Publications by authors named "Ralf Westenfeld"

190 Publications

Impact of pretransplant left ventricular assist device support duration on outcome after heart transplantation.

Interact Cardiovasc Thorac Surg 2021 Oct 14. Epub 2021 Oct 14.

Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.

Objectives: Heart transplantation after left ventricular assist device (LVAD) implantation remains challenging. It is still unclear whether its support duration impacts the outcome after transplantation.

Methods: All patients undergoing heart transplantation between 2010 and 2021 at a single department after previous left ventricular assistance were retrospectively reviewed and divided into 4 different study groups with regard to the duration of LVAD support to examine the impact on the postoperative morbidity and mortality.

Results: A total of n = 198 patients were included and assigned to the 4 study groups (group 1: <90 days, n = 14; group 2: 90 days to 1 year, n = 31; group 3: 1-2 years, n = 29; group 4: >2 years, n = 24). Although there were no differences between the 4 groups concerning relevant mismatch between the recipients and donors, the incidence of primary graft dysfunction was numerically increased in patients with the shortest support duration, and also those patients with >1 year of support (group 1: 35.7%, group 2: 25.8%, group 3: 41.4%, group 4: 37.5%, P = 0.63). The incidence of acute graft rejection was by trend increased in patients of group 1 (group 1: 28.6%, group 2: 3.3%, group 3: 7.1%, group 4: 12.5%, P = 0.06). Duration of LVAD support did not impact on perioperative adverse events (infections, P = 0.79; acute kidney injury, P = 0.85; neurological events, P = 0.74; thoracic bleeding, P = 0.61), neither on postoperative survival (1-year survival: group 1: 78.6%, group 2: 66.7%, group 3: 80.0%, group 4: 72.7%, P = 0.74).

Conclusion: We cannot identify a significant impact of the duration of pretransplant LVAD support on postoperative outcome; therefore, we cannot recommend a certain timeframe for transplantation of LVAD patients.
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http://dx.doi.org/10.1093/icvts/ivab265DOI Listing
October 2021

Evaluation of Radiographic Contrast-Induced Nephropathy by Functional Diffusion Weighted Imaging.

J Clin Med 2021 Oct 1;10(19). Epub 2021 Oct 1.

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

Contrast-induced nephropathy (CIN) resembles an important complication of radiographic contrast medium (XCM) displayed by a rise in creatinine levels 48-72 h after XCM administration. The purpose of the current study was to evaluate microstructural renal changes due to CIN in high-risk patients by diffusion weighted (DWI) and diffusion tensor imaging (DTI). Fifteen patients (five CIN and ten non-CIN) scheduled for cardiological intervention were included in the study. All patients were investigated pre- and post-intervention on a clinical 3T scanner. After anatomical imaging, renal DWI was performed by a paracoronal echo-planar-imaging sequence. Renal clinical routine serum parameters and advanced urinary injury markers were determined to monitor renal function. We observed a drop in cortical and medullar apparent diffusion coefficient (ADC) and fractional anisotropy (FA) before and after XCM administration in the CIN group. In contrast, the non-CIN group differed only in medullary ADC. The decrease of ADC and FA was apparent even before serum parameters of the kidney changed. In conclusion, DWI/DTI may be a useful tool for monitoring high-risk CIN patients as part of multi-modality based clinical protocol. Further studies, including advanced analysis of the diffusion signal, may improve the identification of patients at risk for CIN.
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http://dx.doi.org/10.3390/jcm10194573DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8509538PMC
October 2021

Adequate immune response after SARS-CoV-2 infection and single dose vaccination despite rapid heart transplantation.

ESC Heart Fail 2021 Oct 4. Epub 2021 Oct 4.

Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, Duesseldorf, 40225, Germany.

Adequate immune response to vaccination remains a challenge in patients after solid organ transplantation. We report a case of a 61-year-old male patient who received a left ventricular assist device as a bridge to transplant therapy. Three months before transplantation, he suffered mild SARS-CoV-2 infection and was successfully discharged thereafter. Eight days before his successful heart transplantation, he received mRNA BNT 162b2 vaccination. Immediately after transplantation, we detected sufficient rise of nucleocapsid and spike antibodies despite immune suppression therapy. We suspect potential booster effects of the previous SARS-CoV-2 infection giving rise to adequate immune response following single vaccination.
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http://dx.doi.org/10.1002/ehf2.13635DOI Listing
October 2021

Risk Factors for Acute Kidney Injury Requiring Renal Replacement Therapy after Orthotopic Heart Transplantation in Patients with Preserved Renal Function.

J Clin Med 2021 Sep 12;10(18). Epub 2021 Sep 12.

Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University Duesseldorf, 40225 Duesseldorf, Germany.

Acute kidney injury (AKI), requiring renal replacement therapy (RRT). is a serious complication after orthotopic heart transplantation (HTX). In patients with preexisting impaired renal function, postoperative AKI is unsurprising. However, even in patients with preserved renal function, AKI requiring RRT is frequent. Therefore, this study aimed to identify risk factors associated with postoperative AKI requiring RRT after HTX in this sub-cohort. This retrospective cohort study included patients ≥ 18 years of age with preserved renal function (defined as preoperative glomerular filtration rate ≥ 60 mL/min) who underwent HTX between 2010 and 2021. In total, 107 patients were included in the analysis (mean age 52 ± 12 years, 78.5% male, 45.8% AKI requiring RRT). Based on univariate logistic regression, use of extracorporeal membrane oxygenation, postoperative infection, levosimendan therapy, duration of norepinephrine (NE) therapy and maximum daily increase in tacrolimus plasma levels were chosen to be included into multivariate analysis. Duration of NE therapy and maximum daily increase in tacrolimus plasma levels remained as independent significant risk factors (NE: OR 1.01, 95%CI: 1.00-1.02, = 0.005; increase in tacrolimus plasma level: OR 1.18, 95%CI: 1.01-1.37, = 0.036). In conclusion, this study identified long NE therapy and maximum daily increase in tacrolimus plasma levels as risk factors for AKI requiring RRT in HTX patients with preserved renal function.
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http://dx.doi.org/10.3390/jcm10184117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8470552PMC
September 2021

Sublingual Microcirculation predicts Survival after Out-of-Hospital Cardiac Arrest.

Microcirculation 2021 Sep 26:e12729. Epub 2021 Sep 26.

Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University, Medical Faculty, Düsseldorf, Germany.

Background: Despite successful resuscitation with return of spontaneous circulation (ROSC) prediction of survival in patients suffering out-of-hospital cardiac arrest (OHCA) remains difficult. Several studies have shown alterations in sublingual microcirculation in the critical ill. We hypothesized that early alterations in sublingual microcirculation may predict short-term survival after OHCA.

Methods: We prospectively included all adults admitted to our university hospital between April and September 2019 with ROSC following OHCA. Sidestream darkfield microscopy to obtain sublingual microcirculation was performed at admission and after 6, 12 and 24 hours. Primary outcome was survival until discharge.

Results: 25 patients were included. Six hours after ROSC the proportion of perfused small vessels (PPV ) was lower in non-survivors than in survivors (85 ± 7.9 vs. 75 ± 6.6 %; p= 0.01). PPV did not correlate with serum lactate. Stratification for survival with cut-off values >78.4% for PPV 6 hours post admission and <5.15 mmol/l for initial serum lactate as suggested by ROC-Analyses results in a positive predictive value of 100% and a negative one of 67% for our study population.

Conclusion: Estimating short-term prognosis of OHCA patients with ROSC may be supported by measuring the PPV at the sublingual microcirculation 6 hours after admission.
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http://dx.doi.org/10.1111/micc.12729DOI Listing
September 2021

Machine Learning Identifies Clinical Parameters to Predict Mortality in Patients Undergoing Transcatheter Mitral Valve Repair.

JACC Cardiovasc Interv 2021 Sep;14(18):2027-2036

Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany. Electronic address:

Objectives: The aim of this study was to develop a machine learning (ML)-based risk stratification tool for 1-year mortality in transcatheter mitral valve repair (TMVR) patients incorporating metabolic and hemodynamic parameters.

Background: The lack of appropriate, well-validated, and specific means to risk-stratify patients with mitral regurgitation complicates the evaluation of prognostic benefits of TMVR in clinical trials and practice.

Methods: A total of 1,009 TMVR patients from 3 university hospitals within the Heart Failure Network Rhineland were included; 1 hospital (n = 317) served as external validation. The primary endpoint was all-cause 1-year mortality. Model performance was assessed using receiver-operating characteristic curve analysis. In the derivation cohort, different ML algorithms were tested using 5-fold cross-validation. The final model, called MITRALITY (transcatheter mitral valve repair mortality prediction system) was tested in the validation cohort with respect to existing clinical scores.

Results: Extreme gradient boosting was selected for the MITRALITY score, using only 6 baseline clinical features for prediction (in order of predictive importance): urea, hemoglobin, N-terminal pro-brain natriuretic peptide, mean arterial pressure, body mass index, and creatinine. In the external validation cohort, the MITRALITY score's area under the curve was 0.783 (95% CI: 0.716-0.849), while existing scores yielded areas under the curve of 0.721 (95% CI: 0.63-0.811) and 0.657 (95% CI: 0.536-0.778) at best.

Conclusions: The MITRALITY score is a novel, internally and externally validated ML-based tool for risk stratification of patients prior to TMVR, potentially serving future clinical trials and daily clinical practice.
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http://dx.doi.org/10.1016/j.jcin.2021.06.039DOI Listing
September 2021

Erratum to: Successful Heart Transplantation after Cardiopulmonary Resuscitation of Donors.

Thorac Cardiovasc Surg 2021 Sep 20;69(6):e1-e2. Epub 2021 Sep 20.

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

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http://dx.doi.org/10.1055/s-0040-1716567DOI Listing
September 2021

Cytomegalovirus mismatch after heart transplantation: Impact of antiviral prophylaxis and intravenous hyperimmune globulin.

Immun Inflamm Dis 2021 Sep 15. Epub 2021 Sep 15.

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

Objective: Cytomegalovirus (CMV) infections are correlated with complications following heart transplantation (HTx) and impaired outcome. The impact of a serologic mismatch between donor and recipient and the necessity of prophylactic virostatic medication is still a matter of concern.

Methods: We retrospectively reviewed all patients that underwent HTx between 2010 and 2020 in our department. The recipients (n = 176) could be categorized into four risk groups depending on their serologic CMV matching (D /R  = donor CMV-IgG positive and recipient CMV-IgG negative, n = 32; D /R , n = 51; D /R , n = 35; D /R , n = 58). All patients followed the same protocol of CMV prophylaxis with application of ganciclovir/valganciclovir and intravenous CMV hyperimmune globulin.

Results: Incidence of postoperative morbidity such as primary graft dysfunction, neurological events, infections, and graft rejection were comparable between all groups (p > .05). However, the incidence of postoperative acute kidney injury with hemodialysis was by trend increased in the D /R group (72.0%) compared to the other groups. In-hospital CMV-DNAemia was observed in serologic positive recipients only (D /R : 0.0%, D /R : 25.0%, D /R : 0.0%, D /R : 13.3%, p < .01). During the first year, a total of 18 patients developed CMV-DNAemia (D /R : 31.6%, D /R : 31.9%, D /R : 3.4%, D /R : 11.1%, p = .03).

Conclusions: Seropositive recipients carry an important risk for CMV-DNAemia. However, we did not observe differences in perioperative morbidity and mortality regarding CMV matching, which might be related to regularly administer prophylactic virostatics and additional CMV-IVIG for risk constellations. For high-risk constellation, long-term application of CMV-IVIG during the first year after transplant may be beneficial.
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http://dx.doi.org/10.1002/iid3.508DOI Listing
September 2021

Periprocedural changes in natriuretic peptide levels and clinical outcome after transcatheter mitral valve repair.

ESC Heart Fail 2021 Sep 14. Epub 2021 Sep 14.

Heart Center Bonn, Department of Internal Medicine II, University Hospital Bonn, Venusberg Campus 1, Bonn, 53127, Germany.

Aims: This multicentre study investigated the association of periprocedural changes in the levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) with clinical outcomes after transcatheter edge-to-edge mitral valve repair (TMVR).

Methods And Results: Patients were retrospectively analysed who underwent TMVR with the MitraClip system (Abbott Vascular, Santa Clara, CA, USA) and had available sequential NT-proBNP testing at baseline and 2 months after TMVR. Periprocedural changes in NT-proBNP following TMVR were assessed as the percent change in NT-proBNP between baseline and the 2 month follow-up, and the significant reduction in NT-proBNP was defined as a decrease of >30% in the follow-up NT-proBNP compared with the pre-procedural NT-proBNP level. Primary outcome was defined as a composite outcome consisting of all-cause mortality and hospitalization due to heart failure from 2 months to 2 years after TMVR. Additionally, we identified the cut-off value of pre-procedural NT-proBNP to predict the composite outcome using a receiver operating characteristic analysis (cut-off: 2485 pg/mL). Of 485 patients undergoing TMVR (age: 76.2 ± 9.2 years, female: 42.1%, secondary mitral regurgitation: 67.2%), 150 patients (30.9%) had the significant reduction in NT-proBNP (>30%) following the procedure. Patients with the NT-proBNP reduction had a lower incidence of the composite outcome, compared with those without the reduction in NT-proBNP (31.4% vs. 40.2%; log-rank P = 0.03). The significant reduction in NT-proBNP was also associated with a lower risk of the composite outcome [adjusted hazard ratio (HR): 0.67; 95% confidence interval (CI): 0.45-0.97; P = 0.04], independently of pre-procedural NT-proBNP levels and other clinical parameters. The percent change in NT-proBNP was associated with a linear trend of the incidence of the composite outcome (adjusted HR per 10% decrease: 0.96; 95% CI: 0.94-0.98; P < 0.001). A stratified analysis revealed that the prognostic impact of the significant reduction in NT-proBNP was consistent among clinical subgroups, including aetiology of mitral regurgitation (P for interaction = 0.99). Higher pre-procedural NT-proBNP level (>2485 pg/mL) was associated with the increased risk of the composite outcome (adjusted HR: 1.50; 95% CI: 1.03-2.17; P = 0.03); however, patients with a higher pre-procedural NT-proBNP who achieved the significant reduction in NT-proBNP had a similar risk of the composite outcome to those with a lower pre-procedural NT-proBNP.

Conclusions: Changes in sequential NT-proBNP measurements were associated with clinical outcomes within 2 years after TMVR. The assessment of NT-proBNP dynamics may be valuable to assess the residual risk for patients undergoing TMVR and could assist with post-procedural management after TMVR.
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http://dx.doi.org/10.1002/ehf2.13603DOI Listing
September 2021

Human myocardial mitochondrial oxidative capacity is impaired in mild acute heart transplant rejection.

ESC Heart Fail 2021 Sep 6. Epub 2021 Sep 6.

Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Moorenstraße 5, Düsseldorf, 40225, Germany.

Aims: Acute cellular rejection (ACR) following heart transplantation (HTX) is associated with long-term graft loss and increased mortality. Disturbed mitochondrial bioenergetics have been identified as pathophysiological drivers in heart failure, but their role in ACR remains unclear. We aimed to prove functional disturbances of myocardial bioenergetics in human heart transplant recipients with mild ACR by assessing myocardial mitochondrial respiration using high-resolution respirometry, digital image analysis of myocardial inflammatory cell infiltration, and clinical assessment of HTX patients. We hypothesized that (i) mild ACR is associated with impaired myocardial mitochondrial respiration and (ii) myocardial inflammation, systemic oxidative stress, and myocardial oedema relate to impaired mitochondrial respiration and myocardial dysfunction.

Methods And Results: We classified 35 HTX recipients undergoing endomyocardial biopsy according International Society for Heart and Lung Transplantation criteria to have no (0R) or mild (1R) ACR. Additionally, we quantified immune cell infiltration by immunohistochemistry and digital image analysis. We analysed mitochondrial substrate utilization in myocardial fibres by high-resolution respirometry and performed cardiovascular magnetic resonance (CMR). ACR (1R) was diagnosed in 12 patients (34%), while the remaining 23 patients revealed no signs of ACR (0R). Underlying cardiomyopathies (dilated cardiomyopathy 50% vs. 65%; P = 0.77), comorbidities (type 2 diabetes mellitus: 50% vs. 35%, P = 0.57; chronic kidney disease stage 5: 8% vs. 9%, P > 0.99; arterial hypertension: 59% vs. 30%, P = 0.35), medications (tacrolimus: 100% vs. 91%, P = 0.54; mycophenolate mofetil: 92% vs. 91%, P > 0.99; prednisolone: 92% vs. 96%, P > 0.99) and time post-transplantation (21.5 ± 26.0 months vs. 29.4 ± 26.4 months, P = 0.40) were similar between groups. Mitochondrial respiration was reduced by 40% in ACR (1R) compared with ACR (0R) (77.8 ± 23.0 vs. 128.0 ± 33.0; P < 0.0001). Quantitative assessment of myocardial CD3 -lymphocyte infiltration identified ACR (1R) with a cut-off of >14 CD3 -lymphocytes/mm (100% sensitivity, 82% specificity; P < 0.0001). Myocardial CD3 infiltration (r = -0.41, P < 0.05), systemic oxidative stress (thiobarbituric acid reactive substances; r = -0.42, P < 0.01) and myocardial oedema depicted by global CMR derived T2 time (r = -0.62, P < 0.01) correlated with lower oxidative capacity and overt cardiac dysfunction (global longitudinal strain; r = -0.63, P < 0.01).

Conclusions: Mild ACR with inflammatory cell infiltration associates with impaired mitochondrial bioenergetics in cardiomyocytes. Our findings may help to identify novel checkpoints in cardiac immune metabolism as potential therapeutic targets in post-transplant care.
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http://dx.doi.org/10.1002/ehf2.13607DOI Listing
September 2021

Initial experience covering 50 consecutive cases of large Impella implantation at a single heart centre.

ESC Heart Fail 2021 Sep 4. Epub 2021 Sep 4.

Department of Cardiac Surgery and Research Group for Experimental Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Hospital, Moorenstr. 5, Düsseldorf, 40225, Germany.

Aims: Pre-operative or post-operative heart failure (HF) and cardiogenic shock of various natures frequently remain refractory to conservative treatment and require mechanical circulatory support. We report our clinical experience with large Impella systems (5.0 or 5.5; i.e. Impella 5+) (Abiomed Inc., Boston, USA) and evaluate the parameters that determined patient outcome.

Methods And Results: The initial 50 cases of Impella 5+ implanted for acute HF between November 2018 and August 2020 at a single centre were enrolled in this study. Data, including preoperative characteristics, perioperative clinical course information, and post-operative outcomes, were retrospectively collected from the hospital data management and quality assurance system. Descriptive and univariate analyses were performed. Among the 49 patients in this study, 28 (56.0%) survived in the first 30 days post-operatively, and 3 died of non-cardiac reasons later. In-hospital mortality was significantly higher in patients with biventricular failure [P < 0.01, odds ratio (OR) 5.63] or dilated cardiomyopathy (DCM) (P = 0.02, OR 15.8), whereas ischaemic cardiomyopathy (ICM) was associated with lower mortality (P = 0.03, OR 0.24). Interestingly, the mortality was comparable between the 'solo' Impella group and the veno-arterial extracorporal membrane oxygenation (va-ECMO) plus Impella (ECMELLA) group, despite the severity of the patients' profile in the ECMELLA group ('solo' vs. ECMELLA; 55.6% vs. 52.6%, P = 1.00). All patients who received an additional temporary right ventricular assist device (tRVAD) were successfully weaned from va-ECMO.

Conclusions: Our results suggest that biventricular failure and DCM are predictors of higher mortality in patients with Impella. Considering the pathophysiology of HF, implantation of a large Impella system seems to be promising, especially for ICM patients. The large Impella system might be more effective for better prognosis of patients under va-ECMO, and combination therapy with tRVAD seems to be a promising strategy for early weaning from va-ECMO.
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http://dx.doi.org/10.1002/ehf2.13594DOI Listing
September 2021

Postcardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: Does the Cannulation Technique Influence the Outcome?

Front Cardiovasc Med 2021 9;8:658412. Epub 2021 Aug 9.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be cannulated using either central (cannulation of aorta) or peripheral (cannulation of femoral or axillary artery) access. The ideal cannulation approach for postcardiotomy cardiogenic shock (PCS) is still unknown. The aim of this study is to compare the outcome of patients with PCS who were supported with central vs. peripheral cannulation. This is a single-center retrospective data analysis including all VA-ECMO implantations for PCS from January 2011 to December 2017. The central and peripheral approaches were compared in terms of patient characteristics, intensive care unit (ICU) stay, hospitalization length, adverse event rates, and overall survival. Eighty-six patients met the inclusion criteria. Twenty-eight patients (33%) were cannulated using the central approach, and 58 patients (67%) were cannulated using the peripheral approach. Forty-three patients (50%) received VA-ECMO in the operating room and 43 patients (50%) received VA-ECMO in the ICU. Central VA-ECMO group had higher EuroSCORE II ( = 0.007), longer cross-clamp time ( = 0.054), higher rate of open chest after the procedure ( < 0.001), and higher mortality rate ( = 0.02). After propensity score matching, 20 patients in each group were reanalyzed. In the matched groups, no statistically significant differences were observed in the baseline characteristics between the two groups except for a higher rate of open chests in the central ECMO group ( = 0.02). However, no significant differences were observed in the outcome and complications between the groups. This study showed that in postcardiotomy patients requiring VA-ECMO support, similar complication rates and outcome were observed regardless of the cannulation strategy.
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http://dx.doi.org/10.3389/fcvm.2021.658412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382236PMC
August 2021

Outcome of patients with non-ischaemic cardiogenic shock supported by percutaneous left ventricular assist device.

ESC Heart Fail 2021 Oct 23;8(5):3594-3602. Epub 2021 Aug 23.

Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.

Aims: Percutaneous left ventricular assist devices (pVADs) are used to haemodynamically stabilize patients with cardiogenic shock (CS) caused by acute myocardial infarction (AMI). One out of every two patients has a non-ischaemic cause of CS, and these patients differ profoundly from patients with AMI-related CS. We assessed the usefulness of pVAD support for patients with non-ischaemic CS.

Methods And Results: We analysed 106 patients with CS and Impella® support between 2015 and 2018. CS was non-ischaemic in 36 patients and AMI-related in 70 patients. Compared with the AMI group, those in the non-ischaemic group were significantly younger [median age 62 (50.8, 70.8) years vs. 68 (58.0, 75.5) years, P = 0.007] and had more patients with severely reduced left ventricular function (94% vs. 79%, P = 0.035) and worse glomerular filtration rate [45 (27, 57) mL/min vs. 60 (44, 78) mL/min]. Propensity score matching yielded 31 patients with non-ischaemic CS and 31 patients with AMI-related CS, without a difference in baseline laboratory values or comorbidities. In both groups, pVAD support was performed along with haemodynamic stabilization, reduction of catecholamines and normalization of lactate levels. In 7 days, systolic blood pressure increased from 91 (80, 101) mmHg at baseline to 100 (100, 120) mmHg in the non-ischaemic CS group (P = 0.001) and 89 (80, 100) mmHg at baseline to 112 (100, 128) mmHg in the AMI-related CS group (P = 0.001). Moreover, in 7 days, the need of catecholamines (calculated as vasoactive-inotropic score) decreased from 32.0 (11.1, 47.0) at baseline to 5.3 (0, 16.1) in the non-ischaemic group (P = 0.001) and from 35.2 (18.11, 67.0) to zero (0, 0) in the AMI-related CS group (P = 0.001). Lactate level decreased from 3.8 (2.8, 5.9) mmol/L at baseline to 1.0 (0.8, 2.1) mmol/L (P = 0.001) in the non-ischaemic CS group and from 3.8 (2.6, 6.5) mmol/L to 1.2 (1.0, 2.0) mmol/L in the AMI-related group (P = 0.001). In the non-ischaemic CS group, eight patients (25.8%) were upgraded to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or long-term mechanical circulatory support. Two of these upgraded patients received heart transplantation. In the AMI group, eight patients (25.8%) were upgraded to VA-ECMO or long-term mechanical circulatory support. Ninety-day survival did not significantly differ between the groups (non-ischaemic CS group 48.4%, AMI-related CS group 45.2%, P = 0.799).

Conclusions: pVAD support is useful for haemodynamic stabilization of patients with non-ischaemic CS and is valuable as a bridge to patients' recovery or long-term left ventricular support and heart transplantation.
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http://dx.doi.org/10.1002/ehf2.13546DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497228PMC
October 2021

Incidence of Acute Kidney Injury Is Lower in High-Risk Patients Undergoing Percutaneous Coronary Intervention Supported with Impella Compared to ECMO.

J Cardiovasc Transl Res 2021 Jul 29. Epub 2021 Jul 29.

Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstrasse 5, 40225, Düsseldorf, Germany.

Acute kidney injury (AKI) is a common complication post-PCI. Here, in a single-center observational registry, we compared the frequency of AKI in patients at elevated risk for AKI (based on Mehran risk stratification scoring) who underwent VA-ECMO- or Impella-supported high-risk PCI. A total of 28 patients scheduled for elective high-risk PCI with mechanical circulatory support were studied prospectively. All patients were turned down for surgery due to exceedingly high risk. Allocation to VA-ECMO (n=11) or Impella (n=17) was performed according to site-specific restrictions on the daily availability of the VA-ECMO platform as a prospective enrollment and performed prior to initiation of PCI. We analyzed AKI incidence as our primary endpoint, as well as PCI success, duration, and peripheral complications. All patients were successfully revascularized and had MCS weaned at the end of the procedure. Baseline GFR and procedural contrast media were similar. Despite similar risks for AKI as calculated by the Mehran score (35 ± 18.9 vs. 31 ± 16.6 %; p=0.55), patients supported by Impella during PCI demonstrated a reduced incidence of AKI (55 vs. 12 %; p=0.03). MCS-assisted high-risk PCI with VA-ECMO or Impella is feasible. However, Impella is associated with a shorter procedure time and a lower incidence of AKI.
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http://dx.doi.org/10.1007/s12265-021-10141-9DOI Listing
July 2021

Complete Revascularisation in Impella-Supported Infarct-Related Cardiogenic Shock Patients Is Associated With Improved Mortality.

Front Cardiovasc Med 2021 9;8:678748. Epub 2021 Jul 9.

Department of Cardiology, University Heart Center, Bonn, Germany.

Acute myocardial infarction-related cardiogenic shock (AMI-CS) still has high likelihood of in-hospital mortality. The only trial evidence currently available for the intra-aortic balloon pump showed no benefit of its routine use in AMI-CS. While a potential benefit of complete revascularisation has been suggested in urgent revascularisation, the CULPRIT-SHOCK trial demonstrated no benefit of multivessel compared to culprit-lesion only revascularisation in AMI-CS. However, mechanical circulatory support was only used in a minority of patients. We hypothesised that more complete revascularisation facilitated by Impella support is related to lower mortality in AMI-CS patients. We analysed data from 202 consecutive Impella-treated AMI-CS patients at four European high-volume shock centres (age 66 ± 11 years, 83% male). Forty-seven percentage ( = 94) had cardiac arrest before Impella implantation. Revascularisation was categorised as incomplete if residual SYNTAX-score (rS) was >8. Overall 30-day mortality was 47%. Mortality was higher when Impella was implanted post-PCI (Impella-post-PCI: 57%, Impella-pre-PCI: 38%, = 0.0053) and if revascularisation was incomplete (rS ≤ 8: 37%, rS > 8: 56%, = 0.0099). Patients with both pre-PCI Impella implantation and complete revascularisation had significantly lower mortality (33%) than those with incomplete revascularisation and implantation post PCI (72%, < 0.001). Our retrospective analysis suggests that complete revascularisation supported by an Impella microaxial pump implanted prior to PCI is associated with lower mortality than incomplete revascularisation in patients with AMI-CS.
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http://dx.doi.org/10.3389/fcvm.2021.678748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299360PMC
July 2021

Short- and Mid-Term Outcomes in Patients Deemed Inoperable Undergoing Transapical and Transfemoral TAVR with an STS-PROM below Four Percent.

J Clin Med 2021 Jul 5;10(13). Epub 2021 Jul 5.

Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225 Düsseldorf, Germany.

Transapical (TA) TAVR is known to be associated with increased mortality and vascular complications compared with transfemoral (TF) TAVR in high-risk and inoperable patients. However, safe alternative access methods remain crucial. We aimed to (1) evaluate the 30-day and 1-year outcomes comparing TA and TF TAVR in patients with an STS-PROM of <4% deemed inoperable and (2) determine dependent and independent predictors for all-cause one-year mortality. Data were collected from a single-center registry consisting of 340 eligible patients. One-to-one propensity score matching was performed ( = 50 TA, = 50 TF). Primary endpoints were all-cause mortality, stroke, and major bleeding. Predictors for all-cause one-year mortality were evaluated. Thirty-day mortality (TF vs. TA: 0.0% vs. 4.0%; = 0.153) was comparable in both cohorts. One-year all-cause mortality was twice as high in TA patients (TF vs. TA: 10.0% vs. 20.0%, p logrank = 0.165, HR 2.10). Cerebrovascular events and major bleeding during one-year follow-up were similar. The multivariate analysis identified hemoglobin <12 g/dL at admission and dual antiplatelet therapy as strong predictors for one-year mortality. Although femoral access is the primary access with favorable 30-day and 1-year results, transapical access was successful for patients unsuitable for TF TAVR, showing acceptable short- and mid-term results in inoperable patients with low-risk profiles.
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http://dx.doi.org/10.3390/jcm10132993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8267718PMC
July 2021

Prognostic value of hepatorenal function following transcatheter edge-to-edge mitral valve repair.

Clin Res Cardiol 2021 Jul 12. Epub 2021 Jul 12.

Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.

Background: Hepatorenal dysfunction is a strong prognostic predictor in patients with heart failure. However, the prognostic impact of the hepatorenal dysfunction in patients undergoing transcatheter mitral valve repair (TMVR) has not been well studied.

Methods: In consecutive patients who underwent edge-to-edge TMVR at three German centers, the model for end-stage liver disease excluding international normalized ratio (MELD-XI) score was calculated as 5.11 × ln [serum total bilirubin (mg/dl)] + 11.76 × ln [serum creatinine (mg/dl)] + 9.44. Patients were stratified into high (> 11) or low (≤ 11) MELD-XI score of which an incidence of the composite outcome, consisting of all-cause mortality and heart failure hospitalization, within 2 years after TMVR was assessed.

Results: Of the 881 patients, the mean MELD-XI score was 11.0 ± 5.9, and 415 patients (47.1%) had high MELD-XI score. The MELD-XI score was correlated with male, effective regurgitant orifice area, and tricuspid regurgitation severity and inversely related to left ventricular ejection fraction. Patients with high MELD-XI score had a higher incidence of the composite outcome than those with low MELD-XI score (47.7% vs. 29.8%; p < 0.0001), and in multivariable analysis, the high MELD-XI score was an independent predictor of the composite outcome [adjusted hazard ratio (HR) 1.34; 95% confidence interval (CI) 1.02-1.77; p = 0.04). Additionally, the MELD-XI score as a continuous variable was also an independent predictor (adjusted HR 1.02; 95% CI 1.00-1.05; p = 0.048).

Conclusions: The MELD-XI score was associated with clinical outcomes within 2 years after TMVR and can be a useful risk-stratification tool in patients undergoing TMVR.
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http://dx.doi.org/10.1007/s00392-021-01908-wDOI Listing
July 2021

Rationale and design of the EPCHF trial: the early palliative care in heart failure trial (EPCHF).

Clin Res Cardiol 2021 Jul 9. Epub 2021 Jul 9.

Department of Cardiology, Angiology, Pneumology and Medical Intensive Care, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.

The progressive nature of heart failure (HF) coupled with high mortality and poor quality-of-life (QoL) mandates greater attention to palliative care (PC) as a routine component of HF management. Limited evidence exists from randomized controlled trials supporting the use of interdisciplinary palliative care in the progressive course of HF. The early palliative care in heart failure trial (EPCHF) is a prospective, controlled, nonblinded, multicenter study of an interdisciplinary palliative care intervention in 200 patients with symptomatic HF characterized by NYHA ≥ 2. The 12-month EPCHF intervention includes monthly consultations by a palliative care team focusing on physical and psychosocial symptom relief, attention to spiritual concerns and advance care planning. The primary endpoint is evaluated by health-related QoL questionnaires after 12 months of treatment. First the functional assessment of chronic illness therapy palliative care (FACIT-Pal) score evaluating QoL living with a chronic disease and second the Kansas City cardiomyopathy questionnaire (KCCQ) measuring QoL living with heart failure will be determined. Secondary endpoints are changes in anxiety/depression (HADS), symptom burden score (MIDOS), spiritual well-being functional assessment of chronic illness therapy spiritual well-being scale (FACIT-Sp), medical resource and cost assessment. EPCHF will help evaluate the efficacy and cost-effectiveness of palliative care in symptomatic HF using a patient-centered outcome as well as clinical and economic endpoints. EPCHF is funded by the Bundesministerium für Bildung und Forschung (BMBF, 01GY17).
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http://dx.doi.org/10.1007/s00392-021-01903-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8266990PMC
July 2021

Moderate acceptance of COVID-19 vaccination in patients pre- and post-heart transplantation: Experiences from a German Transplant Centre.

Transpl Infect Dis 2021 Aug 12;23(4):e13681. Epub 2021 Jul 12.

Division of Cardiology, Pulmonology, and Vascular Medicine Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.

Introduction And Objectives: Patients awaiting heart transplantation (HTx) are at increased risk developing severe coronavirus disease 2019 (COVID-19). Patients supported by a left ventricular assist device (LVAD) face additional risks due to coagulopathies during COVID-19. Following HTx, elevated risk factors for severe COVID-19 persist due to chronic immunosuppression and frequent comorbidities. Taken together, COVID-19 vaccination is of critical importance in all three patient cohorts. Here, we report our experience to deliver COVID-19 vaccination in a German transplant center.

Methods And Results: We screened 211 patients for contraindications and offered the remaining 186 eligible patients COVID-19 vaccination. Of those, 133 patients (71%) accepted the offer and were vaccinated. Acceptance of vaccination differed between HTx recipients (84 of 113, 74%), patients on the waiting list (34 of 47, 72%), and patients with LVAD support (28 of 50, 56%). The LVAD cohort demonstrated lower acceptance levels for vaccination compared to HTx recipients and patients awaiting HTx (74% vs. 56%; p = 0.028).

Conclusion: We demonstrate for the first time only moderate acceptance levels of COVID-19 vaccination in HTx recipients and candidates on the waiting list compared to general population, despite perceived high-risk for severe disease. Additionally, those supported by LVAD have even lower adherence. Efforts may need to be made to increase acceptance in this vulnerable as well as cost-intensive patient cohort.
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http://dx.doi.org/10.1111/tid.13681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8420380PMC
August 2021

Crosstalk of Diabetic Conditions with Static Versus Dynamic Flow Environment-Impact on Aortic Valve Remodeling.

Int J Mol Sci 2021 Jun 28;22(13). Epub 2021 Jun 28.

Department of Cardiac Surgery, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany.

Type 2 diabetes mellitus (T2D) is one of the prominent risk factors for the development and progression of calcific aortic valve disease. Nevertheless, little is known about molecular mechanisms of how T2D affects aortic valve (AV) remodeling. In this study, the influence of hyperinsulinemia and hyperglycemia on degenerative processes in valvular tissue is analyzed in intact AV exposed to an either static or dynamic 3D environment, respectively. The complex native dynamic environment of AV is simulated using a software-governed bioreactor system with controlled pulsatile flow. Dynamic cultivation resulted in significantly stronger fibrosis in AV tissue compared to static cultivation, while hyperinsulinemia and hyperglycemia had no impact on fibrosis. The expression of key differentiation markers and proteoglycans were altered by diabetic conditions in an environment-dependent manner. Furthermore, hyperinsulinemia and hyperglycemia affect insulin-signaling pathways. Western blot analysis showed increased phosphorylation level of protein kinase B (AKT) after acute insulin stimulation, which was lost in AV under hyperinsulinemia, indicating acquired insulin resistance of the AV tissue in response to elevated insulin levels. These data underline a complex interplay of diabetic conditions on one hand and biomechanical 3D environment on the other hand that possesses an impact on AV tissue remodeling.
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http://dx.doi.org/10.3390/ijms22136976DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8268732PMC
June 2021

Mitral Regurgitation International Database (MIDA) Score Predicts Outcome in Patients With Heart Failure Undergoing Transcatheter Edge-to-Edge Mitral Valve Repair.

J Am Heart Assoc 2021 07 30;10(13):e019548. Epub 2021 Jun 30.

Department of Internal Medicine II University Hospital Bonn Bonn Germany.

Background Optimizing risk stratification in patients undergoing transcatheter mitral valve repair is an ongoing challenge. The Mitral Regurgitation International Database (MIDA) score represents a user-friendly mortality risk stratification tool that is validated on a large-scale registry of patients with degenerative mitral regurgitation (MR). We here assessed the potential benefit of the MIDA risk score for patients with functional or degenerative MR undergoing transcatheter mitral valve repair. Methods and Results In total, 680 patients undergoing MitraClip implantation were stratified according to MIDA score tertiles into a low (0-7), intermediate (8-9), and a high (10-12) MIDA score group. MR was assessed in follow-up echocardiograms in 416 patients at 323±169 days after transcatheter mitral valve repair. During 2-year follow-up, 8.2% (15/182) of patients with low, 21.3% (64/300) with intermediate, and 26.3% (52/198) with high MIDA score died (log-rank test <0.001). Hazard of all-cause mortality increased by 13% (95% CI, 3%-25%) with every additional point of the MIDA score. Subanalysis of 431 patients with functional MR showed similar results. Furthermore, rates of a combined end point of mortality and hospitalization for heart failure were higher with increasing MIDA score (30% [54/182], 38% [113/300] and 48% [94/198], respectively, log-rank test =0.001). Frequency of residual MR ≥II at follow-up increased with increasing MIDA score group (33%, 44%, and 59%, respectively, <0.001). Conclusions The MIDA mortality risk score maintains its predictive utility in patients undergoing transcatheter mitral valve repair, regardless of MR cause. Moreover, it was predictive of worse event-free survival regarding a combined end point of mortality and hospitalization for heart failure, and was associated with postprocedural residual MR ≥II and MR recurrence.
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http://dx.doi.org/10.1161/JAHA.120.019548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8403297PMC
July 2021

Factors associated with a high or low implantation of self-expanding devices in TAVR.

Clin Res Cardiol 2021 Jun 24. Epub 2021 Jun 24.

Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany.

Objectives: Optimizing valve implantation depth (ID) plays a crucial role in minimizing conduction disturbances and achieving optimal functional integrity. Until now, the impact of intraprocedural fast (FP) or rapid ventricular pacing (RP) on the implantation depth has not been investigated. Therefore, we aimed to (1) evaluate the impact of different pacing maneuvers on ID, and (2) identify the independent predictors of deep ID.

Methods: 473 TAVR patients with newer-generation self-expanding devices were retrospectively enrolled and one-to-one propensity-score-matching was performed, resulting in a matching of 189 FP and RP patients in each cohort. The final ID was analyzed, and the underlying functional, anatomical, and procedural conditions were evaluated by univariate and multivariate analysis.

Results: The highest ID was reached under RP in severe aortic valve calcification and valve size 26 mm. Multivariate analysis identified left ventricular outflow (LVOT) calcification [OR 0.50 (0.31-0.81) p = 0.005*], a "flare" aortic root [OR 0.42 (0.25-0.71), p = 0.001*], and RP (OR 0.49 [0.30-0.79], p = 0.004*) as independent highly preventable predictors of a deep ID. In a model of protective factors, ID was significantly reduced with the number of protective criteria (0-2 criteria: - 5.7 mm ± 2.6 vs. 3-4 criteria - 4.3 mm ± 2.0; p < 0.0001*).

Conclusion: Data from this retrospective analysis indicate that RP is an independent predictor to reach a higher implantation depth using self-expanding devices. Randomized studies should prove for validation compared to fast and non-pacing maneuvers during valve delivery and their impact on implantation depth.

Trail Registration: Clinical Trial registration: NCT01805739.

Study Design: Evaluation of the impact of different pacing maneuvers (fast ventricular pacing-FP vs. rapid ventricular pacing-RP) on implantation depth (ID). After one-to-one-propensity-score-matching, independent protective and risk factors for a very deep ID beneath 6 mm toward the LVOT (< - 6 mm) were identified. Stent frame pictures as a courtesy by Medtronic. AVC aortic valve calcification.
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http://dx.doi.org/10.1007/s00392-021-01901-3DOI Listing
June 2021

Extent and determinants of left ventricular reverse remodeling in patients with secondary mitral regurgitation undergoing MitraClip implantation.

Int J Cardiol Heart Vasc 2021 Jun 3;34:100804. Epub 2021 Jun 3.

Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Medical Faculty, Moorenstraße 5, 40225 Duesseldorf, Germany.

Background: In secondary MR, data on left ventricular (LV) remodeling after MitraClip procedure are rare, even this information may impact patient selection. This study investigated changes in LV structure and function by cardiovascular magnetic resonance (CMR) following MitraClip implantation for secondary mitral regurgitation (MR) in order to assess extent and predictors of LV reverse remodeling (LVRR).

Methods And Results: Twenty-nine patients underwent CMR imaging prior to and six months after MitraClip procedure. LVRR was defined by a decrease of LV end-diastolic volume index (LVEDVi) > 15% compared to baseline. According to the definition of LVRR, 34% of patients displayed LVRR at follow-up CMR. Baseline LV stroke volume index (LVSVi), LV ejection fraction (LVEF), LV circumferential strain and MR volume at baseline were predictors of LVRR at follow-up. At second CMR, we detected an improvement in hemodynamic status as illustrated by an increase in effective LVSVi (28 ± 8 ml/m vs. 33 ± 8 ml/m; p = 0.053) and cardiac index (2.0 ± 0.5 vs. 2.3 ± 0.5 l/min; p = 0.016), while LVEF and LV strain parameters did not change (p > 0.05). Improvements in effective LVSVi were associated with the decrease of MR volume (r = 0.509; p = 0.018) and MR fraction (r = 0.629; p = 0.002) by MitraClip.

Conclusions: Together, MitraClip implantation is associated with LVRR in one third of patients. Baseline LV function and magnitude of MR are important predictors of LVRR. Improvement of hemodynamic status may be assessed by effective stroke volume index and correlates with the reduction of MR by MitraClip implantation, rather than an increase in LV contractility.
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http://dx.doi.org/10.1016/j.ijcha.2021.100804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8188052PMC
June 2021

Iatrogenic atrial septal defect persistence after percutaneous mitral valve repair: a meta-analysis.

Acta Cardiol 2021 Jun 4:1-11. Epub 2021 Jun 4.

Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.

Background: Percutaneous mitral valve repair (PMVR) requires a puncture of the atrial septum, resulting in iatrogenic atrial septal defect (iASD), which usually causes a transient left-to-right shunt. However, the influencing risk factors for iASD persistence and functional consequences are not fully understood. This meta-analysis aimed to summarise available data on the persistence of iASD following PMVR.

Methods: The authors conducted a literature search in PubMed/MEDLINE and EMBASE databases to identify studies investigating iASD persistence in PMVR patients.

Results: Six observational studies ( = 361) met inclusion criteria for the final analysis. Prevalence of persistent iASD was documented with 28% after 12 months follow-up. iASD size increased over time with a diameter of 5.3 ± 0.76 mm after one month and 6.5 ± 0.21 mm after 12 months. Possible predictors of iASD persistence after PMVR appeared to be pre-existing AF (RR 1.24;  = .03), residual mitral regurgitation > II° (RR 2.06;  = .03) and prolonged fluoroscopic time (RR 8.27;  = .01). Patients with iASD persistence had a higher risk for development of right heart overload regarding the increased area of the right atrium (MD 5.24;  = .004) and enlarged diameter of the right ventricle (MD 3.33;  < .0001). Rehospitalization was more frequently reported in iASD patients (RR 9.52;  = .004).

Conclusions: This meta-analysis proved iASD persistence in 28% of PMVR after 12 months follow-up with a higher risk for right heart volume overload and more frequent rehospitalization compared to patients without iASD persistence. Since percutaneous catheter-based treatments with transseptal approaches are rising, further evidence about the hemodynamic impact of persistent iASD is warranted.
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http://dx.doi.org/10.1080/00015385.2021.1899484DOI Listing
June 2021

Computed tomography derived predictors of permanent pacemaker implantation after transcatheter aortic valve replacement: A meta-analysis.

Catheter Cardiovasc Interv 2021 Jun 2. Epub 2021 Jun 2.

Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany.

Objectives: This meta-analysis sought to assess predictors of permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) with focus on preprocedural multi-slice computed tomography (MSCT) derived data.

Background: Transcatheter aortic valve replacement (TAVR) has expanded to a well-established treatment for severe symptomatic aortic stenosis at high and intermediate surgical risk. PPI after TAVR remains one of the most frequent procedure-related complications and appears to be influenced by several factors.

Methods: The authors conducted a literature search in PubMed/MEDLINE and EMBASE databases to identify studies that investigated preprocedural MSCT data and the rate of PPI following TAVR with new-generation devices.

Results: Ten observational studies (n = 2707) met inclusion criteria for the final analysis. PPI was performed in 387 patients (14.3%) after TAVR. Patients requiring PPI had a larger annulus perimeter (MD: 1.66 mm; p < .001) and a shorter membranous septum length (MD: -1.1 mm; p < .05). Concerning calcification distribution, patients with requirement for new pacemaker implantation showed increased calcification of the left coronary cusp (MD: 47.6 mm ; p < .001), and the total left ventricular outflow tract (MD: 24.42 mm ; p < .01). Lower implantation depth (MD: 0.95 mm; p < .05) and oversizing (MD: 1.52%; p < .05) were procedural predictors of PPI following TAVR.

Conclusions: Besides the well-known impact of electrocardiographic and procedure-related factors on conduction disturbances, MSCT derived distribution of the aortic valve and left ventricular outflow tract calcification, as well as membranous septum length, are associated with an increased risk of PPI following TAVR.
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http://dx.doi.org/10.1002/ccd.29805DOI Listing
June 2021

Treatment of donor-specific antibody-mediated rejection after heart transplantation by IgM-enriched human immunoglobulin.

ESC Heart Fail 2021 Aug 10;8(4):3413-3417. Epub 2021 May 10.

Department of Cardiac Surgery, Medical Faculty, Heinrich-Heine-University Medical School, Moorenstraße 5, Duesseldorf, 40225, Germany.

Antibody-mediated graft rejection caused by donor-specific antibodies (DSA-MR) remains a serious problem after heart transplantation (HTx). IgM-enriched human intravenous immunoglobulin (IGM-IVIG) consists of 76% IgG, 12% IgM, and 12% IgA and provides a new multifactorial approach for DSA-MR. Between 2017 and 2020, four (P1-4) of 102 patients developed DSA-MR after HTx in our department and were repetitively treated with IGM-IVIG in combination with anti-thymocyte globulin. While in P1 and P4, DSA-MR occurred within the early post-operative interval, P2 and P3 developed DSA-MR approximately 1 year after transplantation. An impairment of ventricular function was observed in three of four patients. Furthermore, P1 and P4 suffered from malign ventricular arrhythmias. After the application of IGM-IVIG, the ventricular function recovered, and all patients could be discharged from the hospital. As part of a multifactorial therapeutic approach, treatment with IGM-IVIG seems to be a safe and effective strategy to address DSA-MR.
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http://dx.doi.org/10.1002/ehf2.13409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8318410PMC
August 2021

Predictors of calcification distribution in severe tricuspid aortic valve stenosis.

Int J Cardiovasc Imaging 2021 Sep 20;37(9):2791-2799. Epub 2021 Apr 20.

Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany.

We investigated aortic valve calcification (AVC) distribution and predictors for leaflet calcification patterns in patients with severe tricuspid aortic valve stenosis undergoing transcatheter aortic valve replacement (TAVR). Patients undergoing routine multi-sliced computed tomography (MSCT) for procedural planning were enrolled. MSCT data were transferred to a dedicated workstation for evaluation (3mensio Structural Heart™, Pie Medical Imaging BV, Maastricht, The Netherlands) and analyzed. Participants were separated into asymmetrical (AC) and symmetrical (SC) leaflet calcification and potential predictors for calcification distribution were identified with univariate and multivariate regression analysis. 567 Participants with severe tricuspid AS were divided into asymmetrical (AC, n = 443; 78.1%) and symmetrical (SC, n = 124; 21.9%) AVC. In AC, the non-coronary cusp was the most calcified cusp (n = 238; 57.7%). SC is more common in females (AC/SC: 49.2% vs. 67.7%; p < 0.0001). AVC was more severe in patients with AC, who also have larger aortic root dimensions. Multivariate analysis depicted, inter alia, left ventricular outflow tract (LVOT) calcification < 25 Agatston units (OR 1.81 [1.09-3.00], p = 0.021), a mean pressure gradient < 36 mmHg (OR 1.77 [1.03-3.05], p = 0.039), and an annulo-apical angle > 67° (OR 1.68 [1.00-2.80], p = 0.049) as predictors for SC, although with only moderate predictive value. Data from this retrospective analysis indicate that SC occurs more frequently in females. The cumulative leaflet calcification burden is higher in patients with AC, who also present with larger aortic root dimensions. The predictive value for prominent calcification of different aortic valve cusps in AC patients was only low to moderate.Trial registration number: NCT01805739.
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http://dx.doi.org/10.1007/s10554-021-02248-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8390394PMC
September 2021

Levosimendan for Treatment of Primary Graft Dysfunction After Heart Transplantation: Optimal Timing of Application.

Exp Clin Transplant 2021 May 16;19(5):473-480. Epub 2021 Apr 16.

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

Objectives: Primary graft dysfunction remains a serious problem after heart transplant. Pharmacological treatment with the calcium sensitizer levosimendan may be an additive treatment for primary graft dysfunction.

Materials And Methods: Patients undergoing heart transplant between 2010 and 2020 were retrospectively reviewed and divided depending on postoperative treatment with (n = 41) or without (n = 109) levosimendan. Recipients who received levosi mendan were further divided with regard to timing of levosimendan application (early group: started ≤48 hours posttransplant [n = 23]; late group: started >48 hours posttransplant [n = 18]).

Results: Patients who received levosimendan treatment displayed a remarkable incidence (87.8%) of postoperative primary graft dysfunction with need for venoarterial extracorporeal membrane oxygenation and therefore often presented with perioperative morbidity. Patient with early application of levosimendan showed significantly decreased duration of venoarterial extracorporeal membrane oxygenation support (5.1 ± 3.5 days vs 12.6 ± 9.3 days in those with late application; P < .01) and decreased mortality during venoarterial extracorporeal membrane oxygenation support (0.0% vs 33.3% in early vs late group; P < .01). In addition, compared with patients with late levosimendan application, patients with early application needed fewer blood transfusions (P < .05), had shorter ventilation times (279 ± 235 vs 428 ± 293 h; P = .03), and showed a trend of reduced incidence of postoperative renal failure (69.6% vs 94.4%; P = .06). Moreover, survival analyses indicated an increased survival for patients with early start of levosimendan therapy within the first 48 hours after heart transplant (P = .09).

Conclusions: Pharmacotherapy with levosimendan may be a promising additive in the treatment of primary graft dysfunction after heart transplant. With administration of levosimendan within the first 48 hours posttransplant, rates of successful weaning from venoarterial extracorporeal membrane oxygenation and outcomes after heart transplant were shown to increase.
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http://dx.doi.org/10.6002/ect.2020.0342DOI Listing
May 2021

Predictors of functional mitral regurgitation recurrence after percutaneous mitral valve repair.

Heart Vessels 2021 Oct 3;36(10):1574-1583. Epub 2021 Apr 3.

Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, University Hospital Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany.

We aimed to identify predictors of mitral regurgitation recurrence (MR) after percutaneous mitral valve repair (PMVR) in patients with functional mitral regurgitation (FMR). Patients with FMR were enrolled who underwent PMVR using the MitraClip device. Procedural success was defined as reduction of MR of at least one grade to MR grade ≤ 2 + assessed at discharge. Recurrence of MR was defined as MR grade 3 + or worse at one year after initially successful PMVR. A total of 306 patients with FMR underwent PMVR procedure. In 279 out of 306 patients (91.2%), PMVR was successfully performed with MR grade ≤ 2 + at discharge. In 11.4% of these patients, MR recurrence of initial successful PMVR after 1 year was observed. Recurrence of MR was associated with a higher rate of heart failure rehospitalization during the 12 months follow-up (52.0% vs. 30.3%; p = 0.029), and less improvement in New York Heart Association (NYHA) functional class [68% vs. 19% of the patients presenting with NYHA functional class III or IV one year after PMVR when compared to patients without recurrence (p = 0.001)]. Patients with MR recurrence were characterized by a higher left ventricular sphericity index {0.69 [Interquartile range (IQR) 0.64, 0.74] vs. 0.65 (IQR 0.58, 0.70), p = 0.003}, a larger left atrium volume [118 (IQR 96, 143) ml vs. 102 (IQR 84, 123) ml, p = 0.019], a larger tenting height 10 (IQR 9, 13) mm vs. 8 (IQR 7, 11) mm (p = 0.047), and a larger mitral valve annulus [41 (IQR 38, 43) mm vs. 39 (IQR 36, 40) mm, p = 0.015] when compared to patients with durable optimal long-term results. In a multivariate regression model, the left ventricular sphericity index [Odds Ratio (OR) 1.120, 95% Confidence Interval (CI) 1.039-1.413, p = 0.003)], tenting height (OR 1.207, 95% CI 1.031-1.413, p = 0.019), and left atrium enlargement (OR 1.018, 95% CI 1.000-1.038, p = 0.047) were predictors for MR recurrence after 1 year. In patients with FMR, baseline parameters of advanced heart failure such as spherical ventricle, tenting height and a large left atrium might indicate risk of recurrent MR one year after PMVR.
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http://dx.doi.org/10.1007/s00380-021-01828-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8379112PMC
October 2021
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