Publications by authors named "Stefan Baumann"

106 Publications

[Acute ischemic stroke and elevated troponin: Diagnostic work-up and therapeutic consequences].

Dtsch Med Wochenschr 2021 Feb 26. Epub 2021 Feb 26.

I. Medizinische Klinik, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Ruprecht-Karls-Universität Heidelberg, European Center for AngioScience (ECAS) und Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) Standort Heidelberg/Mannheim, Mannheim, Deutschland.

Elevated troponin values are frequently detected in patients with acute ischemic stroke, requiring adequate diagnostic work-up due to the high cardiac mortality after stroke. Since dual platelet inhibition can cause secondary intracerebral hemorrhage careful consideration of invasive coronary intervention is mandatory. Based on three case reports, this review article presents a diagnostic algorithm taking into account latest findings from the literature.
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http://dx.doi.org/10.1055/a-1308-7490DOI Listing
February 2021

Patient Selection for Protected Percutaneous Coronary Intervention: Who Benefits the Most?

Cardiol Clin 2020 Nov 14;38(4):507-516. Epub 2020 Sep 14.

First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.

The evolution of percutaneous coronary intervention (PCI) enables a complete revascularization of complex coronary lesions. However, simultaneously, patients are presenting nowadays with higher rates of comorbidities, which may lead to a lower physiologic tolerance for complex PCI. To avoid hemodynamic instability during PCI and achieve safe complete revascularization, protected PCI using mechanical circulatory support devices has been developed. However, which patients would benefit from the protected PCI is still in debate. Hence, this review provides practical approaches for the selection of patients by outlining current clinical data assessing utility of protected PCI in high-risk patients.
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http://dx.doi.org/10.1016/j.ccl.2020.06.004DOI Listing
November 2020

Preliminary investigation of an idiopathic muscle disease in farmed burbot Lota lota.

Dis Aquat Organ 2020 Aug 20;140:179-186. Epub 2020 Aug 20.

Institute of Natural Resource Sciences (IUNR), Zurich University of Applied Sciences (ZHAW), Grüental, PO Box, 8820 Wädenswil, Switzerland.

The rearing of less established fish species in recirculating aquaculture systems (RASs) is increasing, but may require adaptations of the rearing facilities if health impairments occur. We observed several health issues in burbot Lota lota reared for up to 2 yr in a RAS and used microbiological, histological and molecular-biological methods to identify the causative agents. Minor skin trauma led to the development of ulcers. In addition, several fillets of burbot showed pronounced granulomatous inflammation and calcification with signs of muscle fiber degeneration which resembled a condition called 'sandy flesh disease' in North American walleye. Several infectious agents were able to be excluded as a cause for the disease. Carnobacterium maltaromaticum was isolated in high numbers in some of the affected muscle tissue. However, the role of this bacterium or other causative agents or husbandry conditions remains to be elucidated.
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http://dx.doi.org/10.3354/dao03494DOI Listing
August 2020

Risk stratification in families with history of idiopathic ventricular fibrillation.

HeartRhythm Case Rep 2020 Jul 29;6(7):386-389. Epub 2020 Mar 29.

First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, and DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany.

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http://dx.doi.org/10.1016/j.hrcr.2020.03.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360980PMC
July 2020

Radial versus femoral artery access for percutaneous coronary artery intervention in patients with acute myocardial infarction and multivessel disease complicated by cardiogenic shock: Subanalysis from the CULPRIT-SHOCK trial.

Am Heart J 2020 07 30;225:60-68. Epub 2020 Apr 30.

First Department of Medicine-Cardiology, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.

Background: The use and impact of transradial artery access (TRA) compared to transfemoral artery access (TFA) in patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) complicated by cardiogenic shock (CS) remain unclear.

Methods: This is a post hoc analysis of the CULPRIT-SHOCK trial where patients presenting with MI and multivessel disease complicated by CS were randomized to a strategy of culprit-lesion-only or immediate multivessel PCI. Arterial access was left at operator's discretion. Adjudicated outcomes of interest were the composite of death or renal replacement therapy (RRT) at 30 days and 1 year. Multivariate logistic models were used to assess the association between the arterial access and outcomes.

Results: Among the 673 analyzed patients, TRA and TFA were successfully performed in 118 (17.5%) and 555 (82.5%) patients, respectively. Compared to TFA, TRA was associated with a lower 30-day rate of death or RRT (37.3% vs 53.2%, adjusted odds ratio [aOR]: 0.57; 95% confidence interval [CI] 0.34-0.96), a lower 30-day rate of death (34.7% vs 49.7%; aOR: 0.56; 95% CI 0.33-0.96), and a lower 30-day rate of RRT (5.9% vs 15.9%; aOR: 0.40; 95% CI 0.16-0.97). No significant differences were observed regarding the 30-day risks of type 3 or 5 Bleeding Academic Research Consortium bleeding and stroke. The observed reduction of death or RRT and death with TRA was no longer significant at 1 year (44.9% vs 57.8%; aOR: 0.85; 95% CI 0.50-1.45 and 42.4% vs 55.5%, aOR: 0.78; 95% CI 0.46-1.32, respectively).

Conclusions: In patients undergoing PCI for acute MI complicated by CS, TRA may be associated with improved early outcomes, although the reason for this finding needs further research.
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http://dx.doi.org/10.1016/j.ahj.2020.04.014DOI Listing
July 2020

Demarcating and highlighting in Papuan Malay phrase prosody.

J Acoust Soc Am 2020 04;147(4):2974

Institut für Linguistik - Phonetik / Sonderforschungsbereich (SFB) 1252, Herbert-Lewin-Str. 6, Köln 50931, Germany.

Phrase-level prosody serves two essential functions in many languages of the world: chunking information into units (demarcating) and marking important information (highlighting). Recent work suggests that prosody has a mainly demarcating function in the Trade Malay language family. That is, the use of pitch accents in these languages is limited or absent, as the main prosodic events occur on the final two syllables in a phrase. The current study investigates the extent to which Papuan Malay phrase prosody is used for demarcating and highlighting, taking into account the potential influence of word stress. This is done by means of acoustic analyses on a corpus of spontaneous speech. Both the form (F0 movement) and the possible functions (demarcating and highlighting) of the final two syllables in Papuan Malay phrases are investigated. Although most results favor the demarcating function of Papuan Malay phrase prosody, a highlighting function cannot be ruled out. The results suggest that Papuan Malay might hold an exceptional position in the typology of prosodic prominence.
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http://dx.doi.org/10.1121/10.0001008DOI Listing
April 2020

Prognostic Value of Coronary Computed Tomography Angiography-derived Morphologic and Quantitative Plaque Markers Using Semiautomated Plaque Software.

J Thorac Imaging 2021 Mar;36(2):108-115

Institute of Clinical Radiology and Nuclear Medicine, Faculty of Medicine Mannheim.

Purpose: In this study, we analyzed the prognostic value of coronary computed tomography angiography-derived morphologic and quantitative plaque markers and plaque scores for major adverse cardiovascular events (MACEs).

Materials And Methods: We analyzed the data of patients with suspected coronary artery disease (CAD). Various plaque markers were obtained using a semiautomated software prototype or derived from the results of the software analysis. Several risk scores were calculated, and follow-up data concerning MACE were collected from all patients.

Results: A total of 131 patients (65±12 y, 73% male) were included in our study. MACE occurred in 11 patients within the follow-up period of 34±25 months.CAD-Reporting and Data System score (odds ratio [OR]=11.62), SYNTAX score (SS) (OR=1.11), Leiden-risk score (OR=1.37), segment involvement score (OR=1.76), total plaque volume (OR=1.20), and percentage aggregated plaque volume (OR=1.32) were significant predictors for MACE (all P≤0.05). Moreover, the difference of the corrected coronary opacification (ΔCCO) correlated significantly with the occurrence of MACE (P<0.0001). The CAD-Reporting and Data System score, SS, and Leiden-risk score showed substantial sensitivity for predicting MACE (90.9%). The SS and Leiden-risk score displayed high specificities of 80.8% and 77.5%, respectively. These plaque markers and risk scores all provided high negative predictive value (>90%).

Conclusion: The coronary computed tomography angiography-derived plaque markers of segment involvement score, total plaque volume, percentage aggregated plaque volume, and ΔCCO, and the risk scores exhibited predictive value for the occurrence of MACE and can likely aid in identifying patients at risk for future cardiac events.
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http://dx.doi.org/10.1097/RTI.0000000000000509DOI Listing
March 2021

Comparison of Machine Learning Computed Tomography-Based Fractional Flow Reserve and Coronary CT Angiography-Derived Plaque Characteristics with Invasive Resting Full-Cycle Ratio.

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

First Department of Medicine-Cardiology, University Medical Centre Mannheim, and DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim 68167, Germany.

Background: The aim is to compare the machine learning-based coronary-computed tomography fractional flow reserve (CT-FFR) and coronary-computed tomographic morphological plaque characteristics with the resting full-cycle ratio (RFR) as a novel invasive resting pressure-wire index for detecting hemodynamically significant coronary artery stenosis.

Methods: In our single center study, patients with coronary artery disease (CAD) who had a clinically indicated coronary computed tomography angiography (cCTA) and subsequent invasive coronary angiography (ICA) with pressure wire-measurement were included. On-site prototype CT-FFR software and on-site CT-plaque software were used to calculate the hemodynamic relevance of coronary stenosis.

Results: We enrolled 33 patients (70% male, mean age 68 ± 12 years). On a per-lesion basis, the area under the receiver operating characteristic curve (AUC) of CT-FFR (0.90) was higher than the AUCs of the morphological plaque characteristics length/minimal luminal diameter (LL/MLD; 0.80), minimal luminal diameter (MLD; 0.77), remodeling index (RI; 0.76), degree of luminal diameter stenosis (0.75), and minimal luminal area (MLA; 0.75).

Conclusion: CT-FFR and morphological plaque characteristics show a significant correlation to detected hemodynamically significant coronary stenosis. Whole CT-FFR had the best discriminatory power, using RFR as the reference standard.
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http://dx.doi.org/10.3390/jcm9030714DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141220PMC
March 2020

Additional Value of Machine-Learning Computed Tomographic Angiography-Based Fractional Flow Reserve Compared to Standard Computed Tomographic Angiography.

J Clin Med 2020 Mar 3;9(3). Epub 2020 Mar 3.

First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany, DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany and ECAS (European Center for Angioscience), Faculty of Medicine Mannheim, Heidelberg University, 68167 Mannheim, Germany.

Machine-learning-based computed-tomography-derived fractional flow reserve (CT-FFR) obtains a hemodynamic index in coronary arteries. We examined whether it could reduce the number of invasive coronary angiographies (ICA) showing no obstructive lesions. We further compared CT-FFR-derived measurements to clinical and CT-derived scores. We retrospectively selected 88 patients (63 ± 11years, 74% male) with chronic coronary syndrome (CCS) who underwent clinically indicated coronary computed tomography angiography (cCTA) and ICA. cCTA image data were processed with an on-site prototype CT-FFR software. CT-FFR revealed an index of >0.80 in coronary vessels of 48 (55%) patients. This finding was corroborated in 45 (94%) patients by ICA, yet three (6%) received revascularization. In patients with an index ≤ 0.80, three (8%) of 40 were identified as false positive. A total of 48 (55%) patients could have been retained from ICA. CT-FFR (AUC = 0.96, ≤ 0.0001) demonstrated a higher diagnostic accuracy compared to the pretest probability or CT-derived scores and showed an excellent sensitivity (93%), specificity (94%), positive predictive value (PPV; 93%) and negative predictive value (NPV; 94%). CT-FFR could be beneficial for clinical practice, as it may identify patients with CAD without hemodynamical significant stenosis, and may thus reduce the rate of ICA without necessity for coronary intervention.
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http://dx.doi.org/10.3390/jcm9030676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141259PMC
March 2020

In-Hospital Cost Comparison of Triple-Rule-Out Computed Tomography Angiography Versus Standard of Care in Patients With Acute Chest Pain.

J Thorac Imaging 2020 May;35(3):198-203

Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.

Purpose: The purpose of this study was to evaluate the utilization of invasive and noninvasive tests and compare cost in patients presenting with chest pain to the emergency department (ED) who underwent either triple-rule-out computed tomography angiography (TRO-CTA) or standard of care.

Materials And Methods: We performed a retrospective single-center analysis of 2156 ED patients who presented with acute chest pain with a negative initial troponin and electrocardiogram for myocardial injury. Patient cohorts matched by patient characteristics who had undergone TRO-CTA as a primary imaging test (n=1139) or standard of care without initial CTA imaging (n=1017) were included in the study. ED visits, utilization of tests, and costs during the initial episode of hospital care were compared.

Results: No significant differences in the diagnosis of coronary artery disease, pulmonary embolism, or aortic dissection were observed. Median ED waiting time (4.5 vs. 7.0 h, P<0.001), median total length of hospital stay (5.0 vs. 32.0 h, P<0.001), hospital admission rate (12.6% vs. 54.2%, P<0.001), and ED return rate to our hospital within 30 days (3.5% vs. 14.6%, P<0.001) were significantly lower in the TRO-CTA group. Moreover, reduced rates of additional testing and invasive coronary angiography (4.9% vs. 22.7%, P<0.001), and ultimately lower total cost per patient (11,783$ vs. 19,073$, P<0.001) were observed in the TRO-CTA group.

Conclusions: TRO-CTA as an initial imaging test in ED patients presenting with acute chest pain was associated with shorter ED and hospital length of stay, fewer return visits within 30 days, and ultimately lower ED and hospitalization costs.
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http://dx.doi.org/10.1097/RTI.0000000000000474DOI Listing
May 2020

Asymmetric LSCF Membranes Utilizing Commercial Powders.

Materials (Basel) 2020 Jan 30;13(3). Epub 2020 Jan 30.

Forschungszentrum Jülich GmbH, Institute of Energy and Climate Research, Materials Synthesis and Processing (IEK-1), 52425 Jülich, Germany.

Powders of constant morphology and quality are indispensable for reproducible ceramic manufacturing. In this study, commercially available powders were characterized regarding their microstructural properties and screened for a reproducible membrane manufacturing process, which was done by sequential tape casting. Basing on this, the slurry composition and ratio of ingredients were systematically varied in order to obtain flat, crack-free green tapes suitable for upscaling of the manufacturing process. Debinding and sintering parameters were adjusted to obtain defect-free membranes with diminished bending. The crucial parameters are the heating ramp, sintering temperature, and dwell time. The microstructure of the asymmetric membranes was investigated, leading to a support porosity of approximately 35% and a membrane layer thickness of around 20 µm. Microstructure and oxygen flux are comparable to asymmetric LaSrCoFeO (LSCF) membranes manufactured from custom-made powder, showing an oxygen flux of > 1 mLcmmin at 900 °C in air/Ar gradient.
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http://dx.doi.org/10.3390/ma13030614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7040817PMC
January 2020

[Coronary physiology in the catheter laboratory].

Herz 2020 Jan 14. Epub 2020 Jan 14.

Universitäts-Herzzentrum Freiburg-Bad Krozingen und Medizinische Fakultät Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland.

The regulation of coronary flow is mainly located in the resistance vessels of the microcirculation, so that the functional relevance of a coronary stenosis arises from the interaction between the epicardial stenosis and the downstream microcirculation. These complex interactions are precisely detectable by physiological measurements, such as the instantaneous wave-free ratio (iwFR) or the fractional flow reserve (FFR). In contrast, the purely visual assessment of the coronary anatomy could lead to misinterpretation and possibly to incorrect revascularization decisions. Consequently, in the current guidelines on myocardial revascularization of the European Society of Cardiology (ESC) the measurement of iwFR and FFR has a class IA indication in intermediate stenoses with unclear hemodynamic relevance. Despite this clear recommendation, physiological measurements are not yet regularly used in the clinical routine. Besides the purely hemodynamic assessment, novel methods such as co-registration and coronary mapping can be used for virtual planning of percutaneous coronary interventions, especially in vessels with diffuse lesions and serial stenoses. Furthermore, invasive flow measurements are also helpful for risk stratification between conservative and interventional treatment of patients with acute coronary syndrome, where additional factors of flow limitation, such as coronary spasm, thrombus and acute disturbance of the microcirculation play an important role.
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http://dx.doi.org/10.1007/s00059-019-04878-yDOI Listing
January 2020

Optimal duration for dual antiplatelet therapy with COMBO dual therapy stent.

J Geriatr Cardiol 2019 Nov;16(11):840-843

First Department of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.

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http://dx.doi.org/10.11909/j.issn.1671-5411.2019.11.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911800PMC
November 2019

Coronary CT angiography derived plaque markers correlated with invasive instantaneous flow reserve for detecting hemodynamically significant coronary stenoses.

Eur J Radiol 2020 Jan 20;122:108744. Epub 2019 Nov 20.

Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, Heidelberg University, Germany.

Purpose: The study aimed to compare morphological and anatomic plaque markers derived from coronary computed tomography angiography (cCTA) for the detection of lesion specific ischemia with invasive instantaneous wave free ratio (iFR®) as the reference standard.

Methods: In our prospective study, we enrolled patients with suspected coronary artery disease (CAD), who had undergone cCTA, using a low-dose third-generation dual-source CT and invasive coronary angiography (ICA) with iFR® measurement. Various plaque markers were assessed on cCTA. Discriminatory power of these markers for the detection of ischemia-inducing coronary artery disease was evaluated against invasive iFR®.

Results: Our study cohort included 39 patients (66.6 ± 12.0 years, 72 % male). Among 54 vessel-specific lesions, 15 lesions (28 %) were characterized as hemodynamically significant by iFR® ≤0.89. The area under the curve (AUC) of lesion length/ minimal luminal diameter (LL/MLD) (0.84) was greater than the AUC of minimal luminal area (MLA) (0.82), MLD (0.81), the degree of luminal diameter stenosis (0.81), corrected coronary opacification (CCO) (0.79), remodeling index (RI) (0.75), and percentage aggregate plaque volume (%APV) (0.72). LL, vessel volume (VV), total plaque volume (TPV), calcified and non-calcified plaque volume (CPV and NCPV) did not reach statistical significance and were unable to discriminate between vessels with and without ischemia-inducing coronary stenosis.

Conclusion: LL/MLD, MLA, MLD, the degree of luminal diameter stenosis, CCO, RI, and %APV derived from cCTA can support the detection of hemodynamically significant coronary stenosis as compared with iFR®, with LL/MLD showing the greatest discriminatory power.
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http://dx.doi.org/10.1016/j.ejrad.2019.108744DOI Listing
January 2020

Characterization of circulating thrombin in patients with septic shock: a prospective observational study.

J Thromb Thrombolysis 2020 Jul;50(1):90-97

First Department of Medicine, Faculty of Medicine Mannheim, University Medical Center Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Septic shock is characterized by a dysregulated response to infection, hypotension and activation of the coagulation system. Markers of coagulation activation are commonly used to diagnose and monitor ensuing coagulopathies. In this study, we sought to determine levels of circulating thrombin in patients with septic shock. To characterize levels of circulating, active thrombin in patients with septic shock. 48 patients with septic shock were included in this prospective, observational study. Blood samples were obtained on admission, day 1, day 3 and day 6. Levels of active thrombin were measured using a standardized, clinically applicable oligonucleotide (aptamer)-based enzyme-capture assay (OECA). Thrombin levels were correlated with established indirect thrombin parameters, conventional coagulation tests, laboratory parameters, patient characteristics and outcome. Elevated levels of thrombin were detected in 27 patients (56.3%) during the course of the study. Thrombin levels were positively correlated with thrombin-antithrombin complexes (r = 0.30, p < 0.05) and negatively associated with FVII levels (r = - 0.28, p < 0.05). Thrombin levels on admission did not predict 30-day mortality (OR 0.82, 95% CI 0.23-2.92, p = 0.77). Circulating levels of active thrombin can be measured in a subset of patients with septic shock. Although thrombin levels are correlated with established markers of coagulation, they do not provide additional prognostic information.
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http://dx.doi.org/10.1007/s11239-019-01992-wDOI Listing
July 2020

Correlation of machine learning computed tomography-based fractional flow reserve with instantaneous wave free ratio to detect hemodynamically significant coronary stenosis.

Clin Res Cardiol 2020 Jun 29;109(6):735-745. Epub 2019 Oct 29.

First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany.

Background: Fractional flow reserve based on coronary CT angiography (CT-FFR) is gaining importance for non-invasive hemodynamic assessment of coronary artery disease (CAD). We evaluated the on-site CT-FFR with a machine learning algorithm (CT-FFR) for the detection of hemodynamically significant coronary artery stenosis in comparison to the invasive reference standard of instantaneous wave free ratio (iFR).

Methods: This study evaluated patients with CAD who had a clinically indicated coronary computed tomography angiography (cCTA) and underwent invasive coronary angiography (ICA) with iFR-measurements. Standard cCTA studies were acquired with third-generation dual-source computed tomography and analyzed with on-site prototype CT-FFR software.

Results: We enrolled 40 patients (73% males, mean age 67 ± 12 years) who had iFR-measurement and CT-FFR calculation. The mean calculation time of CT-FFR values was 11 ± 2 min. The CT-FFR algorithm showed, on per-patient and per-lesion level, respectively, a sensitivity of 92% (95% CI 64-99%) and 87% (95% CI 59-98%), a specificity of 96% (95% CI 81-99%) and 95% (95% CI 84-99%), a positive predictive value of 92% (95% CI 64-99%), and 87% (95% CI 59-98%), and a negative predictive value of 96% (95% CI 81-99%) and 95% (95% CI 84-99%). The area under the receiver operating characteristic curve for CT-FFR on per-lesion level was 0.97 (95% CI 0.91-1.00). Per lesion, the Pearson's correlation between the CT-FFR and iFR showed a strong correlation of r = 0.82 (p < 0.0001; 95% CI 0.715-0.920).

Conclusion: On-site CT-FFR correlated well with the invasive reference standard of iFR and allowed for the non-invasive detection of hemodynamically significant coronary stenosis.
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http://dx.doi.org/10.1007/s00392-019-01562-3DOI Listing
June 2020

Six months follow-up of protected high-risk percutaneous coronary intervention with the microaxial Impella pump: results from the German Impella registry.

Coron Artery Dis 2020 05;31(3):237-242

First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim.

Background: Percutaneous coronary intervention (PCI) represents an important alternative to coronary bypass surgery for the treatment of patients with complex coronary artery disease and high perioperative risk. Protected percutaneous coronary intervention applies temporary percutaneous ventricular assist devices to mitigate potential hemodynamic compromise in high-risk patients. The Impella system is currently the most commonly used device for protected percutaneous coronary intervention and showed improved hemodynamic parameters in earlier trials.

Methods: This study was designed as a retrospective, observational multi-center registry conducted in ten hospitals in Germany. We included consecutive patients undergoing protected high-risk percutaneous coronary intervention with Impella support. The primary endpoint was defined as the occurrence of a major adverse cardiac event defined as all-cause mortality, ST-elevation myocardial infarction, or stroke during a postprocedural 180-day follow-up period.

Results: In total, 157 patients (80.3% male; mean age 71.8 ± 10.8 years) were included in the present study, and 180-day follow-up was complete for 149 patients (94.9%). At baseline, the patients had a median left ventricular ejection fraction of 39.0% (interquartile range, 25.0-50.0%). The median SYNergy between PCI with TAXUS and Cardiac Surgery-Score I was 33.0 (interquartile range, 24.0-40.5) and the median EuroSCORE II was 7.2% (interquartile range, 3.2-17.1%). During postprocedural follow-up, 34 patients (22.8%) suffered a major adverse cardiac event. All-cause mortality was 18.1% (27 patients). Nine patients (6.0%) sustained a ST-elevation myocardial infarction, while 4 patients (2.7%) had a stroke.

Conclusions: Patients undergoing protected high-risk percutaneous coronary intervention with Impella support showed an acceptable 180-day clinical outcome regarding major adverse cardiac event and mortality.
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http://dx.doi.org/10.1097/MCA.0000000000000824DOI Listing
May 2020

Gender differences in the diagnostic performance of machine learning coronary CT angiography-derived fractional flow reserve -results from the MACHINE registry.

Eur J Radiol 2019 Oct 7;119:108657. Epub 2019 Sep 7.

Heart & Vascular Center, Medical University of South Carolina, Charleston, SC, USA; Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany; Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-University, Munich, Germany.

Purpose: This study investigated the impact of gender differences on the diagnostic performance of machine-learning based coronary CT angiography (cCTA)-derived fractional flow reserve (CT-FFR) for the detection of lesion-specific ischemia.

Method: Five centers enrolled 351 patients (73.5% male) with 525 vessels in the MACHINE (Machine leArning Based CT angiograpHy derIved FFR: a Multi-ceNtEr) registry. CT-FFR and invasive FFR ≤ 0.80 were considered hemodynamically significant, whereas cCTA luminal stenosis ≥50% was considered obstructive. The diagnostic performance to assess lesion-specific ischemia in both men and women was assessed on a per-vessel basis.

Results: In total, 398 vessels in men and 127 vessels in women were included. Compared to invasive FFR, CT-FFR reached a sensitivity, specificity, positive predictive value, and negative predictive value of 78% (95%CI 72-84), 79% (95%CI 73-84), 75% (95%CI 69-79), and 82% (95%CI: 76-86) in men vs. 75% (95%CI 58-88), 81 (95%CI 72-89), 61% (95%CI 50-72) and 89% (95%CI 82-94) in women, respectively. CT-FFR showed no statistically significant difference in the area under the receiver-operating characteristic curve (AUC) in men vs. women (AUC: 0.83 [95%CI 0.79-0.87] vs. 0.83 [95%CI 0.75-0.89], p = 0.89). CT-FFR was not superior to cCTA alone [AUC: 0.83 (95%CI: 0.75-0.89) vs. 0.74 (95%CI: 0.65-0.81), p = 0.12] in women, but showed a statistically significant improvement in men [0.83 (95%CI: 0.79-0.87) vs. 0.76 (95%CI: 0.71-0.80), p = 0.007].

Conclusions: Machine-learning based CT-FFR performs equally in men and women with superior diagnostic performance over cCTA alone for the detection of lesion-specific ischemia.
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http://dx.doi.org/10.1016/j.ejrad.2019.108657DOI Listing
October 2019

Chemical Environment-Induced Mixed Conductivity of Titanate as a Highly Stable Oxygen Transport Membrane.

iScience 2019 Sep 24;19:955-964. Epub 2019 Aug 24.

Institute of Energy and Climate Research (IEK-1), Forschungszentrum Jülich GmbH, D-52425 Jülich, Germany; The University of Twente, Faculty of Science and Technology, Inorganic Membranes, 7500 AE Enschede, Netherlands.

Coupling of two oxygen-involved reactions at the opposite sides of an oxygen transport membrane (OTM) has demonstrated great potential for process intensification. However, the current cobalt- or iron-containing OTMs suffer from poor reduction tolerance, which are incompetent for membrane reactor working in low oxygen partial pressure (pO). Here, we report for the first time a both Co- and Fe-free SrMgZrTiO (SMZ-Ti) membrane that exhibits both superior reduction tolerance for 100 h in 20 vol.% H/Ar and environment-induced mixed conductivity due to the modest reduction of Ti4+ to Ti3+ in low pO. We further demonstrate that SMZ-Ti is ideally suited for membrane reactor where water splitting is coupled with methane reforming at the opposite sides to simultaneously obtain hydrogen and synthesis gas. These results extend the scope of mixed conducting materials to include titanates and open up new avenues for the design of chemically stable membrane materials for high-performance membrane reactors.
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http://dx.doi.org/10.1016/j.isci.2019.08.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6742913PMC
September 2019

Interaction between the heart and the brain in transient global amnesia.

J Neurol 2019 Dec 10;266(12):3048-3057. Epub 2019 Sep 10.

Department of Neurology, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68135, Mannheim, Germany.

Background: To analyse whether patients with transient global amnesia (TGA) have concomitant cardiac injury by assessing clinical symptoms, as well as blood and cardiologic test results.

Methods: In this retrospective observational study, we analysed 202 consecutive patients presenting with isolated TGA and treated at our institution between March 2010 and December 2018. We examined the incidence of high-sensitivity cardiac troponin I (hs-cTNI) level elevation, electrocardiogram (ECG) findings, and data on clinical management.

Results: Among the TGA patients, 17 (8.4%) exhibited elevated levels of hs-cTNI. Although none of the patients had ST elevation, 12 (6.7%) showed QTc prolongation and 11 (6.1%) an inverted T wave on ECG. No typical clinical symptoms suggestive of myocardial infarction were present in any of the cases, however, 17 (8.4%) patients complained of mild somatic symptoms. Patients with hs-cTNI level elevation had a significantly greater likelihood of a history of coronary heart disease (p = 0.03) and a significantly shorter TGA duration at presentation (p < 0.01). Of the 17 patients with hs-cTNI elevation, Takotsubo syndrome was diagnosed in 2, while in the remaining 15 hs-cTNI level elevation remained unresolved. A literature review indicated the female predominance for the occurrence of cardiac involvement in TGA.

Conclusions: Although the in-hospital outcomes appear favourable in all cases reported thus far, we believe that all patients with TGA should be carefully evaluated for potential underlying cardiac involvement and comorbidity. Further research on cardiac vulnerability in TGA should attempt to develop a diagnostic algorithm and assess the potential causes of cardiac injury in TGA.
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http://dx.doi.org/10.1007/s00415-019-09529-0DOI Listing
December 2019

Influence of Coronary Calcium on Diagnostic Performance of Machine Learning CT-FFR: Results From MACHINE Registry.

JACC Cardiovasc Imaging 2020 03 14;13(3):760-770. Epub 2019 Aug 14.

Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina; Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina. Electronic address:

Objectives: This study was conducted to investigate the influence of coronary artery calcium (CAC) score on the diagnostic performance of machine-learning-based coronary computed tomography (CT) angiography (cCTA)-derived fractional flow reserve (CT-FFR).

Background: CT-FFR is used reliably to detect lesion-specific ischemia. Novel CT-FFR algorithms using machine-learning artificial intelligence techniques perform fast and require less complex computational fluid dynamics. Yet, influence of CAC score on diagnostic performance of the machine-learning approach has not been investigated.

Methods: A total of 482 vessels from 314 patients (age 62.3 ± 9.3 years, 77% male) who underwent cCTA followed by invasive FFR were investigated from the MACHINE (Machine Learning based CT Angiography derived FFR: a Multi-center Registry) registry data. CAC scores were quantified using the Agatston convention. The diagnostic performance of CT-FFR to detect lesion-specific ischemia was assessed across all Agatston score categories (CAC 0, >0 to <100, 100 to <400, and ≥400) on a per-vessel level with invasive FFR as the reference standard.

Results: The diagnostic accuracy of CT-FFR versus invasive FFR was superior to cCTA alone on a per-vessel level (78% vs. 60%) and per patient level (83% vs. 73%) across all Agatston score categories. No statistically significant differences in the diagnostic accuracy, sensitivity, or specificity of CT-FFR were observed across the categories. CT-FFR showed good discriminatory power in vessels with high Agatston scores (CAC ≥400) and high performance in low-to-intermediate Agatston scores (CAC >0 to <400) with a statistically significant difference in the area under the receiver-operating characteristic curve (AUC) (AUC: 0.71 [95% confidence interval (CI): 0.57 to 0.85] vs. 0.85 [95% CI: 0.82 to 0.89], p = 0.04). CT-FFR showed superior diagnostic value over cCTA in vessels with high Agatston scores (CAC ≥ 400: AUC 0.71 vs. 0.55, p = 0.04) and low-to-intermediate Agatston scores (CAC >0 to <400: AUC 0.86 vs. 0.63, p < 0.001).

Conclusions: Machine-learning-based CT-FFR showed superior diagnostic performance over cCTA alone in CAC with a significant difference in the performance of CT-FFR as calcium burden/Agatston calcium score increased. (Machine Learning Based CT Angiography Derived FFR: a Multicenter, Registry [MACHINE] NCT02805621).
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http://dx.doi.org/10.1016/j.jcmg.2019.06.027DOI Listing
March 2020

Relationship Between Pregnancy Complications and Subsequent Coronary Artery Disease Assessed by Coronary Computed Tomographic Angiography in Black Women.

Circ Cardiovasc Imaging 2019 07 15;12(7):e008754. Epub 2019 Jul 15.

Division of Cardiovascular Imaging, Department of Radiology and Radiological Science (J.L.W., R.A.P.T., J.H.N., R.V., S.E.L., C.N.D.C., R.R.B., S.B., M.R., U.J.S.), Medical University of South Carolina, Charleston.

Background: Maternal pregnancy complications, particularly preeclampsia and gestational diabetes mellitus, are described to increase the risk for subsequent coronary artery disease (CAD). In addition, black women are at higher risk for CAD. The objective of this study was to compare the prevalence and extent of CAD as detected by coronary computed tomographic angiography (CCTA) in black women with and without a history of prior pregnancy complications.

Methods: We retrospectively evaluated patient characteristics and CCTA findings in groups of black women with a prior history of preterm delivery (n=154), preeclampsia (n=137), or gestational diabetes mellitus (n=148), and a matched control group of black women who gave birth without such complications (n=445). Univariate and multivariate analyses were performed to assess risk factors of CAD.

Results: All groups with prior pregnancy complications showed higher rates of any (≥20% luminal narrowing) and obstructive (≥50% luminal narrowing) CAD (preterm delivery: 29.2% and 9.1%; preeclampsia: 29.2% and 7.3%; and gestational diabetes mellitus: 47.3% and 15.5%) compared with control women (23.8% and 5.4%). After accounting for confounding factors at multivariate analysis, gestational diabetes mellitus remained a strong risk factor of any (odds ratio, 3.26; 95% CI, 2.03-5.22; P<0.001) and obstructive CAD (odds ratio, 3.00; 95% CI, 1.55-5.80; P<0.001) on CCTA.

Conclusions: Black women with a history of pregnancy complications, particularly gestational diabetes mellitus, have a higher prevalence of CAD on CCTA while only a history of gestational diabetes mellitus was independently associated with any and obstructive CAD on CCTA.
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http://dx.doi.org/10.1161/CIRCIMAGING.118.008754DOI Listing
July 2019

Comparison between treatment of "established" versus complex "off-label" coronary lesions with Absorb bioresorbable scaffold implantation: results from the GABI-R registry.

Clin Res Cardiol 2020 Mar 29;109(3):374-384. Epub 2019 Jun 29.

First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Objectives: The purpose of this study was to compare the clinical outcomes of patients treated with bioresorbable scaffold (BRS) for off-label versus approved indications.

Background: The BRS promised some advantages in terms of complete biodegradation within 2-4 years, restored vascular physiology, and absence of potential stent-related long-term complications. However, the implication of BRS for off-label indications and further long-term follow-up of this particular patient group is not well described.

Methods: The short- and long-term outcome after implantation of an everolimus-eluting, poly-L-lactic acid-based bioresorbable scaffold system (ABSORB, Abbott Vascular, Santa Clara, CA, USA) was evaluated in the prospective, non-interventional, multicenter real-world German-Austrian ABSORB RegIstRy (GABI-R).

Results: A total of 3188 patients were enrolled. Patients were divided into two groups: on-label BRS use (33.0%) and off-label use (66.9%) if at least one off-label use criteria was met. The incidence of scaffold thrombosis in confirmed cases was significantly higher in off-label group (1.3% versus 0.5%, p = 0.04; OR 2.41 (95% CI 1.00-5.82) with also a trend toward higher myocardial infarction rate (2.3% versus 1.4%, p = 0.077; OR 1.70 (95% CI 0.95-3.03) and cardiovascular death (1.2% versus 1.1%, p = 0.76, OR 1.11 (95% CI 0.56-2.21) at 6-month follow-up.

Conclusions: In a real-world setting, the majority patients were treated with BRS for off-label indications. The off-label use of BRS compared to confirmed indications appears to be associated with a higher rate of clinical endpoints considering more complex lesions and higher morbidity in this patients' group. Comparison between treatment of "established" versus complex "off-label" coronary lesions with Absorb bioresorbable scaffold implantation: results from the GABI-R registry.
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http://dx.doi.org/10.1007/s00392-019-01517-8DOI Listing
March 2020

One-year clinical outcome of angiography, fractional flow reserve and instantaneous wave-free ratio guided percutaneous coronary intervention: A PRISMA-compliant meta-analysis.

Exp Ther Med 2019 Mar 7;17(3):1939-1951. Epub 2019 Jan 7.

First Department of Medicine-Cardiology, University Medical Centre Mannheim, University of Heidelberg, D-68167 Mannheim, Germany.

The present study aimed to compare the clinical outcome of patients with coronary artery disease (CAD) who underwent a revascularization using conventional coronary angiography or a physiologically guided revascularization with Fractional Flow Reserve (FFR). Furthermore, outcomes in FFR guided percutaneous coronary intervention (PCI) and instantaneous wave-free ratio (iFR) guided PCI were compared. The analysis was performed for reported outcomes at a 1-year follow-up. After searching PubMed, EMBASE, and Web of Science for suitable publications, a total of 15,880 subjects were included. Comparing angiography guided and FFR guided PCI showed no significant difference in major adverse cardiac events [odds ratio (OR), 0.78; 95% confidence interval (CI), 0.59-1.04; P=0.09; I=73%], death from any cause (OR, 0.74; 95% CI, 0.46-1.18; P=0.20; I=74%), myocardial infarction (OR, 0.93; 95% CI, 0.81-1.07; P=0.31; I=0%) or unplanned revascularization (OR, 0.71; 95% CI, 0.41-1.23; P=0.22; I=79%). In addition, no significant difference could be found between iFR and FFR guided PCI for major adverse cardiac events (OR, 0.97; 95% CI; 0.76-1.23; P=0.81; I=0%), death from any cause (OR, 0.66; 95% CI, 0.40-1.11; P=0.12; I=0%), myocardial infarction (OR, 0.83; 95% CI, 0.56-1.24; P=0.37) or unplanned revascularization (OR, 1.16; 95% CI, 0.85-1.58; P=0.34; I=16%). Overall, there was a tendency towards better outcomes of FFR in all four clinical endpoints compared with angiography guiding of PCI, and furthermore iFR showed no significant inferiority when compared to FFR in said clinical endpoints. When conducting a network meta-analysis, the results confirmed a non-inferiority of iFR compared to angiography guided revascularization.
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http://dx.doi.org/10.3892/etm.2019.7156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6364212PMC
March 2019

Instantaneous wave-free ratio (iFR) to determine hemodynamically significant coronary stenosis: A comprehensive review.

World J Cardiol 2018 Dec;10(12):267-277

First Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany and DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim 68167, Baden-Württemberg, Germany.

Coronary angiography is considered to be the gold standard in the morphological evaluation of coronary artery stenosis. The morphological assessment of the severity of a coronary lesion is very subjective. Thus, the invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic significance of coronary artery stenosis. The FFR-guided revascularization strategy was initially classified as a Class-IA-recommendation in the 2014 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. Both the Deferral Performance of Percutaneous Coronary Intervention of Functionally Non-Significant Coronary Stenosis and Flow Reserve Angiography for Multivessel Evaluation studies showed no treatment advantage for hemodynamically insignificant stenoses. With the help of FFR (and targeted interventions), clinical results could be improved; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the length of the procedure. Instantaneous wave-free ratio (iFR) is a new innovative approach for the determination of the hemodynamic significance of coronary stenosis, which can be obtained at rest without the use of vasodilators. Regarding the periprocedural complications as well as prognosis, iFR showed non-inferiority to FFR in the SWEDEHEART and DEFINE-FLAIR trials. Furthermore, iFR, enhanced by iFR-pullback, provides the possibility to display the iFR-change over the course of the vessel to create a hemodynamic map.
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http://dx.doi.org/10.4330/wjc.v10.i12.267DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6314882PMC
December 2018

Diagnostic performance of cCTA derived stenosis predictors to detect hemodynamic significant coronary stenosis.

Int J Cardiol 2019 01;274:62

First Department of Medicine-Cardiology, University Medical Centre Mannheim, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2018.07.052DOI Listing
January 2019

Unprotected versus protected high-risk percutaneous coronary intervention with the Impella 2.5 in patients with multivessel disease and severely reduced left ventricular function.

Medicine (Baltimore) 2018 Oct;97(43):e12665

First Department of Medicine-Cardiology, University Medical Centre Mannheim.

Selecting a revascularization strategy in patients with multivessel disease (MVD) and severely reduced left ventricular ejection fraction (LVEF) remains a challenge. PCI with Impella 2.5 may facilitate high-risk PCI, however long-term results comparing unprotected versus protected PCI are currently unknown. We sought to evaluate the outcome of patients undergoing protected compared to unprotected percutaneous coronary intervention (PCI) in the setting of MVD and severely reduced LVEF.We included patients with MVD and severely reduced LVEF (≤35%) in this retrospective, single-centre study. Patients that underwent unprotected PCI before the start of a dedicated protected PCI program with Impella 2.5 were compared to patients that were treated with protected PCI after the start of the program. The primary endpoint was defined as major adverse cardiac and cerebrovascular events (MACCE) during a 1-year follow-up. The secondary endpoints consisted of in-hospital MACCE and adverse events.A total of 61 patients (mean age 70.7 ± 10.9 years, 83.6% male) were included in our study, of which 28 (45.9%) underwent protected PCI. The primary endpoint was reached by 26.7% and did not differ between groups (P = .90). In-hospital MACCE (P = 1.00) and in-hospital adverse events (P = .12) also demonstrated no significant differences. Multivariate logistic regression identified procedural success defined as complete revascularization and absence of in-hospital major clinical complications as protective parameter for MACCE (OR 0.17, 95% CI 0.04-0.70, P = .02).Patients with MVD and severely depressed LVEF undergoing protected PCI with Impella 2.5 demonstrate similar in-hospital and one-year outcomes compared to unprotected PCI.
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http://dx.doi.org/10.1097/MD.0000000000012665DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6221604PMC
October 2018

Association of Serum Lipid Profile With Coronary Computed Tomographic Angiography-derived Morphologic and Functional Quantitative Plaque Markers.

J Thorac Imaging 2019 Jan;34(1):26-32

First Department of Medicine-Cardiology, University Medical Centre Mannheim.

Purpose: Recent advances in image quality of coronary computed tomographic angiography (cCTA) have enabled improved characterization of coronary plaques. Thus, we investigated the association between quantitative morphological plaque markers obtained by cCTA and serum lipid levels in patients with suspected or known coronary artery disease.

Materials And Methods: We retrospectively analyzed data of 119 statin-naive patients (55±14 y, 66% men) who underwent clinically indicated cCTA between January 2013 and February 2017. Patients were subdivided into a plaque and a no-plaque group. Quantitative and morphologic plaque markers, such as segment involvement score, segment stenosis score, remodeling index, napkin-ring sign, total plaque volume, calcified plaque volume, and noncalcified plaque volume (NCPV) and plaque composition, were analyzed using a semiautomated plaque software prototype. Total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein, low-density lipoprotein/high-density lipoprotein ratio, and triglycerides were determine in both groups.

Results: Higher age (61±11 y vs. 52±14 y, P<0.0001) and a higher likelihood of male gender (77% vs. 56%, P<0.0001) were observed in the plaque group. Differences in lipid levels were neither observed for differentiation between plaque presence or absence, nor after subcategorization for plaque composition. LDL serum levels >160 mg/dL correlated with higher NCPV compared with patients with LDL between 100 and 160 mg/dL (112 vs. 27 mm, P=0.037). Other markers were comparable between the different groups.

Conclusion: Statin-naive patients with known or suspected coronary artery disease did not show differences in lipid levels related to plaque composition by cCTA. Patients with plaques tended to be men and were significantly older. High LDL levels correlated with high NCPV.
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http://dx.doi.org/10.1097/RTI.0000000000000356DOI Listing
January 2019

Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve Assessment: Many Roads to Reach the Same Goal.

Circ J 2018 08 20;82(9):2448. Epub 2018 Jul 20.

First Department of Medicine-Cardiology, University Medical Centre Mannheim.

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http://dx.doi.org/10.1253/circj.CJ-17-0702DOI Listing
August 2018

The evolution of activated protein C plasma levels in septic shock and its association with mortality: A prospective observational study.

J Crit Care 2018 10 2;47:41-48. Epub 2018 Jun 2.

First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany. Electronic address:

Purpose: Septic shock is commonly associated with hemostatic abnormalities. The endothelium-activated serine protease activated protein C (APC) plays a pivotal role in limiting coagulation and possesses anti-apoptotic and anti-inflammatory properties. We hypothesized that APC levels correlate with established coagulation parameters and provide prognostic information in patients with septic shock.

Methods: We conducted a prospective, observational cohort study in patients with septic shock. APC was measured on admission (day 0) and on days 1, 3, and 6 by a clinically applicable oligonucleotide (aptamer)-based enzyme-capture assay (OECA). The primary endpoint was defined as sepsis-associated 30-day mortality. Furthermore, we analyzed the correlation of APC levels with established coagulation markers.

Results: 48 consecutive patients admitted with septic shock were included (mortality 39.6%). APC levels were elevated upon admission (0.59 ng/ml, IQR 0.26-0.97) and showed a strong correlation with established markers of coagulation and lactate. Multivariable logistic regression identified APC (OR 4.3, 95% CI 1.1-17.8, p = 0.04) and lactate levels (OR 7.0, 95% CI 4.1-18.2, p = 0.04) as independent predictors of 30-day mortality.

Conclusions: APC levels are increased in patients with septic shock and are correlated with established markers of coagulation. Elevated APC levels on admission are an independent predictor of mortality.
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http://dx.doi.org/10.1016/j.jcrc.2018.06.003DOI Listing
October 2018