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Waleczek FJG, Cipriano G, Haas JA, Garg A, Pfanne A, Just A, Neumüller S, Hegermann J, Pich A, Radocaj A, Xiao K, Weber N, Thum T. Prolonged Hypoxia in Rat Living Myocardial Slices Affects Function, Expression, and Structure. Int J Mol Sci 2024; 26:218. [PMID: 39796086 PMCID: PMC11720517 DOI: 10.3390/ijms26010218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2024] [Revised: 12/25/2024] [Accepted: 12/26/2024] [Indexed: 01/13/2025] Open
Abstract
Ischemic heart disease is the leading cause of death worldwide. Reduced oxygen supply and myocardial hypoxia lead to tissue damage and impairment of the heart function. To the best of our knowledge, the primary functional effects of hypoxia in the multicellular model of living myocardial slices (LMSs) have not been investigated so far. In this study, we analyzed force generation, ultrastructure, gene expression, and proteome changes in rat LMS after 24 h of ex vivo culture in normal and reduced levels of oxygen (O2). We observed a significant reduction in absolute force and a slowdown of force kinetics as well as an increase in cardiomyocyte apoptosis and myofibrillar and mitochondrial damage, as well as transcriptomic changes. Proteome analysis revealed the deregulation of proteins involved in metabolic processes, hypoxic response, and neutralizing of reactive oxygen species. Our results indicate that hypoxia induces substantial primary changes in heart tissue, which are independent of perfusion and immune responses. Our new LMS model could serve as a screening system for drug development and new mechanistic insights.
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Affiliation(s)
- Florian J. G. Waleczek
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | - Giuseppe Cipriano
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
| | - Jonas A. Haas
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
| | - Ankita Garg
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
| | - Angelika Pfanne
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
| | - Annette Just
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
| | - Susanne Neumüller
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
| | - Jan Hegermann
- Institute of Functional and Applied Anatomy, Hannover Medical School, 30625 Hannover, Germany;
| | - Andreas Pich
- Institute of Toxicology and Core Unit Proteomics, Hannover Medical School, 30625 Hannover, Germany;
| | - Ante Radocaj
- Institute of Molecular and Cell Physiology, Hannover Medical School, 30625 Hannover, Germany;
| | - Ke Xiao
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
| | - Natalie Weber
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, 30625 Hannover, Germany; (F.J.G.W.); (G.C.); (J.A.H.); (A.G.); (A.P.); (A.J.); (S.N.); (K.X.)
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Tsap MI, Yatsenko AS, Hegermann J, Beckmann B, Tsikas D, Shcherbata HR. Unraveling the link between neuropathy target esterase NTE/SWS, lysosomal storage diseases, inflammation, abnormal fatty acid metabolism, and leaky brain barrier. eLife 2024; 13:e98020. [PMID: 38660940 PMCID: PMC11090517 DOI: 10.7554/elife.98020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/12/2024] [Indexed: 04/26/2024] Open
Abstract
Mutations in Drosophila Swiss cheese (SWS) gene or its vertebrate orthologue neuropathy target esterase (NTE) lead to progressive neuronal degeneration in flies and humans. Despite its enzymatic function as a phospholipase is well established, the molecular mechanism responsible for maintaining nervous system integrity remains unclear. In this study, we found that NTE/SWS is present in surface glia that forms the blood-brain barrier (BBB) and that NTE/SWS is important to maintain its structure and permeability. Importantly, BBB glia-specific expression of Drosophila NTE/SWS or human NTE in the sws mutant background fully rescues surface glial organization and partially restores BBB integrity, suggesting a conserved function of NTE/SWS. Interestingly, sws mutant glia showed abnormal organization of plasma membrane domains and tight junction rafts accompanied by the accumulation of lipid droplets, lysosomes, and multilamellar bodies. Since the observed cellular phenotypes closely resemble the characteristics described in a group of metabolic disorders known as lysosomal storage diseases (LSDs), our data established a novel connection between NTE/SWS and these conditions. We found that mutants with defective BBB exhibit elevated levels of fatty acids, which are precursors of eicosanoids and are involved in the inflammatory response. Also, as a consequence of a permeable BBB, several innate immunity factors are upregulated in an age-dependent manner, while BBB glia-specific expression of NTE/SWS normalizes inflammatory response. Treatment with anti-inflammatory agents prevents the abnormal architecture of the BBB, suggesting that inflammation contributes to the maintenance of a healthy brain barrier. Considering the link between a malfunctioning BBB and various neurodegenerative diseases, gaining a deeper understanding of the molecular mechanisms causing inflammation due to a defective BBB could help to promote the use of anti-inflammatory therapies for age-related neurodegeneration.
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Affiliation(s)
- Mariana I Tsap
- Institute of Cell Biochemistry, Hannover Medical School, Hannover, Germany
| | - Andriy S Yatsenko
- Institute of Cell Biochemistry, Hannover Medical School, Hannover, Germany
| | - Jan Hegermann
- Institute of Functional and Applied Anatomy, Research Core Unit Electron Microscopy, Hannover Medical School, Hannover, Germany
| | - Bibiana Beckmann
- Institute of Toxicology, Hannover Medical School, Hannover, Germany
| | - Dimitrios Tsikas
- Institute of Toxicology, Hannover Medical School, Hannover, Germany
| | - Halyna R Shcherbata
- Institute of Cell Biochemistry, Hannover Medical School, Hannover, Germany
- Mount Desert Island Biological Laboratory, Bar Harbor, United States
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Hanke JS, Schmack B, Dogan G, Ruhparwar A, Schmitto JD. Impella 5.5 implantation in a patient with left ventricular assist device thrombosis as a bridge to recovery strategy. Artif Organs 2023; 47:1898-1899. [PMID: 37776167 DOI: 10.1111/aor.14654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/07/2023] [Accepted: 09/21/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Jasmin S Hanke
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Bastian Schmack
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günes Dogan
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Staar BO, Hegermann J, Auber B, Ewen R, von Hardenberg S, Olmer R, Pink I, Rademacher J, Wetzke M, Ringshausen FC. Ciliary Ultrastructure Assessed by Transmission Electron Microscopy in Adults with Bronchiectasis and Suspected Primary Ciliary Dyskinesia but Inconclusive Genotype. Cells 2023; 12:2651. [PMID: 37998386 PMCID: PMC10670349 DOI: 10.3390/cells12222651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023] Open
Abstract
Whole-exome sequencing has expedited the diagnostic work-up of primary ciliary dyskinesia (PCD), when used in addition to clinical phenotype and nasal nitric oxide. However, it reveals variants of uncertain significance (VUS) in established PCD genes or (likely) pathogenic variants in genes of uncertain significance in approximately 30% of tested individuals. We aimed to assess genotype-phenotype correlations in adults with bronchiectasis, clinical suspicion of PCD, and inconclusive whole-exome sequencing results using transmission electron microscopy (TEM) and ciliary image averaging by the PCD Detect software. We recruited 16 patients with VUS in CCDC39, CCDC40, CCDC103, DNAH5, DNAH5/CCDC40, DNAH8/HYDIN, DNAH11, and DNAI1 as well as variants in the PCD candidate genes DNAH1, DNAH7, NEK10, and NME5. We found normal ciliary ultrastructure in eight patients with VUS in CCDC39, DNAH1, DNAH7, DNAH8/HYDIN, DNAH11, and DNAI1. In six patients with VUS in CCDC40, CCDC103, DNAH5, and DNAI1, we identified a corresponding ultrastructural hallmark defect. In one patient with homozygous variant in NME5, we detected a central complex defect supporting clinical relevance. Using TEM as a targeted approach, we established important genotype-phenotype correlations and definite PCD in a considerable proportion of patients. Overall, the PCD Detect software proved feasible in support of TEM.
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Affiliation(s)
- Ben O. Staar
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School (MHH), 30625 Hannover, Germany; (B.O.S.); (R.E.); (I.P.); (J.R.)
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), 30625 Hannover, Germany; (J.H.); (R.O.); (M.W.)
- European Reference Network for Rare and Complex Lung Diseases (ERN-LUNG), 60596 Frankfurt am Main, Germany
| | - Jan Hegermann
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), 30625 Hannover, Germany; (J.H.); (R.O.); (M.W.)
- Research Core Unit Electron Microscopy, Institute of Functional and Applied Anatomy, Hannover Medical School (MHH), 30625 Hannover, Germany
| | - Bernd Auber
- Department of Human Genetics, Hannover Medical School (MHH), 30625 Hannover, Germany; (B.A.); (S.v.H.)
| | - Raphael Ewen
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School (MHH), 30625 Hannover, Germany; (B.O.S.); (R.E.); (I.P.); (J.R.)
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), 30625 Hannover, Germany; (J.H.); (R.O.); (M.W.)
- European Reference Network for Rare and Complex Lung Diseases (ERN-LUNG), 60596 Frankfurt am Main, Germany
| | - Sandra von Hardenberg
- Department of Human Genetics, Hannover Medical School (MHH), 30625 Hannover, Germany; (B.A.); (S.v.H.)
| | - Ruth Olmer
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), 30625 Hannover, Germany; (J.H.); (R.O.); (M.W.)
- Leibniz Research Laboratories for Biotechnology and Artificial Organs (LEBAO), Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School (MHH), 30625 Hannover, Germany
- REBIRTH—Research Center for Translational and Regenerative Medicine, Hannover Medical School (MHH), 30625 Hannover, Germany
| | - Isabell Pink
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School (MHH), 30625 Hannover, Germany; (B.O.S.); (R.E.); (I.P.); (J.R.)
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), 30625 Hannover, Germany; (J.H.); (R.O.); (M.W.)
- European Reference Network for Rare and Complex Lung Diseases (ERN-LUNG), 60596 Frankfurt am Main, Germany
| | - Jessica Rademacher
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School (MHH), 30625 Hannover, Germany; (B.O.S.); (R.E.); (I.P.); (J.R.)
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), 30625 Hannover, Germany; (J.H.); (R.O.); (M.W.)
- European Reference Network for Rare and Complex Lung Diseases (ERN-LUNG), 60596 Frankfurt am Main, Germany
| | - Martin Wetzke
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), 30625 Hannover, Germany; (J.H.); (R.O.); (M.W.)
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School (MHH), 30625 Hannover, Germany
| | - Felix C. Ringshausen
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School (MHH), 30625 Hannover, Germany; (B.O.S.); (R.E.); (I.P.); (J.R.)
- Biomedical Research in End-Stage and Obstructive Lung Disease Hannover (BREATH), German Center for Lung Research (DZL), 30625 Hannover, Germany; (J.H.); (R.O.); (M.W.)
- European Reference Network for Rare and Complex Lung Diseases (ERN-LUNG), 60596 Frankfurt am Main, Germany
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Khlusov IA, Grenadyorov AS, Solovyev AA, Semenov VA, Zhulkov MO, Sirota DA, Chernyavskiy AM, Poveshchenko OV, Surovtseva MA, Kim II, Bondarenko NA, Semin VO. Endothelial Cell Behavior and Nitric Oxide Production on a-C:H:SiO x-Coated Ti-6Al-4V Substrate. Int J Mol Sci 2023; 24:6675. [PMID: 37047649 PMCID: PMC10095527 DOI: 10.3390/ijms24076675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/31/2023] [Accepted: 04/02/2023] [Indexed: 04/07/2023] Open
Abstract
This paper focuses on the surface modification of the Ti-6Al-4V alloy substrate via a-C:H:SiOx coating deposition. Research results concern the a-C:H:SiOx coating structure, investigated using transmission electron microscopy and in vitro endothelization to study the coating. Based on the analysis of the atomic radial distribution function, a model is proposed for the atomic short-range order structure of the a-C:H:SiOx coating, and chemical bonds (C-O, C-C, Si-C, Si-O, and Si-Si) are identified. It is shown that the a-C:H:SiOx coating does not possess prolonged cytotoxicity in relation to EA.hy926 endothelial cells. In vitro investigations showed that the adhesion, cell number, and nitric oxide production by EA.hy926 endothelial cells on the a-C:H:SiOx-coated Ti-6Al-4V substrate are significantly lower than those on the uncoated surface. The findings suggest that the a-C:H:SiOx coating can reduce the risk of endothelial cell hyperproliferation on implants and medical devices, including mechanical prosthetic heart valves, endovascular stents, and mechanical circulatory support devices.
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Affiliation(s)
- Igor A. Khlusov
- Laboratory of Cellular and Microfluidic Technologies, Siberian State Medical University, 2, Moskovskii Tract, 634050 Tomsk, Russia
| | | | - Andrey A. Solovyev
- The Institute of High Current Electronics SB RAS, 2/3, Akademichesky Ave., 634055 Tomsk, Russia
| | - Vyacheslav A. Semenov
- The Institute of High Current Electronics SB RAS, 2/3, Akademichesky Ave., 634055 Tomsk, Russia
| | - Maksim O. Zhulkov
- E.N. Meshalkin National Medical Research Center of Ministry of Health of Russian Federation, 15, Rechkunovskaya Str., 630055 Novosibirsk, Russia
| | - Dmitry A. Sirota
- E.N. Meshalkin National Medical Research Center of Ministry of Health of Russian Federation, 15, Rechkunovskaya Str., 630055 Novosibirsk, Russia
| | - Aleksander M. Chernyavskiy
- E.N. Meshalkin National Medical Research Center of Ministry of Health of Russian Federation, 15, Rechkunovskaya Str., 630055 Novosibirsk, Russia
| | - Olga V. Poveshchenko
- E.N. Meshalkin National Medical Research Center of Ministry of Health of Russian Federation, 15, Rechkunovskaya Str., 630055 Novosibirsk, Russia
- Research Institute of Clinical and Experimental Lymphology, Branch of Institute of Cytology and Genetics SB RAS, 2, Timakov Str., 630060 Novosibirsk, Russia
| | - Maria A. Surovtseva
- E.N. Meshalkin National Medical Research Center of Ministry of Health of Russian Federation, 15, Rechkunovskaya Str., 630055 Novosibirsk, Russia
- Research Institute of Clinical and Experimental Lymphology, Branch of Institute of Cytology and Genetics SB RAS, 2, Timakov Str., 630060 Novosibirsk, Russia
| | - Irina I. Kim
- E.N. Meshalkin National Medical Research Center of Ministry of Health of Russian Federation, 15, Rechkunovskaya Str., 630055 Novosibirsk, Russia
- Research Institute of Clinical and Experimental Lymphology, Branch of Institute of Cytology and Genetics SB RAS, 2, Timakov Str., 630060 Novosibirsk, Russia
| | - Natalya A. Bondarenko
- E.N. Meshalkin National Medical Research Center of Ministry of Health of Russian Federation, 15, Rechkunovskaya Str., 630055 Novosibirsk, Russia
- Research Institute of Clinical and Experimental Lymphology, Branch of Institute of Cytology and Genetics SB RAS, 2, Timakov Str., 630060 Novosibirsk, Russia
| | - Viktor O. Semin
- Institute of Strength Physics and Materials Science SB RAS, 2/4, Akademichesky Ave., 634055 Tomsk, Russia
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Abstract
Patients undergoing explantation of left ventricular assist devices (LVADs) after improvement of myocardial function remain a minority. Nevertheless, considering the growing population of LVAD patients, increasing demand for new explantation strategies is expected. Herein, we present a retrospective review of seven patients undergoing HeartMate3 explantation with the use of a custom-made apical ring plug in four medical centers. The primary outcome was status at intensive care unit discharge. Secondary outcomes included perioperative complications and transfusions. Six out of seven patients were males. The median age at explantation and time on LVAD support was 35 years (range:13-73) and 10 months (range:9-24), respectively. No technical difficulties were experienced during plug implantation via a conventional sternotomy or through a left lateral thoracotomy, either with or without cardiopulmonary bypass. Perioperative transfusions ranged from 0 to 3 units/patient. No re-operations for bleeding, hemorrhagic, embolic, or plug-related infective events were observed. Heparin was started 6 hours after surgery as a bridge to oral anticoagulation (international normalized ratio: 2-2.5). All patients were discharged alive from intensive care unit. This novel plug device for HeartMate3 explantation was successfully and safely implanted in this first patient series. Notwithstanding, its use should still be considered off-label and larger studies are required to investigate its long-term results.
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Abdallah H, Grasso E, Abdelhamed MI, Ibrahim A, Segur M, Al Khamees K, Lorusso R. Outcome of percutaneous HeartMate3 decommissioning: A single-centre experience. Artif Organs 2022; 46:1429-1435. [PMID: 35554959 DOI: 10.1111/aor.14279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/05/2022] [Accepted: 04/25/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To highlight the role of percutaneous left ventricular assist device (LVAD) decommissioning as a safe procedure after myocardial recovery in patients with advanced heart failure. BACKGROUND The HeartMate3 LVAD (Abbott, Chicago, IL, USA) is designed to provide circulatory support with enhanced hemocompatibility for patients with advanced heart failure. Most VADs are used as a bridge to heart transplantation; however, in certain cases, myocardial function recovers, and VADs can be explanted after the patient is weaned. Although surgical explantation remains the gold standard, minimally invasive percutaneous decommissioning has been described as a successful alternative. In this study, we present our experience, one-year outcomes, and adverse events associated with percutaneous LVAD decommissioning. METHODS We conducted a retrospective review of data from six consecutive patients who underwent percutaneous LVAD decommissioning. RESULTS Six patients were enrolled in the study. For all six patients, HM3 decommissioning was completed at least 6 months ago. No technical complications were documented. No strokes were observed within the study period, and the ejection fraction improved. The mean follow-up duration was 18 ± 8.5 months, and the survival rate was 100%. CONCLUSION Percutaneous HeartMate3 decommissioning appears to be safe. In particular, the survival after the procedure was 100%, and no events, especially thromboembolic ones, occurred.
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Affiliation(s)
- Hassane Abdallah
- Departement of Cardiac Surgery, Prince Sultan Cardiac Center, Al Hassa, Saudi Arabia
| | - Elena Grasso
- Departement of Cardiac Surgery, Prince Sultan Cardiac Center, Al Hassa, Saudi Arabia.,Heart & Vascular Centre, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - M Ibrahem Abdelhamed
- Departement of Cardiac Surgery, Prince Sultan Cardiac Center, Al Hassa, Saudi Arabia
| | - Ahmed Ibrahim
- Departement of Research, Prince Sultan Cardiac Center, Al Hassa, Saudi Arabia
| | - Metin Segur
- Departement of Catheterization Laboratory, Prince Sultan Cardiac Center, Al Hassa, Saudi Arabia
| | - Khalid Al Khamees
- Departement of Cardiac Surgery, Prince Sultan Cardiac Center, Al Hassa, Saudi Arabia
| | - Roberto Lorusso
- Heart & Vascular Centre, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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