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Hasegawa Y, Okada S, Sanada A, Tomii A, Sugiura H, Higuchi K, Chinushi M, Inomata T. The Atrial Natriuretic Peptide-to-brain Natriuretic Peptide Ratio Predicts Left Atrial Reverse Remodeling after Rhythm Control Therapy in Patients with Persistent Atrial Fibrillation. Intern Med 2023; 62:3283-3290. [PMID: 36823080 DOI: 10.2169/internalmedicine.1478-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Objective The association between natriuretic peptide levels in atrial fibrillation (AF) patients with advanced left atrial (LA) remodeling and reverse remodeling after rhythm control therapy has not been clarified. The present study assessed the role of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) measurements to predict LA reverse remodeling after catheter ablation (CA) in persistent AF patients with LA enlargement. Methods This study included 88 persistent AF patients with LA enlargement (volume index >48 mL/m2) who underwent CA. Plasma ANP and BNP levels were analyzed before CA in all patients. The study population was divided into 2 groups according to the extent of decrease in the LA volume index (LAVI) at 6 months after CA responders were those with a ≥15% reduction in the LAVI, and all others were non-responders. Results At follow-up, 58 patients (66%) were classified as responders. The preprocedural ANP level was significantly higher in the responders than in the non-responders (p=0.03). Furthermore, the ANP-to-BNP ratio (ANP/BNP) was significantly higher in the responders than in the non-responders (p<0.01). The ANP/BNP was correlated with the percentage decrease in the LAVI (r=0.391, p<0.01). A multivariate linear regression analysis revealed that the ANP/BNP before CA was an independent predictor of LA reverse remodeling (p<0.01). Conclusion The preprocedural ANP/BNP was a robust predictor of reverse remodeling of the enlarged LA after sinus rhythm restoration by rhythm control therapy in persistent AF patients.
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Affiliation(s)
- Yuki Hasegawa
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Japan
| | | | - Akiko Sanada
- Department of Cardiology, Niigata Medical Center, Japan
| | - Asako Tomii
- Department of Cardiology, Niigata Medical Center, Japan
| | | | | | - Masaomi Chinushi
- Niigata University, Cardiovascular Research of Graduate School of Health Sciences, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Japan
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Matsuda Y, Masuda M, Asai M, Iida O, Okamoto S, Ishihara T, Nanto K, Tsujimura T, Hata Y, Uematsu H, Higashino N, Toyoshima T, Mano T. Low atrial natriuretic peptide to brain natriuretic peptide ratio is associated with left atrial remodeling. J Cardiovasc Med (Hagerstown) 2023; 24:544-551. [PMID: 37161971 DOI: 10.2459/jcm.0000000000001483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
AIMS Atrial natriuretic peptide (ANP) deficiency is thought to be one of the causes of heart failure induced by atrial fibrillation (AF). Although ANP deficiency is thought to occur as a result of atrial remodeling, data to explain this mechanism are limited. The purpose of this study was to investigate the association between ANP and left atrial remodeling or prognosis of heart failure in patients with AF ablation. METHODS In total, 373 consecutive patients who underwent initial ablation for persistent AF [age, 67 ± 10 years; female, 97 (26%)] were retrospectively enrolled. ANP and brain natriuretic peptide (BNP) were measured before the procedure and the ANP/BNP ratio was calculated. Left atrial volume index, left atrial appendage emptying velocity, and left atrial low-voltage areas (LVAs) were used as left atrial-remodeling parameters. The primary outcome of heart failure was defined as the composite of all-cause death or hospitalization due to worsening heart failure. RESULTS The median ANP level was 116 (71-178) pg/ml and the median ANP/BNP ratio was 0.65 (0.46-1.00). The ANP/BNP ratio decreased with increasing left atrial volume index or LVAs and with decreasing left atrial appendage emptying velocity. During the 5-year follow-up, freedom from the primary outcome was significantly lower in patients with ANP/BNP ratio ≤0.65 than in those with ANP/BNP ratio >0.65 (84.6% versus 95.6%, P < 0.01). CONCLUSION Secretion of ANP relative to BNP decreased with progression of left atrial remodeling in patients with AF ablation. Furthermore, prognosis of heart failure was poor in patients with a low ANP/BNP ratio.
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Affiliation(s)
- Yasuhiro Matsuda
- Kansai Rosai Hospital Cardiovascular Center, Amagasaki, Hyogo, Japan
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Horikoshi T, Nakamura T, Yamaguchi K, Yoshizaki T, Watanabe Y, Kuroki K, Uematsu M, Nakamura K, Kobayashi T, Sato A. Prognostic Value of Novel Natriuretic Peptide Index After Percutaneous Coronary Intervention. Circ J 2023; 87:296-305. [PMID: 36261336 DOI: 10.1253/circj.cj-22-0531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The predictive value of both atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) is well known. This study evaluated the prognostic value of a novel natriuretic peptide index (NPI) combining ANP and BNP. METHODS AND RESULTS This study included 849 consecutive patients with coronary artery disease who underwent successful percutaneous coronary intervention (PCI). Patients were followed up clinically for up to 3 years or until the occurrence of major adverse cardiac events (MACE). The primary endpoint was a composite of all-cause death and non-fatal myocardial infarction. The NPI (pg/mL) was defined as √ANP×BNP. MACE occurred in 73 patients (8.6%) during the follow-up period. Receiver operating characteristic curve analysis showed the highest area under the curve for NPI (0.779) compared with ANP and BNP (0.773 and 0.755, respectively). A risk analysis of MACE occurrence adjusted for the multivariable model showed the highest hazard ratio (HR) for NPI (1.33; 95% confidence interval [CI] 1.18-1.51; P<0.001) compared with ANP and BNP (HR 1.25 [95% CI 1.13-1.39] and 1.30 [95% CI 1.13-1.49], respectively; P<0.001). The NPI was a significant independent predictor of MACE, among other clinical parameters, in the multivariable analysis. CONCLUSIONS Compared with ANP and BNP, the NPI was more effective in predicting future adverse events after PCI.
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Affiliation(s)
- Takeo Horikoshi
- Department of Cardiology, University of Yamanashi, Faculty of Medicine
| | | | | | - Toru Yoshizaki
- Department of Cardiology, University of Yamanashi, Faculty of Medicine
| | - Yosuke Watanabe
- Department of Cardiology, University of Yamanashi, Faculty of Medicine
| | - Kenji Kuroki
- Department of Cardiology, University of Yamanashi, Faculty of Medicine
| | - Manabu Uematsu
- Department of Cardiology, University of Yamanashi, Faculty of Medicine
| | - Kazuto Nakamura
- Department of Cardiology, University of Yamanashi, Faculty of Medicine
| | | | - Akira Sato
- Department of Cardiology, University of Yamanashi, Faculty of Medicine
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Zhang MY, Fang S, Gao H, Zhang X, Gu D, Liu Y, Wan J, Xie J. A critical role of AREG for bleomycin-induced skin fibrosis. Cell Biosci 2021; 11:40. [PMID: 33622407 PMCID: PMC7903615 DOI: 10.1186/s13578-021-00553-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 02/10/2021] [Indexed: 12/16/2022] Open
Abstract
We report our discovery of an important player in the development of skin fibrosis, a hallmark of scleroderma. Scleroderma is a fibrotic disease, affecting 70,000 to 150,000 Americans. Fibrosis is a pathological wound healing process that produces an excessive extracellular matrix to interfere with normal organ function. Fibrosis contributes to nearly half of human mortality. Scleroderma has heterogeneous phenotypes, unpredictable outcomes, no validated biomarkers, and no effective treatment. Thus, strategies to slow down scleroderma progression represent an urgent medical need. While a pathological wound healing process like fibrosis leaves scars and weakens organ function, oral mucosa wound healing is a scarless process. After re-analyses of gene expression datasets from oral mucosa wound healing and skin fibrosis, we discovered that several pathways constitutively activated in skin fibrosis are transiently induced during oral mucosa wound healing process, particularly the amphiregulin (Areg) gene. Areg expression is upregulated ~ 10 folds 24hrs after oral mucosa wound but reduced to the basal level 3 days later. During bleomycin-induced skin fibrosis, a commonly used mouse model for skin fibrosis, Areg is up-regulated throughout the fibrogenesis and is associated with elevated cell proliferation in the dermis. To demonstrate the role of Areg for skin fibrosis, we used mice with Areg knockout, and found that Areg deficiency essentially prevents bleomycin-induced skin fibrosis. We further determined that bleomycin-induced cell proliferation in the dermis was not observed in the Areg null mice. Furthermore, we found that inhibiting MEK, a downstream signaling effector of Areg, by selumetinib also effectively blocked bleomycin-based skin fibrosis model. Based on these results, we concluded that the Areg-EGFR-MEK signaling axis is critical for skin fibrosis development. Blocking this signaling axis may be effective in treating scleroderma.
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Affiliation(s)
- Mary Yinghua Zhang
- Department of Pediatrics, The Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Shuyi Fang
- Department of BioHealth Informatics, School of Informatics and Computing At IUPUI, Indiana University, Indianapolis, IN, USA
| | - Hongyu Gao
- The IU Simon Comprehensive Cancer Center, Indiana University, Indianapolis, IN, USA
| | - Xiaoli Zhang
- Department of Pediatrics, The Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dongsheng Gu
- Department of Pediatrics, The Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yunlong Liu
- Department of BioHealth Informatics, School of Informatics and Computing At IUPUI, Indiana University, Indianapolis, IN, USA
- The IU Simon Comprehensive Cancer Center, Indiana University, Indianapolis, IN, USA
- The Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jun Wan
- Department of BioHealth Informatics, School of Informatics and Computing At IUPUI, Indiana University, Indianapolis, IN, USA
- The IU Simon Comprehensive Cancer Center, Indiana University, Indianapolis, IN, USA
- The Center for Computational Biology and Bioinformatics, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jingwu Xie
- Department of Pediatrics, The Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA.
- The IU Simon Comprehensive Cancer Center, Indiana University, Indianapolis, IN, USA.
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Zhang T, Li Y, Song Y, Chen X, Li J, Peng Q, He J, Fei X. Curcumin- and Cyclopamine-Loaded Liposomes to Enhance Therapeutic Efficacy Against Hepatic Fibrosis. Drug Des Devel Ther 2020; 14:5667-5678. [PMID: 33380787 PMCID: PMC7767702 DOI: 10.2147/dddt.s287442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/11/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Hepatic fibrosis is a public health problem characterized by activation of hepatic stellate cells (HSCs), which triggers excessive production of extracellular matrix (ECM). Inhibition of HSC activation may be an effective treatment. Since various pathways control HSC activation, a combination of drugs with different mechanisms may be more effective than monotherapy. METHODS Here, we prepared liposomes loaded with curcumin and cyclopamine to inhibit HSC activation. We systematically analyzed the physicochemical characteristics of liposomes loaded with the two drugs, as well as their effects on HSC proliferation, activation and collagen production on gene, protein and cellular levels. RESULTS The prepared liposomes helped solubilize both drugs, contributing to their uptake by cells. Liposomes loaded with both drugs inhibited cell proliferation, migration and invasion, as well as induced more apoptosis and perturbed the cell cycle more than the free combination of both drugs in solution or liposomes loaded with either drug alone. Liposomes loaded with both drugs strongly suppressed HSC activation and collagen secretion. CONCLUSION Our results suggest that liposome encapsulation can increase the uptake of curcumin and cyclopamine as well as the synergism between them in anti-fibrosis. This approach shows potential for treating hepatic fibrosis.
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Affiliation(s)
- Ting Zhang
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu610041, People’s Republic of China
| | - Yanping Li
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, West China Hospital of Sichuan University, Chengdu, People’s Republic of China
| | - Yi Song
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu610041, People’s Republic of China
| | - Xiaoshuang Chen
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu610041, People’s Republic of China
| | - Jing Li
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu610041, People’s Republic of China
| | - Qiang Peng
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu610041, People’s Republic of China
| | - Jinhan He
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu610041, People’s Republic of China
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, West China Hospital of Sichuan University, Chengdu, People’s Republic of China
| | - Xiaofan Fei
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu610041, People’s Republic of China
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Direct comparison of prognostic ability of cardiac biomarkers for cardiogenic stroke and clinical outcome in patients with stroke. Heart Vessels 2019; 34:1178-1186. [DOI: 10.1007/s00380-019-01345-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 01/11/2019] [Indexed: 01/21/2023]
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Stanciu AE, Hurduc AE, Stanciu MM. Effects of thyroid hormone withdrawal on natriuretic peptides during radioactive iodine therapy in female patients with differentiated thyroid cancer. Scand J Clin Lab Invest 2016; 76:626-631. [PMID: 27666870 DOI: 10.1080/00365513.2016.1230883] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We aimed to investigate the effects of thyroid hormone withdrawal on N-terminal prohormone forms of atrial natriuretic peptide (NT-proANP) and brain natriuretic peptide (NT-proBNP) during radioiodine therapy in female patients with differentiated thyroid cancer (DTC). METHODS Serum concentrations of thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), NT-proANP and NT-proBNP were measured in 51 female patients with DTC (48.7 ± 4.2 years) at three time-points: day of radioiodine therapy (t1 - under acute hypothyroidism), 5 days after radioiodine (t2 - under acute hypothyroidism) and 3 months after radioiodine (t3 - under TSH suppression). Thirty healthy euthyroid women served as controls (42.8 ± 5.6 years). RESULTS At t1/t2/t3, median NT-proANP was 5.2/1.7/487 pmol/L vs. 297.7 pmol/L in control group (p < 0.001), median NT-proBNP was 50.1/36.5/79.5 pmol/L vs. 64.5 pmol/L (p < 0.001) and median NT-proANP/NT-proBNP ratios was 0.20/0.18/4.81 vs. 4.14 (p < 0.001). In acute hypothyroidism, FT3 levels were positively correlated with NT-proANP (r = 0.38, p = 0.005), NT-proANP/NT-proBNP ratios (r = 0.47, p = 0.001), heart rate (r = 0.39, p = 0.005), and negatively with mean arterial blood pressure (r = -0.58, p < 0.001). CONCLUSIONS Our results indicate that NT-proANP reflects more accurately direct thyroid hormone effects than NT-proBNP. Thyroid hormone-dependent hemodynamic effects seem to be overlapped on the direct stimulatory effect of thyroid hormones on NT-proANP secretion by cardiac myocytes.
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Affiliation(s)
- Adina Elena Stanciu
- a Department of Carcinogenesis and Molecular Biology , Institute of Oncology Bucharest , Bucharest , Romania
| | - Anca Elena Hurduc
- b Department of Nuclear Medicine , Institute of Oncology Bucharest , Bucharest , Romania
| | - Marcel Marian Stanciu
- c Department of Electrical Engineering Faculty , University "Politehnica" of Bucharest , Bucharest , Romania
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Daniels LB, Lee NS, Hsu JC. Natriuretic Peptides for Predicting Left Atrial Reverse Remodeling After Atrial Fibrillation Ablation: Too Much of a Stretch? JACC Clin Electrophysiol 2016; 2:159-161. [PMID: 29766865 DOI: 10.1016/j.jacep.2016.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 02/19/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Lori B Daniels
- UC San Diego Health, University of California-San Diego, La Jolla, California, USA.
| | - Noel S Lee
- UC San Diego Health, University of California-San Diego, La Jolla, California, USA
| | - Jonathan C Hsu
- UC San Diego Health, University of California-San Diego, La Jolla, California, USA
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Yoshida N, Okamoto M, Hirao H, Suenari K, Nanba K, Uchida M, Yamazato R, Watari Y, Fukuda Y, Ueda H. High plasma human atrial natriuretic peptide and reduced transthoracic left atrial appendage wall-motion velocity are noninvasive surrogate markers for assessing thrombogenesis in patients with paroxysmal atrial fibrillation. Echocardiography 2013; 31:965-71. [PMID: 24373054 DOI: 10.1111/echo.12501] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The clinical relevance of examining human atrial natriuretic peptide (HANP) or left atrial appendage (LAA) wall-motion velocity during sinus rhythm in paroxysmal atrial fibrillation (AF) patients has not been clearly elucidated. METHODS The subjects were 38 patients with paroxysmal AF who underwent transesophageal and transthoracic echocardiography during sinus rhythm. The presence of spontaneous echocontrast (SEC) was examined with transesophageal echocardiography and LAA wall-motion velocity (LAAWV) was measured with transthoracic tissue Doppler echocardiography. Plasma HANP was measured within 3 hours after echocardiography. RESULTS Human atrial natriuretic peptide ranged from 12 to 106 pg/mL with an average of 43 ± 24 pg/mL and had a significant correlation with LAAWV (r = -0.57) or LAA flow velocity (r = -0.41). HANP was significantly higher in patients with SEC than in patients without SEC (64 ± 29 vs. 34 ± 15 pg/mL, P = 0.008) and LAAWV was significantly lower in patients with SEC than in patients without SEC (13 ± 5 vs. 20 ± 5 cm/sec, P = 0.002). HANP >44 pg/mL had a sensitivity of 73% and specificity of 89% for diagnosing SEC. SEC was more frequently observed (73%) in patients with HANP >44 pg/mL and/or LAAWV <10 cm/sec as compared with patients (11%) with normal HANP and LAA wall-motion velocity (P < 0.0001). CONCLUSION Higher plasma HANP and lower LAA wall-motion velocity may be noninvasive surrogate markers for assessing left atrial thrombogenesis during sinus rhythm in paroxysmal AF patients.
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Affiliation(s)
- Naoyasu Yoshida
- Echocardiography Division, Department of Laboratory Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
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Pizon M, Friedel N, Pizon M, Freundt M, Weyand M, Feyrer R. Impact of epicardial ablation of concomitant atrial fibrillation on atrial natriuretic peptide levels and atrial function in 6 months follow-up: does preoperative ANP level predict outcome of ablation? J Cardiothorac Surg 2013; 8:218. [PMID: 24286219 PMCID: PMC3892101 DOI: 10.1186/1749-8090-8-218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 11/25/2013] [Indexed: 11/13/2022] Open
Abstract
Background Epicardial ablation concomitant to cardiac surgery is an easy and safe approach to treat atrial fibrillation (AF), but its efficacy in longstanding persistent (LsPe) AF remains intermediate. Although larger left atrial size has been associated with worse outcome after ablation, biochemical predictors of success are not well established. The aim of this study was to evaluate relationship between biochemical marker, echo-characteristic and cardiac rhythm in 6 months follow-up after epicardial ultrasound (HIFU) ablation. Methods We included 78 consecutive patients, who underwent elective cardiac surgery. 42 patients with AF (11.9% paroxysmal, 23.8% persistent, 64.3% LsPeAF) underwent concomitant HIFU ablation (AF ablation group), 16 with AF underwent cardiac surgery without ablation (AF control) and 20 had preoperatively normal sinus rhythm (SR control). We measured plasma ANP secretion before, on postoperative day (POD) 1, POD 7 as well as 3 and 6 months after surgery. Moreover, we estimated cardiac rhythm and atrial mechanical function by Atrial Filling Fraction (AFF) and A-wave velocity in follow-up. Results Baseline ANP levels were higher in patients with LsPeAF, as compared to the paroxysmal and permanent AF and to the SR control group. Patients with LsPeAF (n = 27) who converted to SR had preoperatively smaller left atrial diameter (LAD) and LA area (p < 0.05) and higher ANP level (p = 0.009) than those who remained in AF at 6 months after ablation. Multivariate regression analysis revealed that only preoperative ANP level was an independent predictor of cardiac rhythm after ablation. Patients with LsPeAF and preoperative ANP >7.5 nmol/l presented with SR in 80%, in contrast to those with ANP <7.5 nmol/l who converted to SR in 20%. We detected gradual increase of AFF and A-velocity at 6 months after ablation (p < 0.05) solely in AF ablation group. ANP levels were increased on POD 1 in ablation group (p < 0.05), without changes in further follow-up. Conclusion Our results indicate that preoperative ANP levels may be a new biochemical predictor of successful epicardial ablation in patients with concomitant LsPeAF. HIFU ablation caused a significant improvement of atrial mechanical function and gradual increase of AFF and did not associate with alteration of atrial endocrine secretion at 6 months follow-up.
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Affiliation(s)
- Marek Pizon
- Department of Cardiac Surgery, Clinic of Bayreuth, Preuschwitzerstr 101, 95455 Bayreuth, Germany.
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