Correction to: Occlusion of left atrial appendage affects metabolomic profile: focus on glycolysis, tricarboxylic acid and urea metabolism

The article Occlusion of left atrial appendage aff ects metabolomic profile:focus on glycolysis, tricarboxylic acid and urea metabolism, written by K. Sattler, M. Behnes, C. Barth, A. Wenke, B. Sartorius, I. El-Battrawy, K. Mashayekhi, J. Kuschyk, U. Hoffmann, T. Papavasiliu, C. Fastner, S. Baumann, S. Lang, X. Zhou, G. Yücel, M. BorggrefeI, Akin, was originally published Online First without open access.

Alteration of serum levels of inflammatory cytokines and polysomnographic indices after uvulopalatal flap surgery in obstructive sleep apnea

The aim of the current study was to compare the changes in polysomnographic indices and serum levels of C-reactive protein (CRP), cystatin C, tumor necrosis factor-α (TNF-α), and intercellular adhesion molecule-1 (ICAM-1) in patients with obstructive sleep apnea (OSA) who were treated surgically via a uvulopalatal flap (UPF) technique. Twenty-five patients (14 men, 11 women), average age 46.2 ± 9.3 years, who underwent UPF surgery were included in this study. Serum biochemical analyses and polysomnographic examinations were performed before and 6 months after the surgery. Pre- and postoperative values of apnea hypopnea index (AHI), oxygen desaturation index (ODI), and minimum oxygen concentrations, as well as serum levels of CRP, cystatin C, TNF-α, and ICAM-1 were compared. Comparison of variables before and after UPF surgery demonstrated that AHI (p = 0.001), ODI (p < 0.001) and oxygen saturation (p < 0.001) were significantly improved. In addition, serum levels of CRP (p = 0.036), cystatin C (p = 0.005), TNF-α (p < 0.001), and ICAM-1 (p < 0.001) were significantly reduced 6 months after surgery. Our results suggest that UPF is an effective surgical method that alleviates the severity of OSA. Moreover, it may have the potential to prevent the development of atherosclerosis by attenuating the inflammatory process induced by activation of inflammatory mediators such as CRP, TNF-α, ICAM-1, and cystatin C.

Occlusion of left atrial appendage affects metabolomic profile: focus on glycolysis, tricarboxylic acid and urea metabolism

BACKGROUND

Left atrial appendage (LAA) closure (LAAC) by implantation of an occlusion device is an established cardiac intervention to reduce risk of stroke while avoiding intake of oral anticoagulation medication during atrial fibrillation. Cardiac interventions can alter local or systemic gene and protein expression. Effects of LAAC on systemic metabolism have not been studied yet.

OBJECTIVES

We aimed to study the effects of interventional LAAC on systemic metabolism.

METHODS

Products of glycolysis, tricarboxylic acid and urea metabolism were analyzed by ESI-LC-MS/MS and MS/MS using the AbsoluteIDQ™ p180 Kit in plasma of 44 patients undergoing successful interventional LAAC at baseline (T0) and after 6 months (T1).

RESULTS

During follow up, plasma concentrations of several parameters of glycolysis and tricarboxylic acid cycle (TCA) and urea metabolism increased (alanine, hexose, proline, sarcosine), while others decreased (aspartate, glycine, SDMA, serine). Multivariate linear regression analysis showed that time after interventional LAAC was an independent predictor for metabolite changes, including the decrease of SDMA (beta -0.19, p < 0.01) and the increase of sarcosine (beta 0.16, p < 0.01).

CONCLUSIONS

Successful interventional LAAC affects different pathways of the metabolome, which are probably related to cardiac remodeling. The underlying mechanisms as well as the long term effects have to be studied in the future.

[Instantaneous wave-free ratio (iFR®) in patients with coronary artery disease]

Coronary angiography is considered as the gold standard in the morphological representation of coronary artery stenosis. Coronary angiography is often performed without preprocedural non-invasive proof of ischemia and the assessment of the severity of a coronary lesion by morphology is very subjective. Thus, invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic relevance of coronary artery stenosis and facilitates decision making for percutaneous coronary intervention (PCI) and stenting. The FFR-guided revascularization strategy has been classified as a class IA recommendation in the 2014 ESC/EACTS guidelines on myocardial revascularization. Both the DEFER and the FAME studies showed no treatment advantage of hemodynamically irrelevant stenosis. By use of FFR (and targeted interventions), clinical results could be improved as well as the procedure costs were reduced; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the procedure. Instantaneous wave-free ratio (iFR®) is a new innovative approach for the determination of the hemodynamic relevance of coronary stenosis which can be obtained at rest without the use of vasodilators. Regarding periprocedural complications as well as prognosis, iFR® showed non-inferiority compared to FFR in the SWEDEHEART and DEFINE-FLAIR trials.

Coincidental coronary artery disease impairs outcome in patients with takotsubo cardiomyopathy

BACKGROUND AND AIM

Takotsubo cardiomyopathy (TC) is an important differential diagnosis of coronary artery disease (CAD), mimicking acute coronary syndrome in clinical symptoms, biomarker profiles and ST-elevation in ECG. Absence of occlusive coronary disease is an essential criterion distinguishing both diseases. The aim of the study was to explore the influence of co-existing incidental CAD on poorer clinical outcomes and all-cause mortality in TC.

DESIGN, METHODS AND RESULTS

Our mono-centric study cohort constituted 114 consecutive patients diagnosed with TC between 2003 and 2015. The primary endpoint was the all-cause mortality. Additionally, we compared the incidence of thromboembolic events, life-threatening arrhythmias, cardiogenic shock and in-hospital death. There was no significant difference in gender distribution or mean age in both groups. Patients diagnosed with a co-existing CAD (n = 22), had a more pronounced cardiovascular risk profile. The all-cause mortality among patients with co-existing CAD after a 2-year follow-up was higher than those diagnosed with lone TC (22.7 vs. 5.4 %, P = 0.07). In a multivariate cox regression analysis CAD (HR 3.5, 95 %CI 1.0-11.6; P = 0.04), LVEF ≤ 35% (HR 3.8, 95% CI 0.0-0.6, P = 0.01) and cardiogenic shock (HR 3.8, 95% CI 1.2-11.3; P = 0.01) were independent predictors of the primary endpoint.

CONCLUSION

Our study reveals that co-existing CAD impairs the outcome in patients with TC. The diagnostic work-up for TC should therefore not necessarily hinge on ruling out CAD.

Sex differences of in-hospital outcome and long-term mortality in patients with Takotsubo cardiomyopathy

Background

Previous studies revealed that patients with Takotsubo cardiomyopathy (TTC) have a higher mortality rate than the general population. It is still unclear whether sex differences may influence long-term prognosis of TTC patients. The purpose of this study was to determine whether sex differences do influence the short- and long-term outcomes of TTC.

Methods and results

A total of 114 patients with TTC were admitted to the University Medical Centre Mannheim from January 2003 to September 2015 and entered into the TTC database of the University Medical Centre Mannheim, and retrospectively analyzed. Patients were diagnosed by the Mayo Clinic criteria. All-cause mortality over mean follow-up of 1,529±1,121 days was revealed. Significantly more male patients died within long-term follow-up compared to female TTC patients (log-rank test; P=0.01). Most males died of noncardiac causes. In multivariate Cox regression analysis, the male sex (P=0.02, hazard ratio [HR] 2.8, 95% CI 1.1–7.2), the ejection fraction ≤35% (P=0.01, HR 3.3, 95% CI 1.2–9.2) and glomerular filtration rate <60 mL/min (P<0.01, HR 3.1, 95% CI 1.4–7.0) figured out as independent predictors of the adverse outcome.

Conclusion

This study shows that males suffering from TTC reveal a higher long-term all-cause mortality rate than females over a 5 year follow-up period.

[Bedside implantation of a new temporary vena cava inferior filter : German results from the European ANGEL registry]

BACKGROUND

Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients, and the simultaneous occurrence of PE and life-threatening bleeding is a therapeutic dilemma. Inferior vena cava filters (IVCF) may represent an important therapeutic alternative in these cases. The Angel® catheter (Bio2 Medical Inc., San Antonio, TX, USA) is a novel IVCF that provides temporary protection from PE and is implanted at bedside without fluoroscopy.

MATERIAL AND METHODS

The European Angel® Catheter Registry is an observational, multicenter study. In our German substudy, we investigated patients from three German hospitals and four intensive care units, who underwent Angel® catheter implantation between February 2016 and December 2016.

RESULTS

A total of 23 critically ill patients (68 ± 9 years, 43% male) were included. The main indication for implantation was a high risk for or an established PE, combined with contraindications for prophylactic or therapeutic anticoagulation due to either an increased risk of bleeding (81%) or active bleeding (13%). The Angel® catheter was successfully inserted in all patients at bedside. No PE occurred in patients with an indwelling Angel® catheter. Clots with a diameter larger the 20 mm, indicating clot migration, were detected in 5% of the patients by cavography before filter retrieval. Filter retrieval was uneventful in all of our cases, while filter dislocation occurred in 3% of the patients.

CONCLUSION

The German data from the multicenter European Angel® Catheter Registry show that the Angel® catheter is a safe and effective approach for critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.

[Current impact of cardiac implantable electronic devices]

Sudden cardiac death and chronic heart failure are among the main contributors to persisting high mortality rates in Germany. In addition to removal of causal factors and guideline-conform pharmacological therapy, therapy with cardiac implantable electronic devices (CIED) is of undisputed importance. Subcutaneous defibrillators have the advantage that they do not have intracardiac electrodes but still have the same efficacy and safety. For patients with a wide QRS complex and reduced ejection fraction, cardiac resynchronization has led to a reduction of morbidity and mortality. For patients with a normal QRS complex, cardiac contractility modulation had been shown to improve the quality of life, exercise capacity and left ventricular function. As a procedure for autonomic modulation in patients with reduced cardiac strength, the data for baroreceptor stimulation are the most convincing.

Comparison and outcome analysis of patients with apical and non-apical takotsubo cardiomyopathy

BACKGROUND

Takotsubo cardiomyopathy (TTC) is a relevant differential diagnosis in patients presenting with signs of an acute coronary syndrome. Although recent literature has highlighted some salient features of this disorder, there has been little information elucidating the differences in clinical features, electrocardiographic findings, echocardiographic data and TTC-related complications associated with the different variants of TTC.

METHODS AND RESULTS

Our institutional database constituted a collective of 114 patients diagnosed with TTC between 2003 and 2015 and these patients were subsequently divided into two groups based on the presence (n = 82, 72%) or absence (n = 32, 28%) of the apical form of TTC. The protocol for our proposed study was approved by the Ethics Committee of the University Medical Centre in Mannheim. It was noticed that the patients presenting with the apical form of TTC belonged to an older age group as compared to those presenting with the non-apical form (61.1 ± 8.9 years vs. 69.5 ± 11.2; P  < 0.01). The QTc interval prolongation at index-event was observed to be quantifiably greater in the 'apical variant' patients group (484.8 ± 57 ms vs. 464 ± 34.1 ms; P = 0.06). With respect to cardiovascular risk factors, patients with arterial hypertension did have a higher predilection to present with the apical form (63.4% vs. 43.7%; P = 0.06), however, the impact of smoking was less pronounced in this patient group (24.4% vs. 50%, P = 0.01). Furthermore, our study highlighted a significant impact on ejection fraction (EF), with a compromised left ventricular function (36 ± 9% vs. 42.4 ± 9.7%, P < 0.01) and greater involvement of the right ventricle in the apical variant patients group (23% vs. 3%, P = 0.04). Patients with the apical form also showed a greater tendency to develop TTC-related complications such as cardiogenic shock and required longer monitoring and care in comparison.

CONCLUSIONS

The apical and non-apical variants of TTC are manifestations of the same syndrome. They differ significantly, however, in their clinical presentation, related complications and prognosis.

Infective endocarditis - A word of caution on non-typical bacteria

A previously healthy 52-year-old man presented to our department with remitting and relapsing fever for more than 6 weeks. During complex staged work-up, we revealed that he suffered from an Abiotrophia defectiva endocarditis of the mitral valve with mitral regurgitation and vegetation requiring mitral valve replacement. He recovered well postoperatively and is currently being followed at our Outpatient Cardiology Clinic.

[Acute pulmonary embolism and contraindication of anticoagulation : Bedside implantation of a new temporary vena cava inferior filter]

Pulmonary embolism (PE), mostly caused by deep vein thrombosis, is a life-threatening complication in critically ill patients in the intensive care unit. A potential strategy to prevent PE in patients with contraindication for anticoagulant therapy is the implantation of a vena cava filter (VCF), to provide fast and safe PE protection against ascending thrombi. We report the case of a 56-year-old woman with an intracranial hemorrhage, who developed a PE. Because of acute contraindications for anticoagulant therapy, bedside implantation of a new VCF was performed to overcome the period of absolute contraindications for anticoagulation. After explanation, several thrombi were found on the filter.

Functions of the inner ear in psoriatic arthritis

OBJECTIVE

This study aimed to investigate whether there is a negative impact as a result of psoriatic arthritis disease of the inner ear function.

METHODS

Twenty-four successive patients and 38 healthy volunteers, younger than 60 years of age, who were followed up for at least for one year in the outpatient clinics of physical therapy and rehabilitation with the diagnosis of PsA according to CASPAR criteria (17) and who did not complain of any hearing impairment were included in the study. Distortion-product otoacoustic emission (DPOAE) values between 1kHz and 4kHz, tympanometric examination results, stapes reflex values, speech reception threshold (SRT) and speech discrimination (SD) values, pure-tone values between 250 and 8000Hz and high-frequency values between 10,000, 12,500 and 16,000Hz were analyzed. Statistical comparisons between both groups were performed using chi-square test and Mann-Whitney U test. p<0.05 was accepted as the level of statistical significance.

RESULTS

Our study population consisted of 24 [9 male (37.5%) and 15 female (62.5%)] patients with a mean age of 47.21±11.28 (range, 28-59) years and 38 [16 male (42.1%) and 22 female (57.9%)] healthy volunteers with a mean age of 44.39±8.12 (range, 29-59) years as the control group. Mean duration of arthritis was 7.62±4.88 years. In the evaluation of hearing frequencies of the patients between 4000 and 6000Hz, a statistically significant difference was found relative to the control group (p<005). DPOAE values of the patients were analyzed within the 1000-4000Hz interval. When compared with the control group, a statistically significant difference was found at 3000 and 4000Hz (p<005).

CONCLUSION

Our study provides strong evidence suggesting the necessity of monitorization of these patients regarding sensorineural hearing loss so as to take measures against the development of hearing loss during early stage, which may be another disability in patients with PsA, which is itself a potential cause of severe disability.

Thymoma with an incidental benign laryngeal mass mimicking laryngeal carcinoma: Case report

Thymic carcinomas are rarely seen. Because of recurrent laryngeal nerve involvement, hoarseness is a common presenting symptom. Persistent hoarseness in a male smoker past his fifth decade is also a distinctive symptom for laryngeal carcinoma. Stroboscopic laryngeal examination and biopsy are required for the diagnosis. In this article we describe a case involving a patient with thymic carcinoma who, interestingly, also presented with a benign laryngeal mass with unilateral vocal fold fixation. We emphasize the importance of keeping in mind nonlaryngeal pathologies invading the recurrent laryngeal nerve in patients with persistent hoarseness and a nonspesific laryngeal mass.

[Chronic cervical vagal stimulation. Mechanisms of action and clinical relevance for heart failure]

Increased sympathetic nerve activity and reduced vagal activity are associated with increased mortality in patients after myocardial infarction and patients with chronic heart failure; furthermore, vagal withdrawal has been documented to precede acute decompensation. Experimental studies have indicated that increased parasympathetic activity by means of vagal stimulation may reduce mortality in animal models of postinfarction sudden cardiac death and of chronic heart failure. First clinical results have demonstrated that chronic vagus nerve stimulation in heart failure patients with severe systolic dysfunction appears to be safe and tolerable and may improve the quality of life and left ventricular (LV) function. Vagus nerve stimulation gives rise to these potential clinical benefits by multiple mechanisms of action, including reduced heart rate, restoration of heart rate variability and baroreflex sensitivity, suppression of proinflammatory cytokines and antiarrhythmic effects. First clinical results suggest that vagal nerve stimulation is safe and tolerable and could lead to a marked clinical improvement but discrepancies in the findings due to different study designs warrant further discussion.

[Subcutaneous cervical and left thoracic emphysema in a 49-year-old woman on ventilation]

We report the case of a 49-year-old woman who was admitted with community-acquired pneumonia. The medical state worsened despite administration of antibiotics. She was intubated and ventilated because of respiratory distress. Several hours after intubation, she developed massive subcutaneous emphysema. The bronchoscopy showed tracheal transmural rupture 3 cm long on the posterior wall of the trachea. The high-risk surgery and massive doses of catecholamine favoured conservative treatment with bilateral endobronchial intubation and veno-venous extracorporeal membrane oxygenation. The patient made a full recovery.

[Hyponatremia-induced life-threatening cerebral edema after ecstasy use]

Ecstasy, a psychoactive amphetamine derivative, is a popular party drug. We report the cases of 2 young adults who developed cerebral edema due to hyponatremia. One patient was released from the hospital without any sequelae, whereas the second patient died due to cerebral edema. Severe cases of symptomatic hyponatremia after ecstasy consumption are described in the literature with partially fatal clinical outcomes. Thus, physicians should be aware of early and consequent control of the sodium and choose an interdisciplinary treatment decision.