Publications by authors named "Hannan Dalyanoglu"

19 Publications

  • Page 1 of 1

Impact of increasing levels of adaptive statistical iterative reconstruction on image quality in oil-based postmortem CT angiography in coronary arteries.

Int J Legal Med 2021 Feb 24. Epub 2021 Feb 24.

Medical Faculty, Department of Diagnostic and Interventional Radiology, University Dusseldorf, D-40225, Dusseldorf, Germany.

Introduction: Postmortem multi-detector computed tomography (PMCT) has become an important part in forensic imaging. Modern reconstruction techniques such as iterative reconstruction (IR) are frequently used in postmortem CT angiography (PMCTA). The image quality of PMCTA depends on the strength of IR. For this purpose, we aimed to investigate the impact of different advanced IR levels on the objective and subjective PMCTA image quality.

Material And Methods: We retrospectively analyzed the coronary arteries of 27 human cadavers undergoing whole-body postmortem CT angiography between July 2017 and March 2018 in a single center. Iterative reconstructions of the coronary arteries were processed in five different level settings (0%; 30%; 50%; 70%; 100%) by using an adaptive statistical IR method. We evaluated the objective (contrast-to-noise ratio (CNR)) and subjective image quality in several anatomical locations.

Results: Our results demonstrate that the increasing levels of an IR technique have relevant impact on the image quality in PMCTA scans in forensic postmortem examinations. Higher levels of IR have led to a significant reduction of image noise and therefore to a significant improvement of objective image quality (+ 70%). However, subjective image quality is inferior at higher levels of IR due to plasticized image appearance.

Conclusion: Objective image quality in PMCTA progressively improves with increasing level of IR with the best CNR at the highest IR level. However, subjective image quality is best at low to medium levels of IR. To obtain a "classic" image appearance with optimal image quality, PMCTAs should be reconstructed at medium levels of IR.
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http://dx.doi.org/10.1007/s00414-021-02530-1DOI Listing
February 2021

Effects of Donor Age and Ischemia Time on Outcome After Heart Transplant: A 10-Year Single-Center Experience.

Exp Clin Transplant 2021 Apr 11;19(4):351-358. Epub 2021 Jan 11.

From the Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany.

Objectives: In heart failure patients, heart transplant still remains the gold standard of care. Controversy prevails whether organs from older donors or with expected prolonged ischemia times may be accepted for transplant.

Materials And Methods: Between 2010 and 2020, a total of 149 patients underwent heart transplant at our department. In a retrospective analysis, 4 different groups were defined according to donor age and total ischemia time. The younger group with short ischemia time consisted of 62 donors age < 50 years and total ischemia time < 240 minutes; the younger group with long ischemia time consisted of 32 donors age < 50 years and total ischemia time ≥ 240 minutes; the older group with short ischemia time consisted of 43 donors age ≥ 50 years and total ischemia time < 240 minutes; and the older group with long ischemia time consisted of 12 donors age ≥ 50 years and total ischemia time ≥ 240 minutes.

Results: Prolonged total ischemia time increased the risk of primary graft dysfunction (P = .02) and perioperative neurological events (P = .04). In contrast, there were no differences regarding durations of intensive care unit stay and hospital stay, perioperative bleeding, and renal failure. Although the younger donor age group showed excellent short-term survival (30-day survival rates of 97% for the younger group with short ischemia time and 91% for the younger group with long ischemia time), short-term and mid-term survival rates were impaired in patients with prolonged total ischemia time and older donor age (P = .02).

Conclusions: Our results indicate that, in younger donors, prolonged ischemia times may be acceptable. However, in donors older than 50 years, the decision for acceptance as a donor should be made with great caution if the presumed ischemia time exceeds 4 hours.
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http://dx.doi.org/10.6002/ect.2020.0279DOI Listing
April 2021

Successful Heart Transplantation after Cardiopulmonary Resuscitation of Donors.

Thorac Cardiovasc Surg 2020 Jul 16. Epub 2020 Jul 16.

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

Background:  Heart transplantation (HTx) is the best therapy for end-stage heart failure. Unfortunately, death on the waiting list remains a problem. Decreasing the number of rejected organs could increase the donor pool.

Methods:  A total of 144 patients underwent HTx at our department between 2010 and 2019. Of them, 27 patients received organs of donors with cardiopulmonary resuscitation (CPR) prior to organ donation (donor CPR) and were compared with patients who received organs without CPR (control;  = 117).

Results:  We did not observe any disadvantage in the outcome of the donor CPR group compared with the control group. Postoperative morbidity and 1-year survival (control: 72%; donor CPR: 82%;  = 0.35) did not show any differences. We found no impact of the CPR time as well as the duration between CPR and organ donation, but we found an improved survival rate for donors suffering from anoxic brain injury compared with cerebral injury ( = 0.04).

Conclusions:  Donor organs should not be rejected for HTx due to resuscitation prior to donation. The need for CPR does not affect the graft function after HTx in both short- and mid-term outcomes. We encourage the use of these organs to increase the donor pool and preserve good results.
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http://dx.doi.org/10.1055/s-0040-1713351DOI Listing
July 2020

Successful Heart Transplant in a Childhood Cancer Survivor With Chemoradiotherapy-Induced Cardiomyopathy.

Exp Clin Transplant 2020 08 16;18(4):533-535. Epub 2020 Jun 16.

From the Department of Cardiac Surgery, Heinrich-Heine University Hospital, Düsseldorf, Germany.

Cancer therapy-related cardiotoxicity has been presenting a major problem in cancer survivors, who constitute a growing population caused by a significant improvement in cancer therapy during the past decades. Although some listing criteria have been defined for these patients, it is still a compelling decision to list patients with a complex cancer anamnesis. We describe herein a childhood cancer survivor after a cancer anamnesis with 2 different malignancies and an end-stage heart failure following chemoradiotherapy who was successfully treated with orthotopic heart transplant.
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http://dx.doi.org/10.6002/ect.2020.0062DOI Listing
August 2020

The Impact of Intraoperative Patient Blood Management on Quality Development in Cardiac Surgery.

J Cardiothorac Vasc Anesth 2020 Oct 15;34(10):2655-2663. Epub 2020 May 15.

Department of Hemostaseology and Transfusion Medicine, Heinrich-Heine-University, Düsseldorf, Germany.

Objectives: Patient blood management (PBM) is increasingly introduced into clinical practice. Minimizing effects on transfusion have been proven, but relevance for clinical outcome has been sparsely examined. In regard to this, the authors analyzed the impact of introducing intraoperative PBM to cardiac surgery.

Design: Retrospective case-control study.

Setting: Single center.

Participants: A total of 3,170 patients who underwent either coronary artery bypass grafting, isolated aortic valve replacement, or a combined procedure at the authors' institution between January 1, 2007, and December 31, 2015.

Intervention: In 2013, an intraoperative PBM service was established offering therapy recommendations on the basis of real-time laboratory monitoring. Comparisons to conventional coagulation management were adjusted for optimization of general, surgical, and perioperative care standards by interrupted time-series analysis and risk-dependent confounding by propensity- score matching.

Measurements And Main Results: Primary study endpoints were in-hospital mortality and morbidity. Morbidity was defined as clinically relevant prolongation of hospital stay, which was related to accumulation of postoperative complications. Transfusion requirements, bleeding, and thromboembolic complications were not treated as primary endpoints, but were also explored. The recommendations on the basis of real-time laboratory monitoring were adopted by the operative team in 72% of patients. Intraoperative PBM was associated independently with a reduction of morbidity (8.3% v 6.3%, p = 0.034), whereas in-hospitalmortality (3.0% v 2.6%, p = 0.521) remained unaffected. The need for red blood cell transfusion decreased (71.1% v 65.0%, p < 0.001), as did bleeding complications requiring surgical re-exploration (3.5% v 1.8%, p = 0.004). At the same time, stroke increased by statistical trend (1.0% v 1.9%, p = 0.038; after correction for imbalanced type of surgical procedure p = 0.085).

Conclusions: Real-time laboratory recommendations achieved a high acceptance rate early after initiation. Improvement of clinical outcome by intraoperative PBM adds to the optimized surgical care. However, the corridor between hemostatic optimization and thromboembolic risk may be narrow.
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http://dx.doi.org/10.1053/j.jvca.2020.04.025DOI Listing
October 2020

Bilirubin-A Possible Prognostic Mortality Marker for Patients with ECLS.

J Clin Med 2020 Jun 3;9(6). Epub 2020 Jun 3.

Department of Anesthesiology, University Hospital Duesseldorf, Moorenstr. 5, 40225 Duesseldorf, Germany.

Extracorporeal life support (ECLS) is a promising therapeutic option for patients with refractory cardiogenic shock. However, as the mortality rate still remains high, there is a need for early outcome parameters reflecting therapy success or futility. Therefore, we investigated whether liver enzyme levels could serve as prognostic mortality markers for patients with ECLS. The present study is a retrospective single-center cohort study. Adult patients >18 years of age who received ECLS therapy between 2011 and 2018 were included. Bilirubin, glutamic-oxaloacetic transaminase (GOT), and glutamic-pyruvic-transaminase (GPT) serum levels were analyzed at day 5 after the start of the ECLS therapy. The primary endpoint of this study was all-cause in-hospital mortality. A total of 438 patients received ECLS during the observation period. Based on the inclusion criteria, 298 patients were selected for the statistical analysis. The overall mortality rate was 42.6% ( = 127). The area under the curve (AUC) in the receiver operating characteristic curve (ROC) for bilirubin on day 5 was 0.72 (95% confidence interval (CI): 0.66-0.78). Cox regression with multivariable adjustment revealed a significant association between bilirubin on day 5 and mortality, with a hazard ratio (HR) of 2.24 (95% CI: 1.53-3.30). Based on the results of this study, an increase in serum bilirubin on day 5 of ECLS therapy correlates independently with mortality.
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http://dx.doi.org/10.3390/jcm9061727DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7356548PMC
June 2020

Use of Organs for Heart Transplantation after Rescue Allocation: Comparison of Outcome with Regular Allocated High Urgent Recipients.

Thorac Cardiovasc Surg 2020 May 22. Epub 2020 May 22.

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

Background:  The number of patients waiting for heart transplantation (HTx) is exceeding the number of actual transplants. Subsequently, waiting times are increasing. One possible solution may be an increased acceptance of organs after rescue allocation. These organs had been rejected by at least three consecutive transplant centers due to medical reasons.

Methods:  Between October 2010 and July 2019, a total of 139 patients underwent HTx in our department. Seventy (50.4%) of the 139 patients were transplanted with high urgency (HU) status and regular allocation (HU group); the remaining received organs without HU listing after rescue allocation (elective group,  = 69).

Results:  Donor parameters were comparable between the groups. Thirty-day mortality was comparable between HU patients (11.4%) and rescue allocation (12.1%). Primary graft dysfunction with extracorporeal life support occurred in 26.9% of the elective group with rescue allocated organs, which was not inferior to the regular allocated organs (HU group: 35.7%). No significant differences were observed regarding the incidence of common perioperative complications as well as morbidity and mortality during 1-year follow-up.

Conclusions:  Our data support the use of hearts after rescue allocation for elective transplantation of patients without HU status. We could show that patients with rescue allocated organs showed no significant disadvantages in the early perioperative morbidity and mortality as well at 1-year follow-up.
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http://dx.doi.org/10.1055/s-0040-1710053DOI Listing
May 2020

Risk and Consequences of Postoperative Delirium in Cardiac Surgery.

Thorac Cardiovasc Surg 2020 08 29;68(5):417-424. Epub 2020 Mar 29.

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

Background: Delirium is a common complication after cardiac surgery that leads to increased costs and worse outcomes. This retrospective study evaluated the potential risk factors and postoperative impact of delirium on cardiac surgery patients.

Methods: One thousand two hundred six patients who underwent open-heart surgery within a single year were included. Uni- and multivariate analyses of a variety of pre, intra-, and postoperative parameters were performed according to differences between the delirium (D) and nondelirium (ND) groups.

Results: The incidence of delirium was 11.6% ( = 140). The onset of delirium occurred at 3.35 ± 4.05 postoperative days with a duration of 5.97 ± 5.36 days. There were two important risk factors for postoperative delirium: higher age (D vs. ND, 73.1 ± 9.04 years vs. 69.0 ± 11.1 years,  < 0.001) and longer aortic cross-clamp time (D vs. ND, 69.8 ± 49.9 minutes vs. 61.6 ± 53.8 minutes,  < 0.05). We found that delirious patients developed significantly more frequent postoperative complications, such as myocardial infarction (MI) (D vs. ND, 1.43% [ = 3] vs. 0.28% [ = 2],  = 0.05), cerebrovascular accident (D vs. ND, 10.7% [ = 15] vs. 3.75% [ = 40],  < 0.001), respiratory complications (D vs. ND, 16.4% [ = 23] vs. 5.72% [ = 61],  < 0.001), and infections (D vs. ND, 36.4% [ = 51] vs. 16.0% [ = 170],  < 0.001). The hospital stay was longer in cases of postoperative delirium (D vs. ND, 23.2 ± 13.6 days vs. 17.4 ± 12.8 days,  < 0.001), and fewer patients were discharged home (D vs. ND, 56.0% [ = 65] vs. 66.8% [ = 571],  < 0.001).

Conclusions: Because the propensity for delirium-related complications is high after cardiac surgery, a practical, preventative strategy should be developed for patients with perioperative risk factors, including higher age and a longer cross-clamp time.
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http://dx.doi.org/10.1055/s-0040-1708046DOI Listing
August 2020

Extracorporeal Membrane Oxygenation after Heart Transplantation: Impact of Type of Cannulation.

Thorac Cardiovasc Surg 2021 Apr 8;69(3):263-270. Epub 2020 Feb 8.

Department of Cardiovascular Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany.

Background:  Primary graft dysfunction (PGD) is a common cause of early death after heart transplantation (htx). The use of extracorporeal life support (ECLS) after htx has increased during the last years. It is still discussed controversially whether peripheral cannulation is favorable compared to central cannulation. We aimed to compare both cannulation techniques.

Methods:  Ninety patients underwent htx in our department between 2010 and 2017. Twenty-five patients were treated with ECLS due to PGD (10 central extracorporeal membrane oxygenator [cECMO] and 15 peripheral extracorporeal membrane oxygenator [pECMO] cannulation). Pre- and intraoperative parameters were comparable between both groups.

Results:  Thirty-day mortality was comparable between the ECLS-groups (cECMO: 30%; pECMO: 40%,  = 0.691). Survival at 1 year ( = 18) was 40 and 30.8% for cECMO and pECMO, respectively. The incidence of postoperative renal failure, stroke, limb ischemia, and infection was comparable between both groups. We also did not find significant differences in duration of mechanical ventilation, intensive care unit stay, or in-hospital stay. The incidence of bleeding complications was also similar (cECMO: 60%; pECMO: 67%). Potential differences in support duration in pECMO group (10.4 ± 9.3 vs. 5.7 ± 4.7 days,  = 0.110) did not reach statistical significance.

Conclusions:  In patients supported for PGD, peripheral and central cannulation strategies are safe and feasible for prolonged venoarterial ECMO support. There was no increase in bleeding after central implantation. With regard to the potential complications of a pECMO, we think that aortic cannulation with tunneling of the cannula and closure of the chest could be a good option in patients with PGD after htx.
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http://dx.doi.org/10.1055/s-0039-3400472DOI Listing
April 2021

Heart transplantation in patients with ventricular assist devices: Impacts of the implantation technique and support duration.

J Card Surg 2020 Feb 5;35(2):352-359. Epub 2019 Dec 5.

Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany.

Background: Orthotopic heart transplantation (HTx) is the gold standard treatment for patients with terminal heart failure. As donor organs are limited, patients are often on ventricular assist device (VAD) support before receiving HTx. We aimed to compare the outcome after HTx in patients with and without preoperative VADs as well as in patients who underwent different VAD implantation techniques.

Methods: A total of 126 patients underwent HTx at our department between 2010 and 2019 and were retrospectively analyzed. While 47 patients underwent primary transplantation (No VAD), 79 were on VAD support. The preoperative and intraoperative parameters were comparable between the two groups.

Results: VAD support significantly increased the HTx operation time (<0.0001), cardiopulmonary bypass time (P < .01), and warm ischemia time (P = .04). The ventilation time (P = .02), intensive care unit (ICU) stay (P = .01), and hospital stay (P = .02) were also significantly longer in VAD patients than in No VAD patients. Minimally invasive VAD implantation significantly reduced the requirement for perioperative blood transfusion (P = .01) and rethoracotomy (P = .01). Nonetheless, survival analyses did not show significant differences between the groups, but there was a trend of better results for the primary transplantation patients (30-day survival: No VAD = 91.1%, VAD = 86.1%; n.s.).

Conclusions: We observed significantly worse perioperative parameters in patients who underwent transplantation after the implantation of a VAD compared to those who underwent primary transplantation. Minimally invasive VAD implantation without full sternotomy decreased complications during the subsequent HTx. In patients who are dependent on temporary VAD support as a bridge to transplantation, we believe that minimally invasive implantation should be performed if possible.
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http://dx.doi.org/10.1111/jocs.14392DOI Listing
February 2020

Relevance of Leaflet Prolapse to the Indication Policy for Aortic Valve-Sparing Root Replacement.

Heart Surg Forum 2019 06 3;22(3):E241-E246. Epub 2019 Jun 3.

Department of Cardiovascular Surgery, University Hospital, Dusseldorf, Germany.

Background: In aortic root replacement, "preexisting" or "induced" aortic leaflet prolapse is related to advanced aortic root pathology and can indicate valve repair. Efforts should be made to perform root replacement before leaflet prolapse is in its maximum extent.

Materials And Methods: Thirty-nine patients with chronic aortic root dilatation and aortic valve regurgitation (AR) underwent a reimplantation procedure. Contrary to 32 of the 39 patients (group A), 7 of the 39 patients (group B) underwent cusp plication for prolapse. For both groups, data related to the diameter at the level of maximal tubular extension, sinotubular junction, sinus of Valsalva, aorto-ventricular junction (AVJ), and aortic annulus were obtained from preoperative computed tomography scans and analyzed comparatively.

Results: Group B showed a higher mean AR grade (P = .007), a higher mean diameter at the level of the aortic annulus (P = .038), AVJ (P = .037), and aortic sinus (P <.001) and a higher sinus dilatation index (existing-to-predicted diameter ratio) (P <.001) than group A. The sinus of Valsalva displayed the best predictive value regarding a plicature-indicating prolapse (P <.001; 95% confidence interval [CI]: 0.809-1.013). A diameter >40 mm was accompanied by an odds ratio (OR) of 24.6 (95% CI: 1.29-496.02). During the follow-up period of 29.0 ± 18.4 months (range: 6-62 months), 1 patient (group A) required reoperation 5 years postoperatively for progressive AR.

Conclusion: The sinus of Valsalva diameter seems to have the greatest prognostic value for the development of prolapse. Our data suggest that root repair should be considered earlier in time before leaflet prolapse is complete, which most likely occurs when root dilatation becomes an aneurysm.
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http://dx.doi.org/10.1532/hsf.2201DOI Listing
June 2019

Antibody-mediated rejection after cardiac transplant: Treatment with immunoadsorption, intravenous immunoglobulin, and anti-thymocyte globulin.

Int J Artif Organs 2019 Jul 14;42(7):370-373. Epub 2019 Jan 14.

1 Department of Cardiovascular Surgery, Heinrich-Heine University Hospital, Düsseldorf, Germany.

Antibody-mediated rejection of allograft is a poorly understood problem after cardiac transplantation that complicates the postoperative course and impairs the graft function and overall survival. Although plasmapheresis and intravenous immunoglobulins have been used as standard therapies for years, there is no consensus about antibody-mediated rejection therapy and most transplantation centers have their own protocols. We describe herein a successful treatment for an acute antibody-mediated rejection of cardiac allograft combining immunoadsorption, intravenous immunoglobulins, and anti-thymocyte globulin, which manifested with polymorphic ventricular tachycardia and right ventricular dysfunction.
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http://dx.doi.org/10.1177/0391398818823763DOI Listing
July 2019

Conversion of Atrial Fibrillation after Cardiosurgical Procedures by Vernakalant® as an Atrial Repolarization Delaying Agent (ARDA).

Heart Surg Forum 2018 05 25;21(3):E201-E208. Epub 2018 May 25.

Department of Cardiovascular Surgery, Heinrich Heine University, Düsseldorf, Germany.

Background: Postoperative, new-onset atrial fibrillation (POAF) is one of the most common complications after cardiosurgical procedures. Vernakalant has been reported to be effective in the conversion of POAF. The aim of this study was to evaluate the efficacy and safety of vernakalant for atrial fibrillation after cardiac operations, and to investigate predictors for the success of vernakalant treatment. Patients and Methods: Post-cardiac surgery patients with new-onset of atrial fibrillation (AF) were consecutively enrolled in this study. Demographic data as well as intraoperative and postoperative parameters were analyzed. Vernakalant administration was primarily started 5.5 hours after new-onset POAF: 3 mg/kg intravenously over 10 min, and in case of non-conversion, a second dose of 2 mg/kg intravenously over 10 min. Results: 129 consecutive patients (70.2 ± 9.1 years) were included: 61 patients with coronary artery bypass graft (CABG) surgery, 49 patients with isolated valve procedures, and 19 patients with combined procedures (CABG and valve). Conversion in sinus rhythm was achieved after the first vernakalant dose in 57 patients (44%), and after the second dose in 41 patients (32%). The mean time to conversion was 13.7 ± 14.1 min. The patients receiving valve procedures depicted a significantly lower conversion rate. The following variables lowered conversion rate: no preoperative beta blocker, postoperative troponin levels >500 ng/L, and systolic blood pressure >140 mmHg. At the first follow-up, 92% of the converted patients showed sinus rhythm, while 80% of the non-responders showed sinus rhythm (P < .01). Conclusions: The POAF was effectively converted by vernakalant. The conversion rate of POAF after valve surgery was lower when compared to isolated CABG.
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http://dx.doi.org/10.1532/hsf.1970DOI Listing
May 2018

Successful treatment of ventricular arrhythmic storm with percutaneous coronary intervention and catheter ablation in a patient with left ventricular assist device.

Int J Artif Organs 2018 Jun 12;41(6):333-336. Epub 2018 Apr 12.

1 Department of Cardiovascular Surgery, Heinrich Heine University, Düsseldorf, Germany.

Introduction: Ventricular arrhythmias are common in patients with advanced heart failure, which may also persist after sufficient intensive therapy for heart failure even with a left ventricular assist device. Although most ventricular arrhythmias have no hemodynamic relevance during left ventricular assist device support, some patients suffer from right ventricular decompensation due to ventricular arrhythmias resulting in severe hemodynamic deterioration and poor clinical outcomes.

Methods: We describe herein an left ventricular assist device patient with refractory ventricular arrhythmic storm early after left ventricular assist device implantation.

Results: The patient was admitted to our department after stenting of left anterior descending artery with subsequent polymorphic ventricular tachycardia and cardiogenic shock with ongoing multi-organ failure. After 6 days of extracorporeal life-support, a permanent left ventricular assist device was implanted. With postoperatively ongoing tachycardias, a subtotal right coronary artery occlusion was recanalized utilizing a drug-eluting stent. On the first post-intervention day, an additional catheter ablation was successfully performed. No further ventricular tachycardias were detected during the entire hospital stay and the further postoperative course was uneventful. The patient was transferred to a physiotherapy unit to improve his daily physical activities. He is currently at home and doing well 6 months after discharge.

Conclusions: Our case report demonstrates the feasibility of a successful therapeutic approach with a combination of interventional therapies such as coronary stenting and catheter ablation in a patient with persistent ventricular arrhythmias after assist device implantation.
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http://dx.doi.org/10.1177/0391398818768118DOI Listing
June 2018

Four-year experience of providing mobile extracorporeal life support to out-of-center patients within a suprainstitutional network-Outcome of 160 consecutively treated patients.

Resuscitation 2017 12 12;121:151-157. Epub 2017 Sep 12.

Department of Cardiovascular Surgery, Heinrich-Heine University Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany.

Aim: Mobile extracorporeal life support (ECLS) may soon be on the verge to become a fundamental part of emergency medicine. Here, we report on our four-year experience of providing advanced mechanical circulatory support for out-of-center patients within the Düsseldorf ECLS Network (DELSN).

Methods: This retrospective cohort study analyses the outcome of 160 patients with refractory circulatory failure consecutively treated with mobile veno-arterial extracorporeal membrane oxygenation (vaECMO) between July 2011 and October 2015 within the DELSN.

Results: Out of the 160 patients (56±16years, vaECMO initiation under CPR 68%), 59 patients (36%) survived to primary discharge, with 50 patients (31%) still alive after a median follow-up of 1.74 years. Time-discrete mortality was highest during the first 24h. There was no difference between survivors and non-survivors regarding age, etiology of circulatory failure, presence of CPR during implantation or distance to implantation site. Incidence of kidney injury requiring dialysis (61% vs. 24%, p<0.0001), shock liver (27% vs. 12%, p=0.031) and visceral ischemia (19% vs. 3%, p=0.013) were the only complications increased in non-survivors. Subgroup analysis showed no significant outcome difference for ECPR vs. non-ECPR patients. Outcome was significantly impaired with initial neuron-specific enolase ≥45.4μg/L (AUC 0.75, p<0.0001) and lactate ≥5.5mmol/L (AUC 0.70, p<0.0001). Program-year-dependent in-center mortality showed an increasing trend, while program-year-dependent follow-up mortality decreased over time.

Conclusions: This study illustrates that regional mobile ECLS rescue therapy can be provided with encouraging outcomes, although patient selection criteria and early outcome parameters reflecting on therapy success or futility still need to be refined.
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http://dx.doi.org/10.1016/j.resuscitation.2017.08.237DOI Listing
December 2017

Anxiety and Depression in Patients Undergoing Mitral Valve Surgery: A Prospective Clinical Study.

Thorac Cardiovasc Surg 2018 10 6;66(7):530-536. Epub 2017 Aug 6.

Clinic for Cardiovascular Surgery, University Hospital Düsseldorf, Düsseldorf, Germany.

Background: Impending cardiac surgery presents an existential experience that may induce psychological trauma. Moreover, quality of life long after successful coronary artery bypass graft surgery (CABG) can be impaired.

Aim: The aim of this study was to describe the time course of anxiety and depression in patients undergoing mitral valve surgery and compare it with our earlier results of patients undergoing CABG, a disease that is likely to be related to psychosomatic disorders. We hypothesized that patients undergoing mitral valve surgery can better manage stresses of cardiac surgery than patients undergoing CABG.

Patients And Methods: Of 117 patients undergoing mitral valve surgery, 100 patients (22 to 87 years; 53 females) completed the study and were interviewed before (pre), 1 week after (early), and 6 months after (late) surgery. The Hospital Anxiety and Depression Scale (HADS) was employed.

Results: The proportion of patients with elevated anxiety scores (AS ≥ 8) was higher than normal (19.8%): pre, 33.0%; early, 28.0%; and was normalized late (18.0%). Similarly, depression scores (DS ≥ 8) were increased: pre, 15.0%; early, 20.0%; and late 14.0%, respectively (normal: 3.2%).

Conclusion: Coronary heart disease of CABG patients is presented as a systemic disorder, associated with both higher and postoperatively increased distress levels than in mitral valve patients. Anxiety and depression should be recognized as possible symptoms of psychosomatic disorders necessitating psychotherapeutic intervention to prevent postoperative depression and warrant patient-perceived surgical outcome that is additionally affected by expectations with respect to treatment and individual coping capacities. HADS is recommended to screen for vulnerable patients in the clinical routine, and psychosomatic support should be provided.
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http://dx.doi.org/10.1055/s-0037-1604461DOI Listing
October 2018

Surgical decision making for revascularization of chronically occluded right coronary artery.

Gen Thorac Cardiovasc Surg 2017 Jan 8;65(1):17-24. Epub 2016 Aug 8.

Clinic of Cardiovascular Surgery, University of Duesseldorf, Moorenstrasse 5, 40255, Duesseldorf, Germany.

Objective: Chronic totally occluded right coronary artery (CTO-RCA) often poses a problem in decision making for/against bypass grafting due to the lack of standardized indication criteria. The aim of the study was to investigate whether qualitative angiograms can be useful in decision making for/against surgical revascularization of CTO-RCA.

Methods: A retrospective cohort study was conducted with 69 patients who underwent elective CABG procedure, including single graft to the RCA. The distal run-off of the bypassed RCA was measured intraoperatively using the ultrasonic transit-time method. As a primary endpoint of the study, the flow values were analysed in regard to diameter of the recipient artery. As a secondary endpoint, the correlations between the regional and global LV function, Rentrop grading, type of collateral pathway, number of donor sources, comorbidity, and the graft flow and the diameter of the recipient artery were investigated using uni- and multi-variate regression analyses.

Results: In general, the flow values correlated significantly with the diameter of the recipient artery. Significantly lower flow (p < 0.0001) and diameter values (p < 0.05) were found in hypo/akinetic and infarcted area reflecting functionality of the CTO-RCA territory.

Conclusions: The qualitative angiograms combined with regional wall motion studies can be useful in decision making for revascularization of CTO-RCA. Revascularization of akinetic/infarcted CTO-RCA territory is associated with lower graft flows even in patients presented with high Rentrop class and high degree of collaterality, suggesting necessity of viability tests prior to bypass surgery.
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http://dx.doi.org/10.1007/s11748-016-0702-8DOI Listing
January 2017

A Suprainstitutional Network for Remote Extracorporeal Life Support: A Retrospective Cohort Study.

JACC Heart Fail 2016 09 11;4(9):698-708. Epub 2016 May 11.

Department of Cardiovascular Surgery, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.

Objectives: This study sought to evaluate patient outcome within the Düsseldorf Extracorporeal Life Support (ECLS) Network, a suprainstitutional network for rapid-response remote ECLS and to define survival-based predictors.

Background: Mobile venoarterial extracorporeal membrane oxygenation (vaECMO) used for ECLS has become a treatment option for a patient population with an otherwise fatal prognosis. However, outcome data remain scarce and institutional standards required to manage these patients are still poorly defined.

Methods: This retrospective cohort study analyzes the outcome of 115 patients consecutively treated between July 2011 and October 2014 within the Düsseldorf ECLS Network due to refractory circulatory failure.

Results: Of the 115 patients (56 ± 15 years of age, vaECMO initiation under cardiopulmonary resuscitation [CPR] 77%, CPR duration 45 [range 5 to 90] min), 50 patients (44%) survived to primary discharge and 38 patients (33%) were alive after a median follow-up of 1.5 years (95% confidence interval [CI]: 1.2 to 1.7). Thirty-seven (97%) of the long-term survivors showed a favorable neurological outcome. Risk factors associated with mortality during vaECMO were CPR duration (hazard ratio [HR]: 1.006; 95% CI: 1.00 to 1.01) and ischemic stroke (HR: 2.63; 95% CI: 1.52 to 4.56). Risk factors associated with mortality after vaECMO weaning were renal failure (HR: 6.60; 95% CI: 2.72 to 16.01) and sepsis (HR: 3.6; 95% CI: 1.50 to 8.69). Visceral ischemia had a negative impact (HR: 0.30; 95% CI: 0.11 to 0.84) whereas assist device implantation promoted successful vaECMO weaning (HR: 2.95; 95% CI: 1.65 to 5.25). Further, 3 distinct risk groups with significant differences in survival could be identified, demonstrating that in patients with no or short CPR mortality was not conditioned by age, whereas in patients with prolonged CPR young age was associated with increased survival.

Conclusions: This study illustrates the implementation of a suprainstitutional ECLS Network. Further, our data suggest that mobile vaECMO is beneficial for a larger patient population than actually expected, especially regarding young patients presenting with prolonged CPR or patients regardless of age with no or short CPR.
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http://dx.doi.org/10.1016/j.jchf.2016.03.018DOI Listing
September 2016