systemic disease or parasitic infection was found during further work-up. Left ventricular ejection fraction rapidly improved and was completely normalized at discharge.

Discussion: This case demonstrates the usefulness of myocardial biopsy in fulminant myocarditis since the only histopathology guided us towards the diagnosis of eosinophilic myocarditis. Treatment with methylprednisone and an angiotensin-converting enzyme-inhibitor resulted in rapid improvement. Awake mechanical circulatory support with the Impella device proved feasible and might have helped by unloading the left ventricle, as was reflected in an immediate decrease in troponin levels, even before methylprednisone initiation.
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http://dx.doi.org/10.1093/ehjcr/ytaa444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891289PMC
December 2020

Left Impella®-device as bridge from cardiogenic shock with acute, severe mitral regurgitation to MitraClip®-procedure: a new option for critically ill patients.

Eur Heart J Acute Cardiovasc Care 2021 May;10(4):415-421

Department of Adult Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, Sydney St, Chelsea, London SW3 6NP, UK.

Aims: Patients presenting with cardiogenic shock (CS) related to acute, severe mitral regurgitation (MR) are often considered too ill for immediate surgical intervention. Therefore, other less invasive techniques for haemodynamic stabilization should be explored. The purpose of this exploratory study was to investigate the feasibility and outcomes in patients with CS due to severe MR by using a novel approach combining haemodynamic stabilization with left Impella-support plus MR-reduction using MitraClip®.

Methods And Results: We analysed whether a combined left Impella®/MitraClip®-procedure in a rare population of CS-patients with acute MR requiring mechanical ventilation is a feasible strategy to recovery in patients who had been declined cardiac surgery. Six INTERMACS-1 CS-patients with acute MR were studied at two tertiary cardiac intensive care units. The mean EURO-II score was 39 ± 19% and age 66.8 ± 4.9 years. All patients had an initial pulmonary capillary wedge pressure >20 mmHg and pulmonary oedema necessitating invasive ventilation. Cardiac output was severely impaired (left ventricular outflow tract velocity time index 9.8 ± 1.8 cm), requiring mechanical circulatory support (MCS) (Impella®-CP; mean flow 2.9 ± 1.8 L per minute; mean support 9.7 ± 6.0 days). Despite MCS-guided unloading, weaning from ventilation failed due to persisting pulmonary oedema necessitating MR-reduction. In all cases, the severe MR was reduced to mild using percutaneous MitraClip®-procedure, followed by successful weaning from invasive ventilation. Survival to discharge was 86%, with all surviving and rare readmission for heart failure at 6 months.

Conclusions: A combined Impella®/MitraClip®-strategy appears a novel, feasible alternative for weaning CS-patients presenting with acute, severe MR. Upfront Impella®-stabilization facilitates safe bridging to Mitraclip®-procedure and the staged approach facilitates successful weaning from ventilatory support.
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http://dx.doi.org/10.1093/ehjacc/zuaa031DOI Listing
May 2021

Veno-venous extracorporeal membrane oxygenation for the acute respiratory distress syndrome: a bridge too far?

Acta Cardiol 2021 Jul 4;76(5):455-458. Epub 2021 Jan 4.

The Department of Adult Intensive Care Medicine, Royal Brompton Hospital NHS foundation Trust, London, UK.

Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) provides a bridge to recovery in patients with acute respiratory failure due to the acute respiratory distress syndrome (ARDS). Survival in ARDS has improved over 15 years, and VV-ECMO may rescue even the most severe of these patients. Predictors of survival on ICU are based upon the principles of reversibility of the inciting aetiology, and premorbid 'reserve' - an imprecise term encompassing comorbidities and frailty. ECMO can support failing organs for prolonged periods, thus sometimes masking trajectories of decline, or unmasking irretrievable intrinsic conditions at a later time point in the critical illness. Clinicians are confronted with new on-treatment dilemmas: how long should we continue this high level of care? Will the patient's limited respiratory reserve manage off ECMO? Or are we hastening their demise? How long is it justifiable to keep someone on ECMO, if the predicted survival off is ultimately poor, but they are in a stable state whilst supported? The palliative withdrawal from ECMO is unchartered territory that requires further study. We describe two representative cases and discuss the wide ethical issues surrounding the initiation and withdrawal of ECMO.
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http://dx.doi.org/10.1080/00015385.2020.1841971DOI Listing
July 2021

Belgian clinical guidance on anticoagulation management in hospitalised and ambulatory patients with COVID-19.

Acta Clin Belg 2020 Oct 3:1-6. Epub 2020 Oct 3.

Laboratory of Cardiology, GIGA Institute, University of Liège, Liège, Belgium.

Objectives: COVID-19 predisposes patients to thrombotic disease. The aim of this guidance document is to provide Belgian health-care workers with recommendations on anticoagulation management in COVID-19 positive patients.

Methods: These recommendations were based on current knowledge and a limited level of evidence.

Results: We formulated recommendations for the prophylaxis and treatment of COVID-related venous thromboembolism in ambulatory and hospitalised patients, as well as recommendations for the use of antithrombotic drugs in patients with prior indication for anticoagulation who develop COVID-19.

Conclusions: These recommendations represent an easy-to-use practical guidance that can be implemented in every Belgian hospital and be used by primary care physicians and gynaecologists. Of note, they are likely to evolve with increased knowledge of the disease and availability of data from ongoing clinical trials.
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http://dx.doi.org/10.1080/17843286.2020.1829252DOI Listing
October 2020

Pulsus Alternans as a Sign of Right Ventricular Failure After Left Ventricular Assist Device Implantation.

J Card Fail 2020 Dec 19;26(12):1093-1095. Epub 2020 Sep 19.

University Hospitals Leuven, Department of Cardiovascular Diseases & Cardiac Intensive Care Unit, Leuven, Belgium.

Temporary left ventricular assist devices such as the ImpellaTM are increasingly used in patients with cardiogenic shock. The right ventricle remains the Achilles heel of left ventricular assist device-supported circulation. However, right ventricular failure after implantation of a left ventricular assist device remains incompletely defined and understood. We describe the first case of pulsus paradoxus emerging after the initiation of circulatory support using a left ventricular ImpellaTM device, which is an early sign of right ventricular failure, that was completely abolished after the addition of a temporary right ventricular assist device.
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http://dx.doi.org/10.1016/j.cardfail.2020.09.010DOI Listing
December 2020

Münchhausen Syndrome: A Case Report of an Unusual Cause of Vitamin K Antagonist Intoxication.

A A Pract 2020 Apr;14(6):e01189

Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium.

Psychiatric disorders must be considered in the differential diagnosis of patients presenting to the emergency department with unexplainable somatic symptoms. Physicians should be aware of Münchhausen syndrome as a possible diagnosis. A 46-year-old female patient presented at the emergency department with signs of coagulopathy. She denied taking any anticoagulant drugs as well as rat poison. Urine toxicology revealed the presence of vitamin K antagonists (VKAs). After an extensive workup, she was diagnosed with Münchhausen syndrome. Intentional intoxication with VKA is rare.
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http://dx.doi.org/10.1213/XAA.0000000000001189DOI Listing
April 2020

Impella to Resist the Storm.

Circ Heart Fail 2020 05 1;13(5):e006698. Epub 2020 May 1.

Departments of Cardiovascular Diseases (T.C., T.B., T.A., J.E., S.J., R.W., C.V.), University Hospitals Leuven, Belgium.

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006698DOI Listing
May 2020

COVID-19 and gastrointestinal endoscopy: What should be taken into account?

Dig Endosc 2020 Jul 3;32(5):723-731. Epub 2020 Jun 3.

Departments of, Department of, Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.

On March 11, 2020 the World Health Organization declared COVID-19 pandemic, leading to a subsequent impact on the entire world and health care system. Since the causing Severe Acute Respiratory Syndrome Coronavirus 2 houses in the aerodigestive tract, activities in the gastrointestinal outpatient clinic and endoscopy unit should be limited to emergencies only. Health care professionals are faced with the need to perform endoscopic or endoluminal emergency procedures in patients with a confirmed positive or unknown COVID-19 status. With this report, we aim to provide recommendations and practical relevant information for gastroenterologists based on the limited amount of available data and local experience, to guarantee a high-quality patient care and adequate infection prevention in the gastroenterology clinic.
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http://dx.doi.org/10.1111/den.13706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267439PMC
July 2020

Frequency of Thrombocytopenia and Heparin-Induced Thrombocytopenia in Patients Receiving Extracorporeal Membrane Oxygenation Compared With Cardiopulmonary Bypass and the Limited Sensitivity of Pretest Probability Score.

Crit Care Med 2020 05;48(5):e371-e379

Department of Intensive Care Medicine, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.

Objectives: To ascertain: 1) the frequency of thrombocytopenia and heparin-induced thrombocytopenia; 2) positive predictive value of the Pretest Probability Score in identifying heparin-induced thrombocytopenia; and 3) clinical outcome of heparin-induced thrombocytopenia in adult patients receiving venovenous- or venoarterial-extracorporeal membrane oxygenation, compared with cardiopulmonary bypass.

Design: A single-center, retrospective, observational cohort study from January 2016 to April 2018.

Setting: Tertiary referral center for cardiac and respiratory failure.

Patients: Patients who received extracorporeal membrane oxygenation for more than 48 hours or had cardiopulmonary bypass during specified period.

Interventions: None.

Measurements And Main Results: Clinical and laboratory data were collected retrospectively. Pretest Probability Score and heparin-induced thrombocytopenia testing results were collected prospectively. Mean age (± SD) of the extracorporeal membrane oxygenation and cardiopulmonary bypass cohorts was 45.4 (± 15.6) and 64.9 (± 13), respectively (p < 0.00001). Median duration of cardiopulmonary bypass was 4.6 hours (2-16.5 hr) compared with 170.4 hours (70-1,008 hr) on extracorporeal membrane oxygenation. Moderate and severe thrombocytopenia were more common in extracorporeal membrane oxygenation compared with cardiopulmonary bypass throughout (p < 0.0001). Thrombocytopenia increased in cardiopulmonary bypass patients on day 2 but was normal in 83% compared with 42.3% of extracorporeal membrane oxygenation patients at day 10. Patients on extracorporeal membrane oxygenation also followed a similar pattern of platelet recovery following cessation of extracorporeal membrane oxygenation. The frequency of heparin-induced thrombocytopenia in extracorporeal membrane oxygenation and cardiopulmonary bypass were 6.4% (19/298) and 0.6% (18/2,998), respectively (p < 0.0001). There was no difference in prevalence of heparin-induced thrombocytopenia in patients on venovenous-extracorporeal membrane oxygenation (8/156, 5.1%) versus venoarterial-extracorporeal membrane oxygenation (11/142, 7.7%) (p = 0.47). The positive predictive value of the Pretest Probability Score in identifying heparin-induced thrombocytopenia in patients post cardiopulmonary bypass and on extracorporeal membrane oxygenation was 56.25% (18/32) and 25% (15/60), respectively. Mortality was not different with (6/19, 31.6%) or without (89/279, 32.2%) heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation (p = 0.79).

Conclusions: Thrombocytopenia is already common at extracorporeal membrane oxygenation initiation. Heparin-induced thrombocytopenia is more frequent in both venovenous- and venoarterial-extracorporeal membrane oxygenation compared with cardiopulmonary bypass. Positive predictive value of Pretest Probability Score in identifying heparin-induced thrombocytopenia was lower in extracorporeal membrane oxygenation patients. Heparin-induced thrombocytopenia had no effect on mortality.
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http://dx.doi.org/10.1097/CCM.0000000000004261DOI Listing
May 2020

Why we need safer anticoagulant strategies for patients on short-term percutaneous mechanical circulatory support.

Intensive Care Med 2020 04 23;46(4):771-774. Epub 2020 Jan 23.

Department of Adult Intensive Care, Royal Brompton NHS Foundation Trust, Imperial College London, Sydney Street, London, SW36NP, UK.

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http://dx.doi.org/10.1007/s00134-019-05897-3DOI Listing
April 2020

Von Willebrand factor and ADAMTS13 impact on the outcome of Staphylococcus aureus sepsis.

J Thromb Haemost 2020 03 22;18(3):722-731. Epub 2019 Dec 22.

Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium.

Background: Previous clinical evidence correlates levels of von Willebrand factor (VWF) and its cleaving protease ADAMTS13 with outcome in septic patients. No previous studies addressed if VWF and ADAMTS13 affected the outcome of Staphylococcus aureus sepsis.

Objectives: We studied the role of VWF and ADAMTS13 in S. aureus sepsis both in patients and in mice.

Methods: VWF levels and ADAMTS13 activity levels were measured in plasma samples from 89 S. aureus bacteremia patients by chemiluminescent assays and were correlated with clinical sepsis outcome parameters. In wild-type mice and mice deficient in VWF and ADAMTS13, we investigated the outcome of S. aureus sepsis and quantified bacterial clearance and organ microthrombi.

Results: In patients with S. aureus bloodstream infections, high VWF levels and low ADAMTS13 activity levels correlated with disease severity and with parameters of inflammation and disseminated intravascular coagulation. In septic mice, VWF deficiency attenuated mortality, whereas ADAMTS13 deficiency increased mortality. Bacterial clearance was enhanced in VWF-deficient mice. The differences in mortality for the studied genotypes were associated with differential loads of organ microthrombi in both liver and kidneys.

Conclusions: In conclusion, this study reports the consistent relation of VWF, ADAMTS13 and their ratio to disease severity in patients and mice with S. aureus sepsis. Targeting VWF multimers and/or the relative ADAMTS13 deficiency that occurs in sepsis should be explored as a potential new therapeutic target in S. aureus endovascular infections.
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http://dx.doi.org/10.1111/jth.14686DOI Listing
March 2020

Impella Protected PCI: Exploring the Mechanism of Ventriculoarterial Uncoupling.

JACC Cardiovasc Interv 2019 10 17;12(19):1979-1980. Epub 2019 Jul 17.

Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium.

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http://dx.doi.org/10.1016/j.jcin.2019.05.037DOI Listing
October 2019

A challenging ECG in a heterotopic heart transplant: double the trouble.

Acta Cardiol 2020 Apr 10;75(2):156-157. Epub 2019 Jan 10.

Division of Adult Intensive Care and Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom.

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http://dx.doi.org/10.1080/00015385.2018.1557795DOI Listing
April 2020

QTc in the elderly.

Eur Heart J 2018 04;39(16):1445

Department of Adult Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, SW3 6NP, London, UK.

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http://dx.doi.org/10.1093/eurheartj/ehy015DOI Listing
April 2018

PEAR1 is not a major susceptibility gene for cardiovascular disease in a Flemish population.

BMC Med Genet 2017 04 27;18(1):45. Epub 2017 Apr 27.

Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences,, University of Leuven, Campus Sint Rafaël, Kapucijnenvoer 35, Box 7001, BE-3000, Leuven, Belgium.

Background: Platelet Endothelial Aggregation Receptor 1 (PEAR1), a membrane protein highly expressed in platelets and endothelial cells, plays a role in platelet contact-induced activation, sustained platelet aggregation and endothelial function. Previous reports implicate PEAR1 rs12041331 as a variant influencing risk in patients with coronary heart disease. We investigated whether genetic variation in PEAR1 predicts cardiovascular outcome in a white population.

Methods: In 1938 participants enrolled in the Flemish Study on Environment, Genes and Health Outcomes (51.3% women; mean age 43.6 years), we genotyped 9 tagging SNPs in PEAR1, measured baseline cardiovascular risk factors, and recorded Cardiovascular disease incidence. For SNPs, we contrasted cardiovascular disease incidence of minor-allele heterozygotes and homozygotes (variant) vs. major-allele homozygotes (reference) and for haplotypes carriers vs. non-carriers. In adjusted analyses, we accounted for family clusters and baseline covariables, including sex, age, body mass index, mean arterial pressure, the total-to-HDL cholesterol ratio, smoking and drinking, antihypertensive drug treatment, and history of cardiovascular disease and diabetes mellitus.

Results: Over a median follow-up of 15.3 years, 238 died and 181 experienced a major cardiovascular endpoint. The multivariable-adjusted hazard ratios of eight PEAR1 SNPs, including rs12566888, ranged from 0.87 to 1.07 (P ≥0.35) and from 0.78 to 1.30 (P ≥0.15), respectively. The hazard ratios of three haplotypes with frequency ≥10% ranged from 0.93 to 1.11 (P ≥0.49) for mortality and from 0.84 to 1.03 (P ≥0.29) for a cardiovascular complications. These results were not influenced by intake of antiplatelet drugs, nonsteroidal anti-inflammatory drugs, or both (P-values for interaction ≥ 0.056).

Conclusions: In a White population, we could not replicate previous reports from experimental studies or obtained in patients suggesting that PEAR1 might be a susceptibility gene for cardiovascular complications.
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http://dx.doi.org/10.1186/s12881-017-0411-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5408434PMC
April 2017
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