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Khosla A, Zhao Y, Mojibian H, Pollak J, Singh I. High-Risk Pulmonary Embolism: Management for the Intensivist. J Intensive Care Med 2023; 38:1087-1098. [PMID: 37455352 DOI: 10.1177/08850666231188290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
High-risk pulmonary embolism (PE) also known as massive PE carries a high rate of morbidity and mortality. The incidence of high-risk PE continues to increase, yet the outcomes of high-risk PE continue to remain poor. Patients with high-risk PE are often critically ill, with complex underlying physiology, and treatment for the high-risk PE patient almost always requires care and management from an intensivist. Treatment options for high-risk PE continue to evolve rapidly with multiple options for definitive reperfusion therapy and supportive care. A thorough understanding of the physiology, risk stratification, treatment, and support options for the high-risk PE patient is necessary for all intensivists in order to improve outcomes. This article aims to provide a review from an intensivist's perspective highlighting the physiological consequences, risk stratification, and treatment options for these patients as well as providing a proposed algorithm to the risk stratification and acute management of high-risk PE.
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Affiliation(s)
- Akhil Khosla
- Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Yiyu Zhao
- Department of Anesthesia, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Hamid Mojibian
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Jeffrey Pollak
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Inderjit Singh
- Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
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2
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Extracorporeal Life Support for Trauma. Emerg Med Clin North Am 2023; 41:89-100. [DOI: 10.1016/j.emc.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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3
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Uddin S, Anandanadesan R, Trimlett R, Price S. Intensive Care Management of the Cardiogenic Shock Patient. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Optimal management of patients with cardiogenic shock requires a detailed and systematic assessment of all organ systems, balancing the risks and benefits of any investigation and intervention, while avoiding the complications of critical illness. Overall prognosis depends upon a number of factors, including that of the underlying cardiac disease and its potential reversibility, the severity of shock, the involvement of other organ systems, the age of the patient and comorbidities. As with all intensive care patients, the mainstay of management is supportive, up to and including implementation and management of a number of devices, including acute mechanical circulatory support. The assessment and management of these most critically ill patients therefore demands in-depth knowledge and skill relating to cardiac intensive care, extending well beyond standard intensive care or cardiology practice.
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Affiliation(s)
- Shahana Uddin
- Heart, Lung and Critical Care Directorate, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Rathai Anandanadesan
- Heart, Lung and Critical Care Directorate, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Richard Trimlett
- Heart, Lung and Critical Care Directorate, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Susanna Price
- Heart, Lung and Critical Care Directorate, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Sarralde J, Quintana-Villamandos B, Vicente Guillén R. Documento de consenso SEDAR/SECCE sobre el manejo de ECMO. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez AI, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B, Vicente Guillén R. SEDAR/SECCE ECMO management consensus document. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:443-471. [PMID: 34535426 DOI: 10.1016/j.redare.2020.12.002] [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: 04/04/2020] [Accepted: 12/14/2020] [Indexed: 06/13/2023]
Abstract
ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.
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Affiliation(s)
- I Zarragoikoetxea
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - I Moreno
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J Porta
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - T Koller
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - V Cegarra
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A I Gonzalez
- Servicio de Anestesiología y Reanimación, Hospital Puerta de Hierro, Madrid, Spain
| | - M Eiras
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Santiago, La Coruña, Spain
| | - E Sandoval
- Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Aurelio Sarralde
- Servicio de Cirugía Cardiovascular, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - B Quintana-Villamandos
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R Vicente Guillén
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Merkle-Storms J, Djordjevic I, Weber C, Avgeridou S, Krasivskyi I, Gaisendrees C, Mader N, Kuhn-Régnier F, Kröner A, Bennink G, Sabashnikov A, Trieschmann U, Wahlers T, Menzel C. Impact of Lactate Clearance on Early Outcomes in Pediatric ECMO Patients. ACTA ACUST UNITED AC 2021; 57:medicina57030284. [PMID: 33803807 PMCID: PMC8003148 DOI: 10.3390/medicina57030284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/07/2021] [Accepted: 03/15/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Pediatric extracorporeal membrane oxygenation (ECMO) support is often the ultimate therapy for neonatal and pediatric patients with congenital heart defects after cardiac surgery. The impact of lactate clearance in pediatric patients during ECMO therapy on outcomes has been analyzed. Materials andMethods: We retrospectively analyzed data from 41 pediatric vaECMO patients between January 2006 and December 2016. Blood lactate and lactate clearance have been recorded prior to ECMO implantation and 3, 6, 9 and 12 h after ECMO start. Receiver operating characteristic (ROC) analysis was used to identify cut-off levels for lactate clearance. Results: Lactate levels prior to ECMO therapy (9.8 mmol/L vs. 13.5 mmol/L; p = 0.07) and peak lactate levels during ECMO support (10.4 mmol/L vs. 14.7 mmol/L; p = 0.07) were similar between survivors and nonsurvivors. Areas under the curve (AUC) of lactate clearance at 3, 9 h and 12 h after ECMO start were significantly predictive for mortality (p = 0.017, p = 0.049 and p = 0.006, respectively). Cut-off values of lactate clearance were 3.8%, 51% and 56%. Duration of ECMO support and respiratory ventilation was significantly longer in survivors than in nonsurvivors (p = 0.01 and p < 0.001, respectively). Conclusions: Dynamic recording of lactate clearance after ECMO start is a valuable tool to assess outcomes and effectiveness of ECMO application. Poor lactate clearance during ECMO therapy in pediatric patients is a significant marker for higher mortality.
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Affiliation(s)
- Julia Merkle-Storms
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
- Correspondence: (J.M.-S.); (I.D.)
| | - Ilija Djordjevic
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
- Correspondence: (J.M.-S.); (I.D.)
| | - Carolyn Weber
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Soi Avgeridou
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Ihor Krasivskyi
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Christopher Gaisendrees
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Navid Mader
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Ferdinand Kuhn-Régnier
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Axel Kröner
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Gerardus Bennink
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Anton Sabashnikov
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Uwe Trieschmann
- Anaesthesiology and Intensive Care Medicine, University of Cologne, 50924 Cologne, Germany; (U.T.); (C.M.)
| | - Thorsten Wahlers
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Christoph Menzel
- Anaesthesiology and Intensive Care Medicine, University of Cologne, 50924 Cologne, Germany; (U.T.); (C.M.)
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Ortiz Garcia JG, Nathan S, Brorson JR. Neurologic complications of implantable devices. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:211-220. [PMID: 33632440 DOI: 10.1016/b978-0-12-819814-8.00019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Technologies for repairing cardiac structures or sustaining cardiac function with implantable devices have helped patients with an ever-expanding array of cardiac conditions. Patients are surviving and thriving with cardiac conditions that would formerly have been disabling or fatal. With the implantation of devices in the heart, however, comes the inevitable risk of neurological complications. This chapter focuses on devices implanted in the chambers or valves of the heart itself, including prosthetic heart valves, closure devices for patent foramen ovale, atrial appendage occluder devices, short-term implantable circulatory assist devices, and long-term ventricular assist devices, but excluding coronary artery stents or extracardiac devices. Further, it considers the procedural and postprocedural risks of the devices, leaving the discussion of clinical effectiveness of the devices to other chapters of this book.
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Affiliation(s)
- Jorge G Ortiz Garcia
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Sandeep Nathan
- Section of Cardiology, Department of Internal Medicine, University of Chicago, Chicago, IL, United States
| | - James R Brorson
- Department of Neurology, University of Chicago, Chicago, IL, United States.
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Hoyler MM, Flynn B, Iannacone EM, Jones MM, Ivascu NS. Clinical Management of Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 34:2776-2792. [DOI: 10.1053/j.jvca.2019.12.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/04/2019] [Accepted: 12/29/2019] [Indexed: 12/13/2022]
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9
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Lüsebrink E, Stremmel C, Stark K, Joskowiak D, Czermak T, Born F, Kupka D, Scherer C, Orban M, Petzold T, von Samson-Himmelstjerna P, Kääb S, Hagl C, Massberg S, Peterss S, Orban M. Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation. J Clin Med 2020; 9:E992. [PMID: 32252267 PMCID: PMC7230450 DOI: 10.3390/jcm9040992] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 01/14/2023] Open
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.
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Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christopher Stremmel
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Konstantin Stark
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Thomas Czermak
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Frank Born
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Danny Kupka
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Clemens Scherer
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Tobias Petzold
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Patrick von Samson-Himmelstjerna
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Stefan Kääb
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany; (D.J.); (F.B.); (P.v.S.-H.); (C.H.); (S.P.)
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany; (E.L.); (C.S.); (K.S.); (T.C.); (D.K.); (C.S.); (M.O.); (T.P.); (S.K.); (S.M.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany
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