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Morshuis M, Erdoes G, Koster A, Siepe M. We Enter the Bridge and Start to Run Out of Time. J Cardiothorac Vasc Anesth 2022; 36:1251-1253. [DOI: 10.1053/j.jvca.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/11/2022]
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Pappalardo F, Potapov E, Loforte A, Morshuis M, Schibilsky D, Zimpfer D, Riebandt J, Etz C, Attisani M, Rinaldi M, Haneya A, Ramjankhan F, Donker D, Jorde UP, Lewin D, Wieloch R, Ayala R, Cremer J, Bertoldi L, Borger M, Lichtenberg A, Gummert J, Saeed D. Left ventricular assist device implants in patients on extracorporeal membrane oxygenation: do we need cardiopulmonary bypass? Interact Cardiovasc Thorac Surg 2021; 34:676-682. [PMID: 34788423 PMCID: PMC8972226 DOI: 10.1093/icvts/ivab311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 09/12/2021] [Accepted: 09/20/2021] [Indexed: 11/18/2022] Open
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Schramm R, Zittermann A, Fuchs U, Fleischhauer J, Costard-Jäckle A, Ruiz-Cano M, Krenz LA, Fox H, Götte J, Günther SPW, Wlost S, Rojas SV, Hakim-Meibodi K, Morshuis M, Gummert JF. Donor-recipient risk assessment tools in heart transplant recipients: the Bad Oeynhausen experience. ESC Heart Fail 2021; 8:4843-4851. [PMID: 34704397 PMCID: PMC8712925 DOI: 10.1002/ehf2.13673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/15/2021] [Accepted: 10/04/2021] [Indexed: 11/11/2022] Open
Abstract
AIMS Some risk assessment tools have been developed to categorize mortality risk in heart transplant recipients, but it is unclear whether these tools can be used interchangeable in different transplant regions. METHODS AND RESULTS We performed a retrospective single-centre study in 1049 adult German heart transplant recipients under jurisdiction of Eurotransplant. Univariable and multivariable Cox regression analysis was used to generate a risk scoring system. C-statistics were used to compare our score with a US score and a French score regarding their ability to discriminate between 1 year survivors and non-survivors within our study cohort. Of 38 parameters assessed, seven recipient-specific parameters [age, height, dilated cardiomyopathy (DCM), ischaemic cardiomyopathy (ICM), total bilirubin, extracorporeal membrane oxygenation (ECMO), and biventricular assist device/total artificial heart (BVAD/TAH) implant], one donor-specific parameter (cold ischaemic time), and one recipient-independent and donor-independent other parameter (late transplant era) were statistically significant in predicting 1 year mortality. The initial score was generated by using the regression coefficients from the multivariable analysis as follows: 1.70 * ln age - 4.0 * ln height - 0.9 * diagnosis (= 1 if diagnosis = DCM) - 0.67 * diagnosis (= 1 if diagnosis = ICM) + 0.33 * ln total bilirubin + 1.74 * ln cold ischaemic time + 0.98 * mechanical circulatory support (MCS) implant (= 1 if MCS implant = ECMO) + 0.47 * MCS implant (= 1 of MCS implant = BVAD/TAH) - 0.66 * transplant era (= 1 if transplant era = 2017-2018). The initial score was converted into the Bad Oeynhausen (BO) score as a positive integer variable by means of the following formula: BO score = (initial score + 8) * 3. In patients scoring 2 to <7 points (n = 112), 7 to <11 points (n = 580), 11 to <15 points (n = 339), and 15 to 20 points (n = 18), 1 year survival was 93.1%, 84.2%, 66.9%, and 27.8%, respectively. The c-index of our score was 0.73 [95% confidence interval (CI): 0.69-0.77]. Values were in our cohort for the US and French scores 0.66 (95% CI: 0.62-0.70) and 0.63 (95% CI: 0.59-0.67), respectively. CONCLUSIONS Data indicate that our score, but also risk assessment tools from other transplant regions, may be used as a reliable support for risk-adjusted organ allocation and potentially help to improve outcomes in heart transplantation. Further developments will have to include as yet unaccounted risk factors for even more reliable predictions.
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Deutsch MA, Zittermann A, Renner A, Schramm R, Götte J, Börgermann J, Fox H, Rojas SV, Gyoten T, Morshuis M, Koster A, Hulde N, Hinse D, Hakim-Meibodi K, Gummert JF. Risk-adjusted analysis of long-term outcomes after on- versus off-pump coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2021; 33:857-865. [PMID: 34333605 DOI: 10.1093/icvts/ivab179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/23/2021] [Accepted: 05/19/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Recent data suggested that off-pump coronary artery bypass (OPCAB) may carry a higher risk for mortality in the long term when compared to on-pump coronary artery bypass (ONCAB). We, therefore, compared long-term survival and morbidity in patients undergoing ONCAB versus OPCAB in a large single-centre cohort. METHODS A total of 8981 patients undergoing isolated elective/urgent coronary artery bypass grafting between January 2009 and December 2019 were analysed. Patients were stratified into 2 groups (OPCAB n = 6649/ONCAB n = 2332). The primary end point was all-cause mortality. Secondary endpoints included repeat revascularization, stroke and myocardial infarction. To adjust for potential selection bias, 1:1 nearest neighbour propensity score (PS) matching was performed resulting in 1857 matched pairs. Moreover, sensitivity analysis was applied in the entire study cohort using multivariable- and PS-adjusted Cox regression analysis. RESULTS In the PS-matched cohort, 10-year mortality was similar between study groups [OPCAB 36.4% vs ONCAB 35.8%: hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.87-1.12; P = 0.84]. While 10-year outcomes of secondary endpoints did not differ significantly, risk of stroke (OPCAB 1.50% vs ONCAB 2.8%: HR 0.51, 95% CI 0.32-0.83; P = 0.006) and mortality (OPCAB 3.1% vs ONCAB 4.8%: HR 0.65, 95% CI 0.47-0.91; P = 0.011) at 1 year was lower in the OPCAB group. In the multivariable- and the PS-adjusted model, mortality at 10 years was not significantly different (OPCAB 34.1% vs ONCAB 35.7%: HR 0.97, 95% CI 0.87-1.08; P = 0.59 and HR 1.01, 95% CI 0.90-1.13; P = 0.91, respectively). CONCLUSIONS Data do not provide evidence that elective/urgent OPCAB is associated with significantly higher risks of mortality, repeat revascularization, or myocardial infarction during late follow-up when compared to ONCAB. Patients undergoing OPCAB may benefit from reduced risks of stroke and mortality within the first year postoperatively.
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Ruiz-Cano MJ, Ramazyan L, Schramm R, Lauenroth V, Paluszkiewicz L, Rojas S, Gummert J, Morshuis M. Clinical implications of late-onset right ventricular failure after implantation of a continuous-flow left ventricular assist device as bridge to transplantation. Eur J Cardiothorac Surg 2021; 60:177-185. [PMID: 33783490 DOI: 10.1093/ejcts/ezab114] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The development of late-onset right ventricular failure (LoRVF) that occurs months after a continuous-flow left ventricular assist device (LVAD) is implanted is a clinical problem that warrants investigation. Our goal was to study the incidence, clinical manifestations and prognosis of LoRVF in a population of patients who received an LVAD as bridge to transplantation. METHODS Data were analysed from 97 consecutive patients who received an LVAD as bridge to transplantation and underwent a right heart catheterization at least 3 months after receiving an LVAD implantation. LoRVF was defined if both haemodynamic criteria of a central venous pressure >16 mmHg and a cardiac index <2.3 l/min/m2 were present. Clinical and echocardiographic variables, hospitalizations for heart failure and survival were compared between patients with and without LoRVF. RESULTS LoRVF was diagnosed in 13% of patients after a median time of 11 months. Patients with LoRVF presented preoperative worse right ventricular (RV) dilatation and severe tricuspid regurgitation. LORVF was also associated with postoperative RV dilatation, moderate to severe tricuspid regurgitation and lower tricuspid annular plane systolic excursion. LoRVF resulted in increased brain natriuretic peptide levels and the need for diuretics, lower haemoglobin levels and a higher rate of atrial fibrillation and gastrointestinal bleeding. The rate of hospitalizations for heart failure in patients with LoRVF was 46%, and 15% required an urgent transplantation due to refractory RV failure. LoRVF decreased global survival and survival free from hospitalizations for heart failure (P < 0.0001). CONCLUSIONS LoRVF after the implantation of an LVAD as bridge to transplantation is associated with higher morbidity and lower survival. The results suggest that the routine use of a right heart catheterization and transthoracic echocardiography may contribute to an early diagnosis before further severe complications due to refractory RV failure might occur. ID NUMBER OF THE IRB APPROVAL AZ-2019-521 on 10 July 2019.
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Schmitto JD, Mariani S, Li T, Dogan G, Hanke JS, Bara C, Pya Y, Zimpfer D, Krabatsch T, Garbade J, Rao V, Morshuis M, Beyersdorf F, Marasco S, Netuka I, Bauersachs J, Haverich A. Five-year outcomes of patients supported with HeartMate 3: a single-centre experience. Eur J Cardiothorac Surg 2021; 59:1155-1163. [PMID: 33585913 DOI: 10.1093/ejcts/ezab018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/01/2020] [Accepted: 12/07/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES The HeartMate 3 left ventricular assist device was first implanted in 2014 and received the Conformité Européenne mark in 2015. Since then, several trials demonstrated its high haemocompatibility associated with good survival and low adverse events rates. Herein, we report our institutional experience with patients supported with HeartMate 3 for 5 years. METHODS This prospective cohort study included patients receiving a HeartMate 3 implantation in 2014 as part of the HeartMate 3 Conformité Européenne Mark clinical trial. Patients had follow-up visits every 3 months while on left ventricular assist device support, and all patients completed the 5-year follow-up. The primary end point was survival at 5 years. Secondary end points included adverse events, health status and quality of life. RESULTS Eight patients (men: 75%) aged 59 years (min-max: 52-66 years) were enrolled. At 5 years, survival was 100%. Patients remained on support for a median time of 1825 days (min-max: 101-1825 days); 2 patients successfully received cardiac transplants. No right heart failure, haemolysis, pump thrombosis, pump malfunction or neurological events occurred in any patients. A driveline infection was observed in 6 patients (0.25 events/patient-year). Compared to baseline, a significant improvement in quality of life and in New York Heart Association functional class was noted after the implant and for the whole follow-up time. A slight decline in kidney function and in the 6-min walk test results occurred after 3 years. CONCLUSIONS This study reports the longest single-centre follow-up of the HeartMate 3, showing excellent haemocompatibility over time with high survival and low complication rates at 5 years.
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Gyoten T, Rojas SV, Fox H, Hata M, Deutsch MA, Schramm R, Gummert JF, Morshuis M. Cardiac recovery following left ventricular assist device therapy: experience of complete device explantation including ventricular patch plasty. Eur J Cardiothorac Surg 2021; 59:855-862. [PMID: 33367693 DOI: 10.1093/ejcts/ezaa461] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/02/2020] [Accepted: 10/18/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Myocardial recovery is a rare phenomenon in left ventricular assist device (LVAD) therapy. Surgical LVAD removal is associated with the risk of cardiac failure, and the individual evaluation of sufficient myocardial recovery is crucial. Thus, complete device explantation is not consistently performed to minimize perioperative risk. However, the remaining ventricular assist device components bear significant risks of infection or thrombosis. Therefore, we developed this study to evaluate a complete LVAD explantation protocol. METHODS All patients in our institution who had an LVAD explanted were enrolled in the study. Explant surgery involved removal of the driveline, pump housing, sewing ring and outflow graft. The ventricular wall was reconstructed by double patch plasty. Our analysis focused on surgical and postoperative outcome parameters, including all-cause mortality and major adverse cardiac and cerebrovascular events. RESULTS A total of 12 patients (HVAD, n = 5; HeartMate II, n = 3; HeartMate 3, n = 4) had myocardial recovery and qualified for our LVAD explantation study protocol [median age: 40 years, interquartile range (IQR) 33-52 years; 50% men]. Primary heart failure aetiology: myocarditis (n = 5), dilated cardiomyopathy (n = 4), toxic cardiomyopathy (n = 2) and valvular heart failure (n = 1). The median average duration on LVAD was 10 months (25-75%: IQR 8.5-30 months). The median left ventricular ejection fraction was 15% (IQR 13-18%) at LVAD implantation and 50% (IQR 45-50%) before LVAD explantation (P = 0.0025).The 30-day survival was 100%. The 1-year survival was 91.7%. All patients were discharged after a median 13 days (IQR 10-18 days) postoperatively. No patient had major adverse cardiac and cerebrovascular events. The New York Heart Association functional class remained consistent during the follow-up period (median New York Heart Association functional class: II, IQR II-II class) including preservation of ventricular function. CONCLUSIONS Complete LVAD explantation with ventricular patch plasty is feasible and has consistent long-term results.
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Zimpfer D, Gustafsson F, Potapov E, Pya Y, Schmitto J, Berchtold-Herz M, Morshuis M, Shaw SM, Saeed D, Lavee J, Heatley G, Gazzola C, Garbade J. Two-year outcome after implantation of a full magnetically levitated left ventricular assist device: results from the ELEVATE Registry. Eur Heart J 2021; 41:3801-3809. [PMID: 33107561 DOI: 10.1093/eurheartj/ehaa639] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/26/2020] [Accepted: 07/27/2020] [Indexed: 12/28/2022] Open
Abstract
AIMS The ELEVATE Registry was designed to study long-term outcomes with the Heartmate 3 (HM3), a fully magnetically levitated centrifugal ventricular assist device, in a real-world population following CE-mark approval. METHODS AND RESULTS A total of 540 patients, implanted in Europe and the Middle East were followed in ELEVATE. The registry included 463 patients receiving the HM3 as primary implant (Primary Implant Cohort), 19 patients underwent a pump upgrade from another device (Pump Exchange Cohort) and 58 patients who had experienced an outcome before having the possibility to sign the Informed Consent, for which only outcome data were collected (Anonymized Cohort). Data collection included demographics, survival, adverse events, EQ-5D Visual Analog Score quality of life (EQ-5D VAS QOL) questionnaire, and 6-min walk distance (6MWD). Mean age was 55.6 ± 11.7 years (89% male, 48% ischaemic cardiomyopathy). Seventy per cent of patients were in INTERMACS Profile 1-3 and 12.7% were on temporary mechanical circulatory support. Primary Implant Cohort survival was 83% after 2 years. In the Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation Primary Implant Cohort, strokes were observed in 10.2%, gastrointestinal bleedings in 9.7%, pump thrombosis in 1.5%, and outflow graft twists in 3.5%. Heartmate 3 implantation resulted in a significant and sustained improvement of functional capacity and QOL. CONCLUSION In a real-world population, cohort implanted with the HM3 left ventricular assist device we demonstrate good long-term survival, sustained improvement of functional capacity, and low rates of adverse events (including pump thrombosis). CLINICALTRIALS.GOV IDENTIFIER NCT02497950.
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Oesterschlink J, Wolf LK, Gilis-Januszewski J, Dumitrescu D, Mellwig KP, Schramm R, Rojas SV, Fruend A, Morshuis M, Rudolph V, Gummert JF, Fox H. Exercise capacity in patients implanted with left ventricular assist devices for end-stage heart failure treatment. Eur J Prev Cardiol 2021. [DOI: 10.1093/eurjpc/zwab061.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction
Left ventricular assist device (LVAD) is an expanding therapy in end-stage heart failure today. Although LVAD therapy bears the potential to normalize cardiac output, a majority of patients show a severely impaired physical condition at the time of LVAD implantation. To date, no validated standardized training protocol is available, and established practices to effectively improve LVAD patients’ exercise tolerance is lacking. This study sought to investigate exercise capacity quantified by cardiopulmonary exercise testing (CPX) and a standardized six-minute walk test (6MWT) in patients after LVAD implantation.
Methods
We enrolled 30 end-stage heart failure patients who had received an LVAD implantation 20.7 ± 7.6 days prior to examination, mean age 54.9 ± 7.8 years, 26 males (87 %). Exercise tolerance was assessed using cardiopulmonary exercise testing (CPX) for maximal and submaximal exercise capacity, followed by a standardized (6MWT).
Results
Patients showed peak oxygen uptake values of 8.3 ± 2.4 ml/min/kg at a mean workload of 46.7 ± 11.3 watts and a mean anaerobic threshold of 6.7 ± 1.7 ml/min/kg at a workload of 32.6 ± 6.9 watts. Mean standardized 6-minute walking distance was at 183.8 ± 71.4 meters. There were no adverse events during exercise testing.
Conclusions
Cardiopulmonary exercise testing (CPX) and standardized 6MWT show severely impaired cardiopulmonary exercise capacity in patients after LVAD implantation, warranting further studies for dedicated training protocols, specifically focusing on LVAD patients to improve exercise tolerance at an acceptable safety profile.
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Saeed D, Potapov E, Loforte A, Morshuis M, Schibilsky D, Zimpfer D, Riebandt J, Pappalardo F, Attisani M, Rinaldi M, Pacini D, Haneya A, Ramjankhan F, Donker DW, Jorde UP, Otto W, Stein J, Tsyganenko D, Al-Naamani A, Wieloch R, Ayala R, Cremer J, Borger M, Lichtenberg A, Gummert J. Impact of extra-corporeal life support (ECLS) cannulation strategy on outcome after durable mechanical circulation support system implantation on behalf of durable MCS after ECLS Study Group. Ann Cardiothorac Surg 2021; 10:353-363. [PMID: 34159116 DOI: 10.21037/acs-2020-cfmcs-251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The literature on outcomes of patients requiring durable mechanical circulatory support (MCS) after extra-corporeal life support (ECLS) is limited. The aim of this study was to investigate the impact of preoperative ECLS cannulation on postoperative outcome after durable MCS implantation. Methods The durable MCS after ECLS registry is a multicenter retrospective study that gathered data on consecutive patients who underwent durable MCS implantation after ECLS between January 2010 and August 2018 in eleven high volume European centers. Patients who underwent the implantation of total artificial heart, pulsatile pumps, or first-generation pumps after ECLS were excluded from the analysis. The remaining patients were divided into two groups; central ECLS group (cECLS) and peripheral ECLS group (pECLS). A 1:1 propensity score analysis was performed to identify two matched groups. The outcome of these two groups was compared. Results A total of 531 durable MCS after ECLS were implanted during this period. The ECLS cannulation site was peripheral in 87% (n=462) and central in 13% (n=69) of the patients. After excluding pulsatile pumps and total artificial heart patients, a total of 494 patients remained (pECLS =434 patients, cECLS =60 patients). A 1:1 propensity score analysis resulted in 2 matched groups (each 55 patients) with median age of 54 years (48-60 years) in cECLS group and 54 years (43-60 years) in pECLS group. HeartWare HVAD (Medtronic, Minneapolis, MN) was implanted in the majority of the patients (cECLS =71% vs. pECLS =76%, P=0.67). All postoperative morbidities were comparable between the groups. The thirty-day, one year and long-term survival was comparable between the groups (P=0.73). Conclusions The cannulation strategy of ECLS appears to have no impact on the post-operative outcome after durable MCS implantation.
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RUIZ-CANO M, Ramazyan L, Schramm R, Hernandez SR, Paluszkiewicz L, Gummert J, Morshuis M. Incidence and Clinical Findings Associated to Incomplete Hemodynamic Unloading of the Left Ventricle under LVAD Support. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Saeed D, Potapov E, Loforte A, Morshuis M, Schibilsky D, Zimpfer D, Riebandt J, Pappalardo F, Attisani M, Rinaldi M, Haneya A, Ramjankhan F, Donker D, Jorde U, Stein J, Tsyganenko D, Jawad K, Wieloch R, Ayala R, Cremer J, Borger M, Lichtenberg A, Gummert J. Neurological Complications in Patients Requiring Durable VAD Systems after ECLS Support. On Behalf of ECLS- Durable MCS Study Group. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Saeed D, Potapov E, Loforte A, Morshuis M, Schibilsky D, Zimpfer D, Riebandt J, Pappalardo F, Attisani M, Rinaldi M, Haneya A, Ramjankhan F, Donker DW, Jorde UP, Stein J, Tsyganenko D, Jawad K, Wieloch R, Ayala R, Cremer J, Borger MA, Lichtenberg A, Gummert J. Transition From Temporary to Durable Circulatory Support Systems. J Am Coll Cardiol 2021; 76:2956-2964. [PMID: 33334424 DOI: 10.1016/j.jacc.2020.10.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The decision to implant durable mechanical circulatory systems (MCSs) in patients on extracorporeal life support (ECLS) is challenging due to expected poor outcomes in these patients. OBJECTIVES The aim of this study was to identify outcome predictors that may facilitate future patient selection and decision making. METHODS The Durable MCS after ECLS registry is a multicenter retrospective study that gathered data on consecutive patients who underwent MCS implantation after ECLS between January 2010 and August 2018 in 11 high-volume European centers. Several perioperative parameters were collected. The primary endpoint was survival at 1 year after durable MCS implantation. RESULTS A total of 531 durable MCSs after ECLS were implanted during this period. The average patient age was 53 ± 12 years old. ECLS cannulation was peripheral in 87% of patients and 33% of the patients had history of cardiopulmonary resuscitation before ECLS implantation. The 30-day, 1-year, and 3-year actuarial survival rates were 77%, 53%, and 43%, respectively. The following predictors for 1-year outcome have been observed: age, female sex, lactate value, Model of End-Stage Liver Disease XI score, history of atrial fibrillation, redo surgery, and body mass index >30 kg/m2. On the basis of this data, a risk score and an app to estimate 1-year mortality was created. CONCLUSIONS The outcome in patients receiving durable MCS after ECLS remains limited, yet preoperative factors may allow differentiating futile patients from those with significant survival benefit.
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Gyoten T, Morshuis M, Fox H, Deutsch MA, Hakim-Meibodi K, Schramm R, Gummert JF, Rojas SV. Secondary aortic valve replacement in continuous flow left ventricular assist device therapy. Artif Organs 2021; 45:736-741. [PMID: 33432621 DOI: 10.1111/aor.13906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/29/2020] [Accepted: 01/04/2021] [Indexed: 01/04/2023]
Abstract
The purpose of the study was to investigate the outcome of secondary surgical aortic valve replacement (sSAVR) in patients with severe aortic regurgitation (AR) in the context of ventricular assist device (VAD) therapy. From 2009 to 2020, 792 patients underwent cf-LVAD implantation [HVAD (Medtronic, USA), n = 585, and HM 3 (Abbott, USA), n = 207]. All cf-LVAD patients with severe AR requiring secondary AVR were enrolled in this study. A total of six patients (median, 40 years, IQR; 34-61 years, 50% male) underwent secondary surgical aortic valve replacement (sSAVR) after cf-LVAD implantation. Median time of previous LVAD support was 26 months (IQR: 21-29 months). Two patients required additional tricuspid valve repair (TVR) and one patient underwent SAVR after failed TAVR. Four patients needed temporary right ventricular assist device (RVAD) with a median of 30 days (IQR; 29-33 days). Three patients were bridged to urgent heart transplantation due to persevering right heart failure, whereas two destination therapy (DT) candidates survived without any associated complications. An additional DT patient died of pneumonia 1 month after sSAVR. Secondary surgical aortic valve replacement in ongoing LVAD patients is an advanced procedure for a complex cohort. In our series, sSAVR was safely performed and effective, but involved a high-risk for subsequent right heart failure, requiring urgent heart transplantation. In LVAD patients with severe AR requiring treatment where TAVR is not feasible, sSAVR can be evaluated as salvage option for bridge to transplant patients or selected destination therapy candidates.
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Potapov E, Loforte A, Pappalardo F, Morshuis M, Schibilsky D, Zimpfer D, Lewin D, Riebandt J, Von Aspern K, Stein J, Attisani M, Haneya A, Ramjankhan F, Donker DW, Jorde UP, Wieloch R, Ayala R, Cremer J, Rinaldi M, Montisci A, Borger M, Lichtenberg A, Gummert J, Saeed D. Impact of a surgical approach for implantation of durable left ventricular assist devices in patients on extracorporeal life support. J Card Surg 2021; 36:1344-1351. [PMID: 33547707 DOI: 10.1111/jocs.15401] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/28/2020] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of the surgical approach on the postoperative outcome in patients who underwent left ventricular assist device (LVAD) implantation after having received veno-arterial extracorporeal life support (va-ECLS) using data from a European registry (ECLS-VAD). Five hundred and thirty-one patients were included. METHODS A propensity score-adjusted outcome analysis was performed, resulting in 324 patients in the full sternotomy (FS) group and 39 in the less invasive surgery (LIS) group. RESULTS The surgery lasted in median 236 min in the FS group versus 263 min in the LIS group (p = 0.289). The median chest tube output during the first 24 h was similar in both groups. Patients who underwent implantation with an FS required more blood products during the first 24 postoperative hours (median 16 vs. 12, p = 0.033). The incidence of revision due to bleeding was also higher (35.5 vs. 15.4%, p = 0.016). A temporary postoperative right ventricular assist device was necessary in 45.1 (FS) versus 23.1% (LIS) of patients, respectively (p = 0.067). No stroke occurred in the LIS group during the first 30 days after surgery (7.4% in the FS group). The incidence of stroke and of renal, hepatic, and respiratory failure during the follow-up was similar in both groups. The 30-day and one-year survival were similar in both groups. CONCLUSION LIS for implantation of a durable LVAD in patients on va-ECLS implanted for cardiogenic shock is associated with less revision due to bleeding, less administration of blood products and absence of perioperative stroke, with no impact on survival.
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Immohr MB, Boeken U, Mueller F, Prashovikj E, Morshuis M, Böttger C, Aubin H, Gummert J, Akhyari P, Lichtenberg A, Schramm R. Complications of left ventricular assist devices causing high urgency status on waiting list: impact on outcome after heart transplantation. ESC Heart Fail 2021; 8:1253-1262. [PMID: 33480186 PMCID: PMC8006689 DOI: 10.1002/ehf2.13188] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/19/2020] [Accepted: 12/11/2020] [Indexed: 01/10/2023] Open
Abstract
Aims Heart transplantation (HTx) represents optimal care for advanced heart failure. Left ventricular assist devices (LVADs) are often needed as a bridge‐to‐transplant (BTT) therapy to support patients during the wait for a donor organ. Prolonged support increases the risk for LVAD complications that may affect the outcome after HTx. Methods and results A total of 342 patients undergoing HTx after LVAD as BTT in a 10‐year period in two German high‐volume HTx centres were retrospectively analysed. While 73 patients were transplanted without LVAD complications and with regular waiting list status (T, n = 73), the remaining 269 patients were transplanted with high urgency status (HU) and further divided with regard to the observed leading LVAD complications (infection: HU1, n = 91; thrombosis: HU2, n = 32; stroke: HU3, n = 38; right heart failure: HU4, n = 41; arrhythmia: HU5, n = 23; bleeding: HU6, n = 18; device malfunction: HU7, n = 26). Postoperative hospitalization was prolonged in patients with LVAD complications. Analyses of perioperative morbidity revealed no differences regarding primary graft dysfunction, renal failure, and neurological events except postoperative infections. Short‐term survival, as well as Kaplan–Meier survival analysis, indicated comparable results between the different study groups without disadvantages for patients with LVAD complications. Conclusions Left ventricular assist device therapy can impair the outcome after HTx. However, the occurrence of LVAD complications may not impact on outcome after HTx. Thus, we cannot support the prioritization or discrimination of HTx candidates according to distinct mechanical circulatory support‐associated complications. Future allocation strategies have to respect that device‐related complications may define urgency but do not impact on the outcome after HTx.
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Netuka I, Pya Y, Zimpfer D, Potapov E, Garbade J, Rao V, Morshuis M, Beyersdorf F, Marasco S, Sood P, Gazzola C, Schmitto JD. First 5-year multicentric clinical trial experience with the HeartMate 3 left ventricular assist system. J Heart Lung Transplant 2021; 40:247-250. [PMID: 33500187 DOI: 10.1016/j.healun.2021.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 11/29/2022] Open
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Saeed D, Potapov E, Loforte A, Morshuis M, Schibilsky D, Zimpfer D, Riebandt J, Pappalardo F, Attisani M, Haneya A, Ramjankhan F, Donker D, Tsyganenko D, Jorde U, Jawad K, Wieloch R, Ayala R, Cremer J, Borger M, Lichtenberg A, Gummert J. Stroke Complications in Patients Requiring Durable VAD Systems after VA-ECMO Support. Thorac Cardiovasc Surg 2021. [DOI: 10.1055/s-0041-1725609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Gyoten T, Morshuis M, Rojas SV, Deutsch MA, Schramm R, Gummert JF, Fox H. Identification of characteristics, risk factors, and predictors of recurrent LVAD thrombosis: conditions in HeartWare devices. J Artif Organs 2020; 24:173-181. [PMID: 33337536 PMCID: PMC8154821 DOI: 10.1007/s10047-020-01228-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/04/2020] [Indexed: 11/24/2022]
Abstract
Background Redictors of repetitive left-ventricular assist device (LVAD)-thrombosis have not been studied yet. Methods We identified predictors of recurrent LVAD thrombosis in HeartWare (HVAD) patients in a long-term study from 2010 until 2020. We included all patients with two or more thrombolysis treatments for repetitive HVAD thrombosis and effectiveness of thrombolytic therapy was defined as freedom from stroke, death, another HVAD thrombosis, or surgical device exchange within 30 days after the event. Study endpoints also include all-cause mortality and heart transplantation. Results A total of 534 HVAD implantations have been screened, and 73 patients (13.7%) developed first HVAD thrombosis after a median of 10 months (IQR; 6–21 months). 46 of these patients had effective thrombolysis in 71.7% (n = 33/46). After a median of 14 months (IQR 4–32 months) follow-up, 17 patients (51.5%) had developed a second HVAD thrombosis and all were treated with t-PA therapy again, resulting in effectiveness in 76.5% (n = 13/17). The four patients with ineffective t-PA therapy underwent subsequent surgical HVAD exchange. Multiple Cox regression model analysis revealed time interval between HVAD implantation and first thrombosis as an independent risk factor of recurrent thrombosis (HR, 0.93, 95% CI 0.87–0.99, p = 0.031). Kaplan–Meier analysis at 3 year follow-up showed no significant difference in overall survival for recurrent vs non-recurrent thrombosis groups (log-rank test, p = 0.959). Conclusion Recurrent HVAD thrombosis mostly appears within 12 months after first thrombosis. Systemic t-PA therapy for recurrent pump thrombosis seems safe, achieving comparable effectiveness rates to initial t-PA therapy. Survival does not differ between patients with or without recurrent HVAD thrombosis.
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Gyoten T, Rojas SV, Irimie A, Schramm R, Morshuis M, Gummert JF, Sitzer M, Fox H. Patients with ventricular assist device and cerebral entrapment-Supporting skullcap reimplantation. Artif Organs 2020; 45:473-478. [PMID: 33141976 DOI: 10.1111/aor.13856] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/22/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022]
Abstract
Effects of cranioplasty (CP) and skullcap reimplantation after decompressive craniectomy (DC) for cerebral hemorrhage or malignant brain infarction in patients with left ventricular assist device (LVAD) support as bridge to transplantation has not been surveyed yet. The aim of this study was to evaluate outcome and management after CP when aiming for transplantation. Data were collected from our prospective institutional database including all patients undergoing LVAD implantation between 2010 and 2019. Six patients needed CP procedures and were included. Our analysis focused on postoperative outcome, survival, and facilitation of heart transplantation. Study endpoints included also all-cause mortality. From a total of 1010 LVAD implantations during analysis period in our center, six bridge-to-transplantation LVAD patients [median age at LVAD implantation: 32.5 years (IQR: 24.8-39.5 years); four male, HVAD, n = 3; HM II, n = 1; HM 3, n = 2] underwent CP with imminent entrapment secondary to cerebral hemorrhage or malignant infarction. Primary heart failure etiology was myocarditis (n = 2), dilated (n = 2), or ischemic (n = 2). Median INTERMACS class was 1.5 (IQR; 1.0-2.8). Median time on LVAD support to DC procedure was 33 months (IQR: 16-48 months). The indication for DC was intraparenchymal hemorrhage (n = 4), subdural hematoma (n = 1), and malignant middle cerebral artery infarction (n = 1). After a median time of 4 months (IQR: 3.3-4.0 months, range; 2.0-10 months) post DC procedure, CP was subsequently performed without profound neurologic disabilities in all patients. After median time of 26 months (IQR: 21-42 months) follow-up, three patients successfully received heart transplantation, one patient could undergo LVAD explantation for myocardial recovery, and the remaining two patients are still on the list awaiting heart transplantation. CP procedure with skullcap reimplantation is feasible and can be safely performed in LVAD patients, which subsequently may even be eligible for heart transplantation with beneficial prognosis.
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Gyoten T, Rojas SV, Fox H, Schramm R, Hakim-Meibodi K, Ruiz-Cano M, Gummert JF, Morshuis M, Sandica E. Mechanical circulatory support as a bridge to candidacy in adults with transposition of the great arteries and a systemic right ventricle. Eur J Cardiothorac Surg 2020; 59:ezaa373. [PMID: 33226086 DOI: 10.1093/ejcts/ezaa373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Clinical experience with continuous flow ventricular assist devices (VADs) in patients with transposition of the great arteries (TGA) including dextro-TGA and congenitally corrected TGA is rare, and indications as well as potential benefits or specific hurdles remain unclear. Therefore, our goal was to report on our experience regarding VAD therapy in adult patients with TGA as a bridge to candidacy. METHODS We performed a single-centre retrospective study of all adult patients with TGA with systemic right ventricular failure who had continuous flow VAD implants between 2010 and 2018. Study end points were all causes of death, major cardiac and cerebrovascular adverse events or pump thrombosis. Follow-up continued until the time of the heart transplant. RESULTS A total of 6 patients (4 men) had a continuous flow VAD implanted in the context of a failing systemic right ventricle (dextro-TGA after the Mustard procedure: n = 3; congenitally corrected TGA: n = 3). Demographics: mean age 32 ± 5.7 years; median Interagency Registry for Mechanically Assisted Circulatory Support: level II (range 1-4), mean pulmonary artery 48 ± 13 mmHg, mean pulmonary vascular resistance 5.6 ± 3.5 Wood units. Postoperative data: intensive care unit stay: 16 ± 9.7 days; in-hospital survival: 100%; no early VAD-related complications occurred. Mean follow-up: 33 ± 18 months; persistent left-side paresis: n = 1; minor (non-disabling) stroke: n = 2. Post-VAD pulmonary artery: 19 ± 3.4 mmHg; P < 0.005; post-VAD pulmonary resistance: 2.2 ± 0.55 Wood units; P = 0.066. Four patients had heart transplants after a mean waiting time of 30 months after the VAD was implanted; 2 patients are still on the waiting list (waiting time: 52 and 24 months). CONCLUSIONS Continuous flow VAD therapy is a feasible therapeutic option in adult patients with TGA and a failing systemic right ventricle as a bridge to candidacy and a bridge to a heart transplant.
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Kassner A, Oezpeker C, Gummert J, Zittermann A, Gärtner A, Tiesmeier J, Fox H, Morshuis M, Milting H. Mechanical circulatory support does not reduce advanced myocardial fibrosis in patients with end-stage heart failure. Eur J Heart Fail 2020; 23:324-334. [PMID: 33038287 DOI: 10.1002/ejhf.2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 11/07/2022] Open
Abstract
AIMS Mechanical unloading by ventricular assist devices (VADs) has become increasingly important for the therapy of end-stage heart failure during the last decade. However, VAD support was claimed to be associated with partial reverse remodelling. Unfortunately, the literature describes the contradictory effects of VAD systems on cardiac fibrosis, a hallmark of cardiac remodelling. To clarify these inconsistent results, the effects on cardiac fibrosis before and after mechanical unloading in 125 patients were examined. METHODS AND RESULTS Left ventricular myocardial tissue from ischaemic or non-ischaemic cardiomyopathy patients undergoing VAD implantation and subsequent cardiac transplantation and non-failing hearts of the control group were analysed for 4-hydroxyproline (4OH-P) content as a marker for collagen protein. In addition, collagen cross-linking and mRNAs of collagens I and III and transforming growth factor beta-1 were measured. 4OH-P content was significantly increased in failing hearts compared with the control group and increased (P < 0.05) after mechanical unloading (nmol/mg tissue, mean ± standard deviation: 16.74 ± 9.68 vs. 7.75 ± 2.39 and 18.57 ± 9.19). However, plotting of the 4OH-P ratios (post/pre-VAD) against the collagen content pre-VAD could be fitted by non-linear regression. Collagen cross-linking correlated strongly with the total collagen content in pre- and post-VAD myocardium (r2 = 0.73 and 0.71, respectively). In contrast to the total collagen content, all three mRNAs of fibrotic genes were significantly down-regulated during VAD support when compared to pre-VAD. CONCLUSIONS This investigation of a comparably large patient cohort revealed that cardiac fibrosis was strongly increased in heart failure and increased even after mechanical unloading. The mRNAs of collagens I and III are independently regulated from the collagen protein.
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Zittermann A, Schramm R, Becker T, von Rössing E, Hinse D, Wlost S, Morshuis M, Gummert JF, Fuchs U. Renal Function in Patients with or without a Left Ventricular Assist Device Implant During Listing for a Heart Transplant. Ann Transplant 2020; 25:e925653. [PMID: 33168796 PMCID: PMC7667956 DOI: 10.12659/aot.925653] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Left ventricular assist device (LVAD) implantation may improve kidney function, but in patients awaiting heart transplantation, the long-term effects of LVAD implantation on renal function and subsequent clinical outcome are unclear. Material/Methods We analyzed data in patients with LVAD implants (n=139) and without LVAD implants (n=1038) who were listed for a heart transplant at our institution between 2000 and 2019. The primary endpoint was an impairment in renal function (decrease of creatinine-based estimated glomerular filtration rate [eGFR] by ≥30%) up to a maximum of 2 years after listing. Secondary endpoints were chronic kidney disease stage 4 or 5, heart transplantation, survival during listing, and 1-year survival after transplantation. Results Values for eGFR increased after LVAD implantation (P=0.001) and were higher at the time of waitlisting in the LVAD group than in the non-LVAD group (P=0.002), but were similar between groups at the end of waitlisting (P=0.75). Two-year freedom from renal impairment was 50.6% and 66.7% in the LVAD and non-LVAD groups, respectively, with a multivariable-adjusted hazard ratio for the LVAD versus the non-LVAD group of 1.78 (95% confidence interval 1.19–2.68; P=0.005). Two-year freedom from chronic kidney disease stages 4–5 was similar between study groups (LVAD group: 83.5%; non-LVAD group: 80.1%; =0.50). The 2-year probability of transplantation was slightly lower in the LVAD group than in the non-LVAD group (50.0% and 55.8%, respectively, P=0.017). However, 2-year survival on the waiting list and 1-year survival after transplantation did not differ significantly between study groups (P-values >0.20). Conclusions Our data indicate a transient improvement in creatinine-based eGFR values by LVAD implantation without influencing survival.
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Gaertner A, Klauke B, Felski E, Kassner A, Brodehl A, Gerdes D, Stanasiuk C, Ebbinghaus H, Schulz U, Dubowy KO, Tiesmeier J, Laser KT, Bante H, Bergau L, Sommer P, Fox H, Morshuis M, Gummert J, Milting H. Cardiomyopathy-associated mutations in the RS domain affect nuclear localization of RBM20. Hum Mutat 2020; 41:1931-1943. [PMID: 32840935 DOI: 10.1002/humu.24096] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 08/06/2020] [Accepted: 08/19/2020] [Indexed: 12/30/2022]
Abstract
Mutations in RBM20 encoding the RNA-binding motif protein 20 (RBM20) are associated with an early onset and clinically severe forms of cardiomyopathies. Transcriptome analyses revealed RBM20 as an important regulator of cardiac alternative splicing. RBM20 mutations are especially localized in exons 9 and 11 including the highly conserved arginine and serine-rich domain (RS domain). Here, we investigated in several cardiomyopathy patients, the previously described RBM20-mutation p.Pro638Leu localized within the RS domain. In addition, we identified in a patient the novel mutation p.Val914Ala localized in the (glutamate-rich) Glu-rich domain of RBM20 encoded by exon 11. Its impact on the disease was investigated with a novel TTN- and RYR2-splicing assay based on the patients' cardiac messenger RNA. Furthermore, we showed in cell culture and in human cardiac tissue that mutant RBM20-p.Pro638Leu is not localized in the nuclei but causes an abnormal cytoplasmic localization of the protein. In contrast the splicing deficient RBM20-p.Val914Ala has no influence on the intracellular localization. These results indicate that disease-associated variants in RBM20 lead to aberrant splicing through different pathomechanisms dependent on the localization of the mutation. This might have an impact on the future development of therapeutic strategies for the treatment of RBM20-induced cardiomyopathies.
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Schramm R, Morshuis M, Schoenbrodt M, Boergermann J, Hakim-Meibodi K, Hata M, Gummert JF. Current perspectives on mechanical circulatory support. Eur J Cardiothorac Surg 2020; 55:i31-i37. [PMID: 30608535 PMCID: PMC6526098 DOI: 10.1093/ejcts/ezy444] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 01/29/2023] Open
Abstract
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Mechanical circulatory support gained a significant value in the armamentarium of heart failure therapy because of the increased awareness of the prevalence of heart failure and the tremendous advances in the field of mechanical circulatory support during the last decades. Current device technologies already complement a heart transplant as the gold standard of treatment for patients with end-stage heart failure refractory to conservative medical therapy. This article reviews important aspects of mechanical circulatory support therapy and focuses on currently debated issues.
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