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Background The ABO blood group system is linked to hemostasis via its relationship with von Willebrand factor (VWF) and factor VIII (FVIII). In the current study, we investigated the association of the ABO system with clinical outcomes as well as VWF and platelet function in patients with left ventricular assist devices (LVADs). Methods Bleeding and thromboembolic complications were assessed in 111 patients during 1 year after LVAD implantation. In 67 LVAD patients, VWF antigen, VWF activity, VWF ristocetin cofactor, VWF collagen-binding, and FVIII activity were assessed. Platelet surface P-selectin and activated glycoprotein IIb/IIIa were determined by flow cytometry, and soluble P-selectin was measured with an enzyme-linked immunoassay. Platelet aggregation was assessed by light transmission and impedance aggregometry. Results Thirty-six patients (32.4%) experienced a bleeding and 22 patients (19.8%) a thromboembolic event. In univariate analyses, patients with blood group O had numerically more bleeding complications and less thromboembolic events as compared to patients with blood group non-O (both p ≥ 0.05). After multivariable adjustment, blood group O was significantly associated with a higher risk of bleeding (hazard ratio 2.42 [95% confidence interval 1.03–5.70], p = 0.044) but not linked to thromboembolic complications. Conclusion Patients with blood group O had significantly lower levels of VWF and FVIII (all p

Despite increasing popularity and multiple postulated benefits, less invasive (LIS) left ventricular assist device (LVAD) implantation has not been sufficiently compared with standard full sternotomy (FS). We report the outcomes of a propensity score analysis designed to compare LIS and FS LVAD implantation, with perioperative blood product use, adverse event rates, and mortality as primary objective. From September 2010 to August 2016, 159 consecutive patients received a Medtronic HVAD or Abbott HeartMate 3 LVAD via a FS or LIS approach. Outcomes were analyzed using proportional hazard Cox regression, with risk adjustment based on a LIS approach propensity score model computed from demographics, risk factors, and operative covariates. Seventy-five patients were matched and compared (HVAD 83% [n = 62]; LIS approach 43% [n = 32]; mean age 60 ± 12 years; 89% [n = 67] male; 48% [n = 36] ischemic cardiomyopathy [ICMP]; 37% [n = 28]). Patient groups were comparable with regard to preoperative patient characteristics. Less invasive LVAD implantation was successful in all patients with no intraoperative conversions. In-hospital mortality was 16% in both groups, despite 37% Interagency Registry for Mechanically Assisted Circulatory Support Level I patients. Overall, 28% of the LIS patients did not receive any blood products intraoperatively, whereas, in the FS group, only two patients (5%) did not require the administration of blood products (p = 0.000). This was also a significant finding in the overall perioperative phase in which seven LIS patients (22%) who not receive any blood products versus two FS patients (5%; p = 0.033). Otherwise, outcomes were comparable. Less invasive LVAD implantation is a feasible, safe, and reduces blood product use.

Tricuspid regurgitation in patients with left ventricular assist device (LVAD) has a significant impact on prognosis and quality of life, and its effects on liver and renal function could negatively impact planned heart transplantation. The aim of the present case is to report the feasibility and the clinical impact of tricuspid transcatheter edge‐to‐edge repair in LVAD patients as adjunctive bridge to transplantation strategy. A 59‐year‐old female patient previously treated with LVAD implantation (HeartMate III) and tricuspid valve repair with 32 mm rigid ring (Medtronic Contour 3D) as bridge to transplantation developed recurrence of significant tricuspid regurgitation with right ventricular decompensation needing inotropic support. Preoperative echo showed torrential tricuspid valve regurgitation Effective regurgitant orifice area(EROA 1.4 cm2) with suspicious of partial detachment of the prosthetic ring. The patient was successfully treated with transcatheter edge‐to‐edge repair with the MitraClip XTR device. Tricuspid regurgitation was reduced by 50% (postoperative EROA 0.7 cm2). She remained stable under continuous inotropic support with no other episodes of right ventricular decompensation and was successfully transplanted 30 days after the clipping procedure. Transcatheter treatment of tricuspid regurgitation in a patient with LVAD was an effective strategy to gain time and bridge the patient to heart transplantation.

A relation between the left ventricular assist device inflow cannula (IC) malposition and pump thrombus has been reported. This study aimed to investigate if the pump position, derived from chest X-rays in HeartMate 3 (HM3) patients, correlates with neurological dysfunction (ND), ischemic stroke (IS), hemorrhagic stroke (HS) and survival.This analysis was performed on routinely acquired X-rays of 42 patients implanted with a HM3 between 2014 and 2017. Device position was quantified in patients with and without ND from frontal and lateral X-rays characterizing the IC and pump in relation to spine, diaphragm or horizontal line. The primary end-point was freedom from stroke and survival one-year after HM3 implantation stratified by pump position.The analysis of X-rays, 33.5 (41.0) days postoperative, revealed a significant smaller IC angle of HM3 patients with ND versus no ND (0.1° ± 14.0° vs. 12.9° ± 10.1°, p = 0.005). Additionally, the IC angle in the frontal view, IS: 4.1 (20.9)° versus no IS: 13.8 (7.5)°, p = 0.004 was significantly smaller for HM3 patients with IS. Using receiver operating characteristics derived cut-off, IC angle10° provided 75% sensitivity and 100% specificity (C-statistic = 0.85) for predicting IS. Stratified by IC angle, freedom from IS at 12 months was 100% (10°) and 60% (10°) respectively (p = 0.002). No significant differences were found in any end-point between patients with and without HS. One-year survival was significantly higher in patients with IC angle10° versus10° (100% vs. 71.8%, p = 0.012).IC malposition derived from standard chest X-rays serves as a risk factor for ND, IS and worse survival in HM3 patients.

Several risk scores and classifications are available to predict peri- and post-operative mortality of patients with end stage heart failure receiving Left Ventricular Assist Device (LVAD) therapy. Sarcopenia has been suggested as a sensitive predictor for post-operative mortality. We evaluated whether the psoas muscle area can predict mortality in patients undergoing LVAD implantation. The indexed psoas mean area (PMAi) was obtained by measuring the psoas muscle area at the superior endplate of the third lumbar vertebra correlated to body surface area of 106 adult patients undergoing LVAD implantation (Medtronic HVAD n = 41, Abbott HeartMate II n = 4, Abbott HeartMate 3 n = 61, mean age 65, IQR 12, 90.6% male, INTERMACS Level 1 24.5%, ischemic CMP 64.2%). Patients were divided in two groups: high/moderate and low muscle mass. The primary endpoint was 30-day mortality, assessed using a multivariate Cox proportional hazards model. Baseline characteristics did not differ between patients with high or moderate and low PMAi. Estimated survival calculated a significant higher 30-day mortality in patients with low PMAi (p = 0.04). Multivariable Cox proportional hazards regression analysis indicated low PMAi, history of previous cardiac surgery and levels of bilirubin as independent predictors of mortality in the first 30 days. In conclusion, indexed psoas muscle area predicts mortality after LVAD implantation and can be used as an additional tool for risk stratification.

Left-ventricular assist devices (LVADs) improve outcomes in end-stage heart failure patients. Two centrifugal-flow LVAD systems are currently approved, HeartMate 3 (HM3) and Medtronic/Heartware HVAD (HVAD). Clinical findings suggest differences in thrombogenicity between both systems. We compared markers of platelet activation and aggregation between HM3 and HVAD. We prospectively included 59 LVAD patients (40 HM3, 19 HVAD). Platelet

Anticoagulation therapy in patients using left ventricular assist device (LVAD) is essential to reduce hemocompatibility related adverse events (HRAEs). Vitamin K-antagonist dosage must be adapted and monitored by INR point-of-care testing (POCT) in outpatients. The study aims to determine if the frequency of INR POCT in LVAD outpatients has an influence on the quality of anticoagulation therapy (ACQ), HRAEs, and outcomes. This retrospective study included n = 48 patients who received LVAD implantation (HMII, HM3, and HVAD) between 2013 and 2017. ACQ (% of INR tests in range, PTR), outcomes and HRAEs using Kaplan-Meier curves were compared in a daily (n = 36) and 3×/week (n = 12) INR POCT group. Further, based on the achieved PTR ranging from 0-60% (poor), 61-70% (acceptable), and 71-100% (well controlled), HRAEs and outcomes were compared. Daily and 3×/week groups were similar in perioperative risk factors and INR target (p = 0.28). Freedom from any HRAE (38.9% vs. 25.0%, p = 0.44), any readmission (72.2% vs. 75.0%, p = 0.97), and 1 year survival (91.7% vs. 91.7%, p = 0.98) were comparable in both groups. The PTR was significantly higher with the daily self-assessments (73.5% vs. 68.4%, p = 0.006). Well vs. poorly controlled INR POCT patients more often had (p = 0.01) a daily POCT frequency (92%) vs. poorly controlled (54%) and significantly higher freedom from neurologic events (96.0 vs. 69.2%, p = 0.024) as well as hemorrhagic strokes (100% vs. 76.9%, p = 0.011). Well-controlled anticoagulation of LVAD outpatients is associated with less neurologic events. The frequency of INR POCT could be one of the key factors in the reduction of HRAEs, so future prospective, large-scale studies should help to clarify the effects.

The Berlin Heart EXCOR® is a mechanical, pulsatile ventricular assist device. The paracorporeal assist device is pneumatically driven and can be used for long-term bridging therapy of one or both ventricles (LVAD, BIVAD, RVAD). It is specifically designed for pediatric patients and can be used in neonates as well as juveniles and adults. The infant presented in this video tutorial was diagnosed with myocarditis leading to end-stage heart failure and severe mitral valve regurgitation. A bridging therapy was indicated and a Berlin Heart EXCOR® VAD was implanted. This tutorial provides detailed insight on how to perform this procedure. In addition, a safe and effective way of extending the outflow cannula is demonstrated.

Background/Aims: Clinical studies have reported a better outcome of smokers after myocardial infarction compared to non-smokers. The data are controversial, as some clinical studies did not observe this effect. The cell biological processes involved, which might account for a ‘Smoker’s Paradox’, have not been investigated yet. Therefore, the aim was to elucidate the effect of cigarette smoke on the viability of cardiomyocytes in the context of hypoxia and reperfusion. Methods: HL-1 cells were incubated with different concentrations of cigarette smoke extract (CSE) and subjected to hypoxia/reperfusion to further evaluate influence of CSE on viability of HL-1 cells using flow cytometry analyses, Western Blot and immunofluorescence staining. Results: Incubation with CSE led to a concentration-dependent reduction in HL-1 viability. Adding hypoxia as a stressor enhanced cell death. Caspase-independent apoptosis was the observed type of cell death partly induced by P53 and apoptosis-inducing-factor. Yet a significant increase in LDH release in cardiomyocytes incubated with 4%, 8% and 16% CSE suggests necrosis with rapid DNA depletion. Interestingly, after hypoxia a decreased LDH release under lower CSE concentrations was observed. Moreover, a concentration-dependent increase in proliferation and a trend for increased ATP availability under hypoxic conditions was shown. Conclusions: The trend for less LDH release in hypoxia after low-level CSE incubation might represent a switch from necrosis to apoptosis, which in combination with the increase in metabolic activity and ATP availability might account for the ‘Smoker’s Paradox’. These findings could partly explain inconsistent results of previous clinical studies as the data showed strong evidence for the crucial relevance of the amount of cigarettes smoked. We are in need of future studies distinguishing between different types of smokers to finally verify or falsify the ‘Smoker’s Paradox’.

Purpose The relation between left ventricular assist device (LVAD) inflow cannula malposition and pump thrombus has been reported. This study aimed to investigate pump position, derived from chest X-rays of HM3 patients, in correlation to any neurological dysfunction (ND) and specifically to ischemic stroke (IS) and intracranial hemorrhage (ICH). Methods This retrospective analysis was performed on routinely acquired X-rays of 33 patients (Age: 62.4±9.3 yrs, male: 89.5%, BMI: 28.3±4.9kg/m2) implanted with a HM3 between 2014 and 2017. Device position was quantified in patients with and without any neurological dysfunction (noND) from frontal and lateral X-ray parameters characterizing the inflow cannula (IC), pump depth in relation to spine, diaphragm or horizontal line. Results The analysis of X-rays (38.6±24.3 days postoperative) revealed a significant smaller IC angle of HM3 patients with any ND vs. noND (2.52±11.59° vs. 13.92±9.74°, p=0.029). Additionally, the IC angle in the frontal view (IS: 0.23±11.34° vs. noIS: 13.92±9.45°, p=0.012) as well as the pump depth (IS: 19.7±16.8mm vs. noIS: 38.3±19.6mm, p=0.044) were significantly smaller for HM3 patients with IS. Using receiver operating characteristic (ROC) curve-derived cut-points, IC angle 10.06°) and 50.4% ( Conclusion In HM3 patients, inflow cannula malposition identified from X-rays serves as a risk factor for neurological dysfunction and especially ischemic stroke.

Purpose Several risk scores and classifications are available to predict peri- and post-operative mortality of patients with end stage heart failure receiving Left Ventricular Assist Device (LVAD) implantation. The INTERMACS classification is most commonly used but recently assessment of sarcopenia has been suggested as additional predictor for post-operative outcome. Therefore, we evaluated whether or not psoas muscle area can serve as additional prognostic marker. Methods A retrospective analysis on our patient cohort in the time span from January 2014 to April 2019 was performed. During that time period a total of 178 adult LVAD implantations were performed (Heart Ware n=42, HeartMate II n=4, HeartMate III n=61). Of those, 107 patients received an abdominal CT scan prior to surgery. Psoas mean area at level of the superior endplate of the third lumbar vertebra was measured axially corrected and correlated with patients body surface area, giving the indexed psoas mean area (PMAi). Patients then were divided in high or moderate muscle mass and low muscle mass in accordance to patient sex. Results Estimated survival calculated using the Kaplan-Meier-curve found a significant higher 30-day mortality in patients with low PMAi (log rank: 0.009). Whereas no differences were observed concerning in-hospital, 90-day and 1-year mortality. Lower muscle mass also had no impact on the length of ICU stay or necessity of temporary RVAD. Comparison of the distribution on the INTERMACS classification, revealed that patients with lower muscle mass had a higher probability to classify as INTERMACS level 1 or 2 (Level 1: 21% vs. 38.1%; Level 2: 14.8% vs. 23.8%). Conclusion Patients with low PMAi in our cohort represented the sicker patients and had statistically significant higher short-term mortality. These findings suggest that PMAi can be used as an additional tool for risk stratification in patients undergoing LVAD implantation.

Purpose Long-term survival after heart transplant is still limited due to immunological and drug related adverse events. Immunosuppressive therapy is solely managed via pharmacokinetic analysis and clinical events. TTV (Torque Teno Virus) is a small single-stranded DNA virus associated with increasing viral load under immune compromising conditions. Studies in both kidney and lung transplantation have already shown that the level of plasma TTV - DNA load is associated with the magnitude of immunosuppression. The aim of this prospective observational study was to analyze TTV viral load in patients after heart transplantation (HTX). Methods We prospectively determined the TTV load in 50 heart transplant patients. Samples were collected at pre-transplant and each HTX visit in the out-patient clinic. Viral load analysis was performed by PCR from plasma or serum on the Department of Virology. TTV viral load was compared between pre-transplant and peak levels post transplant. Pre-TX TTV load was compared between different patient groups and between different immunosuppressive protocols after transplantation. Results Patients were transplanted between 1/2016-6/2018. Median age at transplant was 60 (42-67) years and 38% were female. 50%(n=25) of patients were transplanted due to ischemic disease, 44% (n=22) due to dilative Cardiomyopathy and 6% (n=3) due to other disease. 16% of patients were bridged with a mechanical assist device (n=8). Pretransplant TTV levels were 4.4E+00±2.03E+00 cps/ml and significantly increased to 9.39E+00 ±0.75E+00 (p Conclusion TTV viral load increases significantly after heart transplantation and reaches its peak after 90-120 days. VAD pretransplant has an influence of TTV viral load and the choice of calcineurin inhibitor drug seems to be associated with differences in TTV viral load. TTV viral load might be useful as a biomarker for the state of immunosuppression.

Das Marchen „Die Spinne und die Weisheit“ stammt aus Afrika und erzahlt eine ausergewohnliche Geschichte uber eine Spinne auf Reisen, die einem intelligenten Hasen begegnet. Hauptsachlich dreht sich das Marchen um das Thema Weisheit und darum, wie man diese erlangen kann. Dem Spinnenmannchen unterlaufen auf seiner Reise diesbezuglich einige Fehler. Das vorliegende Kapitel setzt sich mit den dazugehorigen psychologischen Phanomenen wie Wissensmanagement, Feedback und Macht auseinander. Zudem stellt dieses Kapitel das alte Marchen zur heutigen Zeit in Bezug. Aus den Erkenntnissen konnen einige Implikationen fur die Arbeitswelt und Lebensgestaltung abgeleitet werden, die dazu dienen, die Fehler der Spinne sinnvoll zu reflektieren, sodass Sie selbst nicht Gefahr laufen, dieselben zu begehen. Diese werden in sechs Leitsatzen prasentiert.

In diesem Kapitel wird das Marchen „Der Jager, der seine Frauen ungleich behandelte“ thematisiert. Das Marchen stammt aus Guinea und handelt von einem Jager, der mit zwei Frauen zusammenlebt. Dabei entsteht fur eine der beiden Frauen eine grose Ungerechtigkeit, da sie sich vernachlassigt fuhlt. Dies resultiert in einer Racheaktion, in der sie vom Opfer zur Taterin wird. Nach einer Beschreibung aller Charaktere wird der Zusammenhang des Marchens mit psychologischen Phanomenen hergestellt. Hierzu zahlen der Glaube an eine gerechte Welt, die Frustrations-Aggressions-Theorie sowie soziale Zuruckweisung. Abschliesend wird die Relevanz dieser Themen in unserer heutigen Zeit diskutiert: Wo erfahren wir Ungerechtigkeit?