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Al-Shakarchi NJ, Ho JSY, Bray JJH, D'Ascenzo F, Duffy E, Hewett J, Adegbie D, Khan F, Kumar NS, Patel N, Ahmad M, Banerjee A, Haq I, Providencia R. Cardiac resynchronization therapy in inotrope-dependent heart failure: a meta-analysis. ESC Heart Fail 2024. [PMID: 38710670 DOI: 10.1002/ehf2.14835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/03/2024] [Accepted: 04/10/2024] [Indexed: 05/08/2024] Open
Abstract
AIMS The viability of cardiac resynchronization therapy (CRT) in inotrope-dependent heart failure (HF) has been a matter of debate. METHODS AND RESULTS We searched Medline, EMBASE, Scopus, and the Cochrane Library until 31 December 2022. Studies were included if (i) HF patients required inotropic support at CRT implantation; (ii) patients were ≥18 years old; and (iii) they provided a clear definition of 'inotrope dependence' or 'inability to wean'. A meta-analysis was performed in R (Version 3.5.1). Nineteen studies comprising 386 inotrope-dependent HF patients who received CRT (mean age 64.4 years, 76.9% male) were included. A large majority survived until discharge at 91.1% [95% confidence interval (CI): 81.2% to 97.6%], 89.3% were weaned off inotropes (95% CI: 77.6% to 97.0%), and mean discharge time post-CRT was 7.8 days (95% CI: 3.9 to 11.7). After 1 year of follow-up, 69.7% survived (95% CI: 58.4% to 79.8%). During follow-up, the mean number of HF hospitalizations was reduced by 1.87 (95% CI: 1.04 to 2.70, P < 0.00001). Post-CRT mean QRS duration was reduced by 29.0 ms (95% CI: -41.3 to 16.7, P < 0.00001), and mean left ventricular ejection fraction increased by 4.8% (95% CI: 3.1% to 6.6%, P < 0.00001). The mean New York Heart Association (NYHA) class post-CRT was 2.7 (95% CI: 2.5 to 3.0), with a pronounced reduction of individuals in NYHA IV (risk ratio = 0.27, 95% CI: 0.18 to 0.41, P < 0.00001). On univariate analysis, there was a higher prevalence of males (85.7% vs. 40%), a history of left bundle branch block (71.4% vs. 30%), and more pronounced left ventricular end-diastolic dilation (274.3 ± 7.2 vs. 225.9 ± 6.1 mL). CONCLUSIONS CRT appears to be a viable option for inotrope-dependent HF, with some of these patients seeming more likely to respond.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Amitava Banerjee
- Institute for Health Informatics, University College London, London, UK
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
| | | | - Rui Providencia
- Institute for Health Informatics, University College London, London, UK
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
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de Juan Bagudá J, de Frutos F, López-Vilella R, Couto Mallón D, Guzman-Bofarull J, Blazquez-Bermejo Z, Cobo-Belaustegui M, Mitroi C, Pastor-Pérez FJ, Moliner-Abós C, Rangel-Sousa D, Díaz-Molina B, Tobar-Ruiz J, Salterain Gonzalez N, García-Pinilla JM, García-Cosío Carmena MD, Crespo-Leiro MG, Dobarro D, Almenar L, Delgado-Jiménez JF, Paredes-Galán E, González-Vílchez F, González-Costello J. Repetitive ambulatory levosimendan as a bridge to heart transplantation. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:290-301. [PMID: 37516313 DOI: 10.1016/j.rec.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 07/07/2023] [Indexed: 07/31/2023]
Abstract
INTRODUCTION AND OBJECTIVES Repetitive ambulatory doses of levosimendan are an option as a bridge to heart transplantation (HT), but evidence regarding the safety and efficacy of this treatment is scarce. The objective of the LEVO-T Registry is to describe the profile of patients on the HT list receiving levosimendan, prescription patterns, and clinical outcomes compared with patients not on levosimendan. METHODS We retrospectively reviewed all patients listed for elective HT from 2015 to 2020 from 14 centers in Spain. RESULTS A total of 1015 consecutive patients were included, of whom 238 patients (23.4%) received levosimendan. Patients treated with levosimendan had more heart failure (HF) admissions in the previous year and a worse clinical profile. The most frequent prescription pattern were fixed doses triggered by the patients' clinical needs. Nonfatal ventricular arrhythmias occurred in 2 patients (0.8%). No differences in HF hospitalizations were found between patients who started levosimendan in the first 30 days after listing and those who did not (33.6% vs 34.5%; P=.848). Among those who did not, 102 patients (32.9%) crossed over to levosimendan after an HF admission. These patients had a rate of 0.57 HF admissions per month before starting levosimendan and 0.21 afterwards. Propensity score matching analysis showed no differences in survival at 1 year after listing between patients receiving levosimendan and those who did not (HR, 1.03; 95%CI, 0.36-2.97; P=.958) or in survival after HT (HR, 0.97; 95%CI, 0.60-1.56; P=.958). CONCLUSIONS Repetitive levosimendan in an ambulatory setting as a bridge to heart transplantation is commonly used, is safe, and may reduce HF hospitalizations.
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Affiliation(s)
- Javier de Juan Bagudá
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea de Madrid, Spain.
| | - Fernando de Frutos
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardíaca Avanzada y Trasplante, Servicio de Cardiología, Hospital Universitari de Bellvitge. BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Raquel López-Vilella
- Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - David Couto Mallón
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
| | | | | | - Manuel Cobo-Belaustegui
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Cristina Mitroi
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Instituto Investigación Sanitaria Puerta de Hierro - Segovia de Arana (IDIPHISA), Madrid, Spain
| | | | - Carlos Moliner-Abós
- Servicio de Cardiología, Instituto Investigación Biomédica (IIB) SANT PAU, Universitat Autònoma de Barcelona, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Diego Rangel-Sousa
- Unidad de Insuficiencia Cardíaca y Trasplante Cardíaco, Servicio de Cardiología, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Beatriz Díaz-Molina
- Servicio de Cardiología, Área Gestión Clínica (AGC) del Corazón, Hospital Universitario Central de Asturias, Asturias, Spain
| | - Javier Tobar-Ruiz
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - José Manuel García-Pinilla
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardiaca y Cardiopatías Familiares, Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, Spain; Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - María Dolores García-Cosío Carmena
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - María Generosa Crespo-Leiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain; Grupo de Investigación Cardiovascular (GRINCAR), Universidad de A Coruña (UDC), A Coruña, Spain
| | - David Dobarro
- Unidad de Insuficiencia Cardiaca e Hipertensión Pulmonar, Hospital Álvaro Cunqueiro, Complexo Hospitalario Universitario de Vigo, Vigo, Pontevedra, Spain
| | - Luis Almenar
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Juan F Delgado-Jiménez
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Francisco González-Vílchez
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José González-Costello
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Unidad de Insuficiencia Cardíaca Avanzada y Trasplante, Servicio de Cardiología, Hospital Universitari de Bellvitge. BIOHEART-Cardiovascular diseases group; Cardiovascular, Respiratory and Systemic Diseases and cellular aging Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
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Allen LA, Teerlink JR, Gottlieb SS, Ahmad T, Lam CSP, Psotka MA. Heart Failure Spending Function: An Investment Framework for Sequencing and Intensification of Guideline-Directed Medical Therapies. Circ Heart Fail 2022; 15:e008594. [PMID: 35000432 DOI: 10.1161/circheartfailure.121.008594] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Heart failure with reduced ejection fraction is managed with increasing numbers of guideline-directed medical therapies (GDMT). Benefits tend to be additive. Burdens can also be additive. We propose a heart failure spending function as a conceptual framework for tailored intensification of GDMT that maximizes therapeutic opportunity while limiting adverse events and patient burden. Each patient is conceptualized to have reserve in physiological and psychosocial domains, which can be spent for a future return on investment. Key domains are blood pressure, heart rate, serum creatinine, potassium, and out-of-pocket costs. For each patient, GDMT should be initiated and intensified in a sequence that prioritizes medications with the greatest expected cardiac benefit while drawing on areas where the patient has ample reserves. When reserve is underspent, patients fail to gain the full benefit of GDMT. Conversely, when a reserve is fully spent, addition of new drugs or higher doses that draw upon a domain will lead to patient harm. The benefit of multiple agents drawing upon varied physiological domains should be balanced against cost and complexity. Thresholds for overspending are explored, as are mechanisms for implementing these concepts into routine care, but further health care delivery research is needed to validate and refine clinical use of the spending function. The heart failure spending function also suggests how newer therapies may be considered in terms of relative value, prioritizing agents that draw on different spending domains from existing GDMT.
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Affiliation(s)
- Larry A Allen
- Division of Cardiology, Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora (L.A.A.)
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and Department of Medicine, School of Medicine, University of California San Francisco (J.R.T.)
| | | | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (T.A.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
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Lee SS, Kwon HJ, Park KM, On YK, Kim JS, Park SJ. Cardiac resynchronization therapy in New York Heart Association class-IV patients dependent on intravenous drugs or invasive supportive treatments. ESC Heart Fail 2020; 7:3109-3118. [PMID: 32790157 PMCID: PMC7524047 DOI: 10.1002/ehf2.12940] [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: 04/03/2020] [Revised: 06/03/2020] [Accepted: 07/19/2020] [Indexed: 11/10/2022] Open
Abstract
Aims We sought to evaluate the effectiveness of cardiac resynchronization therapy (CRT) in far‐advanced heart failure (FA‐HF) patients with New York Heart Association (NYHA) class‐IV status and dependency on intravenous drugs (IVDs) and/or invasive supportive treatments (ISTs). Methods and results Among 305 patients who underwent CRT implantation between October 2005 to December 2019, we identified 17 FA‐HF patients with NYHA class‐IV status and dependency on IVDs (inotropes, diuretics, vasopressors, or vasodilators) and/or ISTs (extracorporeal membranous oxygenator or continuous renal replacement therapy). All patients (median age = 68.7 years, non‐ischaemic cardiomyopathy = 15) remained dependent on several IVDs (2.2 ± 1.3 per patient) and/or ISTs for 11.3 ± 7.8 days due to multiple tapering failure (4.3 ± 3.2 per patient) before CRT implantation. However, 14 (82%) patients were successfully weaned from IVDs/ISTs within 5.2 ± 5.3 days following CRT, and 12 (71%) stayed alive for more than 1 year free of ventricular assist device or heart transplantation with symptom improvement (≥1 NYHA class) and a reduced annual HF hospitalization rate (P = 0.002). Considerable improvements in ventricular systolic function (P = 0.004) and volumetric reverse remodelling (P = 0.007) were noticed during the long‐term follow‐up period (35 ± 15 months post‐CRT). The ventricular assist device/heart transplantation/death‐free survival rate post‐CRT was 71% and 65% at 1 and 3 years, respectively. Conclusions Cardiac resynchronization therapy implantation may be a feasible treatment that can offer short‐term and long‐term clinical benefits for NYHA class‐IV FA‐HF patients who are dependent on IVDs/ISTs. When considering treatment options, CRT should not be prematurely excluded solely based on a patient's dependency on IVDs/ISTs without first attempting to identify favourable CRT response factors.
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Affiliation(s)
- Seong Soo Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Hee-Jin Kwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Kyoung-Min Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Young Keun On
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - June Soo Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
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Kimura Y, Kondo T, Mutsuga M, Morimoto R, Kazama S, Shibata N, Oishi H, Arao Y, Kuwayama T, Kato H, Yamaguchi S, Hiraiwa H, Okumura T, Fujimoto K, Usui A, Murohara T. Impella 5.0 for Cardiogenic Shock After Thrombectomy in a Patient With Intraventricular Thrombosis. Can J Cardiol 2020; 36:1690.e13-1690.e15. [PMID: 32835686 DOI: 10.1016/j.cjca.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/02/2020] [Accepted: 04/05/2020] [Indexed: 11/29/2022] Open
Abstract
A 43-year-old man was admitted to a referring hospital for cardiogenic shock caused by dilated cardiomyopathy. Intra-aortic balloon pump and percutaneous venoarterial extracorporeal membrane oxygenation (VA-ECMO) were started initially; however, a thrombus was detected in the left ventricle. After transfer to our institution, we performed thrombectomy through minithoracotomy. Subsequently, an Impella 5.0 device was inserted via the left subclavian artery. His cardiac function gradually improved, and both VA-ECMO and the Impella 5.0 could be weaned off. He was discharged without any thromboembolic event. Impella insertion with thrombectomy was possible, minimally invasive, and effective for a patient with intraventricular thrombosis associated with VA-ECMO.
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Affiliation(s)
- Yuki Kimura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shingo Kazama
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Shibata
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideo Oishi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshihito Arao
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tasuku Kuwayama
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroo Kato
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shogo Yamaguchi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuro Fujimoto
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Lawin D, Stellbrink C. Change in indication for cardiac resynchronization therapy? Eur J Cardiothorac Surg 2019; 55:i11-i16. [PMID: 31106336 PMCID: PMC6526095 DOI: 10.1093/ejcts/ezy488] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 12/11/2018] [Accepted: 12/22/2018] [Indexed: 12/28/2022] Open
Abstract
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Cardiac resynchronization therapy (CRT) has rapidly evolved as a standard therapy for heart failure (HF) patients with ventricular conduction delay. Although in early trials, only patients with sinus rhythm and advanced stages of HF have been candidates for CRT, more recent data have expanded the indications to patients with mild-to-moderate HF and atrial fibrillation and patients in need of antibradycardia pacing with reduced left ventricular function. On the other hand, it is now well recognized that patients with a wide QRS (>150 ms) and left bundle branch block morphology benefit most from CRT, whereas in patients with a more narrow QRS complex (<130 ms) CRT may actually be harmful despite the evidence of ventricular dyssynchrony by echocardiography. There is no prospective randomized study showing mortality benefit from a combined CRT defibrillating device over a CRT pacer alone. This is especially important because recent data indicate that older patients with non-ischaemic cardiomyopathy may not benefit from the implantable cardioverter-defibrillator as much as previously thought. Thus, the decision for a CRT pacer versus CRT defibrillating should be tailored to the therapeutic goal (improvement in prognosis versus symptomatic relief), patient age, underlying cardiac disease and comorbidities. This article gives an overview over the current indications for CRT according to published literature and the European guidelines for pacing and HF.
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Affiliation(s)
- Dennis Lawin
- Klinik für Kardiologie und Internistische Intensivmedizin, Klinikum Bielefeld, Bielefeld, Germany
| | - Christoph Stellbrink
- Klinik für Kardiologie und Internistische Intensivmedizin, Klinikum Bielefeld, Bielefeld, Germany
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