Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: the biology of a neglected disease.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a chronic, debilitating disease characterised by a wide range of symptoms that severely impact all aspects of life. Despite its significant prevalence, ME/CFS remains one of the most understudied and misunderstood conditions in modern medicine. ME/CFS lacks standardised diagnostic criteria owing to variations in both inclusion and exclusion criteria across different diagnostic guidelines, and furthermore, there are currently no effective treatments available. Moving beyond the traditional fragmented perspectives that have limited our understanding and management of the disease, our analysis of current information on ME/CFS represents a significant paradigm shift by synthesising the disease's multifactorial origins into a cohesive model. We discuss how ME/CFS emerges from an intricate web of genetic vulnerabilities and environmental triggers, notably viral infections, leading to a complex series of pathological responses including immune dysregulation, chronic inflammation, gut dysbiosis, and metabolic disturbances. This comprehensive model not only advances our understanding of ME/CFS's pathophysiology but also opens new avenues for research and potential therapeutic strategies. By integrating these disparate elements, our work emphasises the necessity of a holistic approach to diagnosing, researching, and treating ME/CFS, urging the scientific community to reconsider the disease's complexity and the multifaceted approach required for its study and management.

Unraveling the enigma of long COVID: novel aspects in pathogenesis, diagnosis, and treatment protocols.

Long COVID, now unmistakably identified as a syndromic entity encompassing a complex spectrum of symptoms, demands immediate resolution of its elusive pathogenic underpinnings. The intricate interplay of diverse factors presents a complex puzzle, difficult to resolve, and thus poses a substantial challenge. As instances of long COVID manifest by repeated infections of SARS-CoV-2 and genetic predisposition, a detailed understanding in this regard is needed. This endeavor is a comprehensive exploration and analysis of the cascading pathogenetic events driven by viral persistence and replication. Beyond its morbidity, long COVID, more disabling than fatal, exacts one of the most substantial tolls on public health in contemporary times, with the potential to cripple national economies. The paper introduces a unified theory of long COVID, detailing a novel pathophysiological framework that interlinks persistent SARS-CoV-2 infection, autoimmunity, and systemic vascular pathology. We posit a model where viral reservoirs, immune dysregulation, and genetic predispositions converge to perpetuate disease. It challenges prevailing hypotheses with new evidence, suggesting innovative diagnostic and therapeutic approaches. The paper aims to shift the paradigm in long COVID research by providing an integrative perspective that encapsulates the multifaceted nature of the condition. We explain the immunological mechanisms, hypercoagulability states, and viral reservoirs in the skull that feed NeuroCOVID in patients with long COVID. Also, this study hints toward a patient approach and how to prioritize treatment sequences in long COVID patients in hospitals and clinics.

The potential of heparin-induced extracorporeal LDL/fibrinogen precipitation (H.E.L.P.)-apheresis for patients with severe acute or chronic COVID-19.

Patients with long COVID and acute COVID should benefit from treatment with H.E.L.P. apheresis, which is in clinical use for 37 years. COVID-19 can cause a severe acute multi-organ illness and, subsequently, in many patients the chronic illness long-COVID/PASC. The alveolar tissue and adjacent capillaries show inflammatory and procoagulatory activation with cell necrosis, thrombi, and massive fibrinoid deposits, namely, unsolvable microthrombi, which results in an obstructed gas exchange. Heparin-induced extracorporeal LDL/fibrinogen precipitation (H.E.L.P.) apheresis solves these problems by helping the entire macro- and microcirculation extracorporeally. It uses unfractionated heparin, which binds the spike protein and thereby should remove the virus (debris). It dissolves the forming microthrombi without bleeding risk. It removes large amounts of fibrinogen (coagulation protein), which immediately improves the oxygen supply in the capillaries. In addition, it removes the precursors of both the procoagulatory and the fibrinolytic cascade, thus de-escalating the entire hemostaseological system. It increases myocardial, cerebral, and pulmonary blood flow rates, and coronary flow reserve, facilitating oxygen exchange in the capillaries, without bleeding risks. Another factor in COVID is the "cytokine storm" harming microcirculation in the lungs and other organs. Intervention by H.E.L.P. apheresis could prevent uncontrollable coagulation and inflammatory activity by removing cytokines such as interleukin (IL)-6, IL-8, and TNF-α, and reduces C-reactive protein, and eliminating endo- and ecto-toxins, without touching protective IgM/IgG antibodies, leukocyte, or platelet function. The therapy can be used safely in combination with antiviral drugs, antibiotics, anticoagulants, or antihypertensive drugs. Long-term clinical experience with H.E.L.P. apheresis shows it cannot inflict harm upon patients with COVID-19.

Relapsing and Progressive Complications of Severe Hypertriglyceridemia: Effective Long-Term Treatment with Double Filtration Plasmapheresis.

BACKGROUND: Severe hypertriglyceridemia (HTG) is associated with major complications such as acute or relapsing pancreatitis (AP) and atherosclerotic cardiovascular disease (ASCVD). Rapid elimination of triglyceride (TG)-rich lipoproteins (LP) with double filtration plasmapheresis (DFPP) without need for substitution has been found to be effective for the acute, short-term treatment of HTG-induced AP. Data on the long-term use of DFPP to prevent HTG-associated complications are scarce. OBJECTIVES: To evaluate the use and efficacy of regular DFPP treatment in clinical practice for preventing recurrence of HTG-associated complications in thera-py refractory patients. METHODS: Retrospective multicenter study in patients with severe symptomatic drug and diet refractory HTG with regular DFPP treatment. Patients' incidence of HTG-associated pancreatic or cardiovascular complications was compared before treatment and with regular DFPP treatment. RESULTS: Ten patients (3 female) were identified with baseline maximal TG concentrations of 2,587-28,090 mg/dL (median 5,487 mg/dL; interquartile range [IQR] 4,340-12,636). The mean observation period was 3.9 ± 3.4 years before and 3.8 ± 3.0 years after commencement of DFPP. In 5 patients, severe HTG was related to chylomicronemia, 2 patients had familial partial lipodystrophy Dunnigan, and 1 patient had additional LP(a)-hyperlipoproteinemia. The main HTG-associated complication was recurrent AP in 8 patients, including 1 patient treated during pregnancy. Two patients presented severe progressive ASCVD. With long-term DFPP treatment, the annual rate of HTG-associa-ted pancreatic or cardiovascular complications declined from median 1.4 (IQR 0.7-2.6) to 0 (IQR 0.0-0.4; p < 0.005). The absolute number of events was reduced by 77%. In 6 patients (60%) episodes of AP did not occur, nor was progression of ASCVD detected clinically or by routine imaging techniques. DFPP was effective in the elimination of TG-rich LP from plasma, and was safe and well-tolerated. CONCLUSION: Long-term, regular DFPP treatment resulted in stabilization of patients with severe HTG and related recurrent AP or progression of ASCVD, who were refractory to conventional dietary and drug therapy.

Rationale and design of MultiSELECt: A European Multicenter Study on the Effect of Lipoprotein(a) Elimination by lipoprotein apheresis on Cardiovascular outcomes.

BACKGROUND: Dyslipidemia is a well-known risk factor for atherosclerosis and subsequent cardiovascular disease (CVD). While low density lipoprotein cholesterol (LDL-C) is well-established and taken into consideration for risk management and therapy, lipoprotein(a) is another established CVD risk factor frequently not undergoing screening due to a lack of medical treatment options. For patients suffering from CVD due to massive elevation of Lp(a) in presence of normal LDL-C levels, lipoprotein apheresis is the only available treatment option. While this constellation is an accepted indication for lipoprotein apheresis (LA) in Germany, prospective studies including a control group are still lacking. OBJECTIVE: Primary objective of this trial is to evaluate the clinical benefit of lipoprotein apheresis on myocardial infarction, PCI, CABG and death from cardiovascular disease in subjects with elevated Lp(a). This study evaluates the clinical benefit of weekly LA in subjects with progressive cardiovascular disease, as accepted by the German Federal Joint Committee (treatment group). Comparator will be well-matched subjects under maximum tolerated lipid lowering therapy without access to LA treatment (control group). METHODS: MultiSELECt, is a prospective, multicenter, multinational, two-arm matched-pair cohort study designed to directly compare subjects with significantly elevated Lp(a) approved for LA subsequently undergoing weekly apheresis treatment versus a continuation of maximal medical therapy. The follow-up period will be 2 years after the baseline visit and until at least 60 events of the primary end-point occurred in the control group. A central trial expert committee will review all subjects with respect to their potential indication for LA according to established German guidelines in a blinded fashion. All control subjects will be contacted monthly via telephone visits to compensate for the more frequent visits during apheresis. Approximately 150 matched pairs will be necessary to detect an event reduction of at least 10% in subjects under LA treatment. CONCLUSION: The MultiSELECt trial provides the unique opportunity to demonstrate the efficiency of LA on CVD in patients with elevated Lp(a) under strongly controlled conditions.

Cardiac allograft vasculopathy: Microvascular arteriolar capillaries ('capioles") and survival.

Cardiac allograft vasculopathy (CAV) is a serious complication of heart transplantation in adults and children. Risk factors include human leukocyte antigen mismatches, number and duration of rejection episodes, type of immunosuppression, antibody-mediated rejection, hypertension, hyperlipidemia, obesity, smoking, diabetes, cytomegalovirus infection, mode of donor brain death, donor age and ischemia/reperfusion injury. Endothelial injury and dysfunction in CAV are characterized by changes in adhesion molecules and up-regulation of major histocompatibility class II antigens followed by endothelial activation of complement C4d. Subsequently, activation of the coagulation cascade leads to deposition of fibrin on endothelium followed by proliferation and migration of vascular smooth muscle cells. The development of a special type of microvessels with phenotypic characteristics of arterial capillaries ("capioles") seems to provide a survival advantage for patients with CAV. Novel therapies of CAV include statins, and heparin-induced extracorporeal low-density lipoprotein apheresis. B beta15-42 which is a fibrin peptide has been shown to improve the graft microvasculature and to reduce ischemia/reperfusion-induced damage. Despite these advances, there is a need to identify and stratify individual CAV risk factors, to develop early biomarkers of CAV, and to better decipher the events that lead to antibody-mediated rejection.

Postoperative Heparin-Mediated Extracorporeal Low-Density Lipoprotein Fibrinogen Precipitation Aphaeresis Prevents Early Graft Occlusion after Coronary Artery Bypass Grafting.

Background Early graft occlusion due to thromboembolic events is a well-known complication after coronary artery bypass grafting (CABG). Fibrinogen, the coagulation factor I, is a glycoprotein that is transformed by thrombin into fibrin. It plays a major role in thrombus formation and is highly elevated after CABG. Our aim was to determine if postoperative lowering of fibrinogen levels by H.E.L.P. (heparin-mediated extracorporeal low-density lipoprotein [LDL] fibrinogen precipitation) aphaeresis could reduce the rate of early graft occlusion in patients with hypercholesterolemia undergoing CABG. Methods Between December 2004 and September 2009, 36 male patients with hypercholesterolemia (mean LDL cholesterol 128 ± 12 mg/dL), mean age 58 ± 9 years, underwent CABG. Mean preoperative fibrinogen level was 387 ± 17 mg/dL. H.E.L.P. aphaeresis was postoperatively performed when fibrinogen levels exceeded 350 mg/dL on day 1 and 250 mg/dL every consecutive day up to day 8. Pre- and postaphaeresis blood samples were obtained and plasma fibrinogen level reduction was calculated. Early graft occlusion was evaluated by means of coronary angiography or multislice computed tomography before discharge. Results A total of 128 distal anastomoses were performed in 36 patients (mean 3.6/patient). Postoperatively, 191 H.E.L.P. aphaeresis sessions were performed (mean 5.3/patient). Fibrinogen levels were lowered from 391 ± 10 mg/dL (preaphaeresis) to 171 ± 5 mg/dL (postaphaeresis; p < 0.001). Coronary angiography (multislice computed tomography in 7 patients) revealed graft patency in 125 of 128 grafts (98% patency) with three occluded venous grafts to target vessels of 1.5 mm. H.E.L.P. aphaeresis-related complications were limited to hypotensive episodes in two patients and bacteremia in one patient. Conclusions H.E.L.P. apheresis offers an easy, save, and efficient method to decrease fibrinogen postoperatively in patients having CABG. Showing excellent graft patency rates in comparison to the literature, this method is a promising tool to reduce early graft occlusion after CABG.

Early inflammatory markers are independent predictors of cardiac allograft vasculopathy in heart-transplant recipients.

BACKGROUND: Identification of risk is essential to prevent cardiac allograft vasculopathy (CAV) and graft failure due to CAV (GFDCAV) in heart transplant patients, which account for 30% of all deaths. Early CAV detection involves invasive, risky, and expensive monitoring approaches. We determined whether prediction of CAV and GFDCAV improves by adding inflammatory markers to a previously validated atherothrombotic (AT) model. METHODS AND FINDINGS: AT and inflammatory markers interleukin-6 (IL-6) and C-reactive protein (CRP) were measured in heart biopsies and sera of 172 patients followed prospectively for 8.9±5.0 years. Models were estimated for 5- and 10-year risk using (1) the first post-transplant biopsy only, or (2) all biopsies obtained within 3 months. Multivariate models were adjusted for other covariates and cross-validated by bootstrapping. After adding IL-6 and CRP to the AT models, we evaluated the significance of odds ratios (ORs) associated with the additional inflammatory variables and the degree of improvement in the area under the receiver operating characteristic curve (AUROC). When inflammatory markers were tested alone in prediction models, CRP (not IL-6) was a significant predictor of CAV and GFDCAV at 5 (CAV: p<0.0001; GFDCAV: p = 0.005) and 10 years (CAV: p<0.0001; GFDCAV: p = 0.003). Adding CRP (not IL-6) to the best AT models improved discriminatory power to identify patients destined to develop CAV (using 1st biopsy: p<0.001 and p = 0.001; using all 3-month biopsies: p<0.04 and p = 0.008 at 5- and 10-years, respectively) and GFDCAV (using 1st biopsy: 0.92 vs. 0.95 and 0.86 vs. 0.89; using all 3-month biopsies: 0.94 vs. 0.96 and 0.88 vs. 0.89 at 5- and 10-years, respectively), as indicated by an increase in AUROC. CONCLUSIONS: Early inflammatory status, measured by a patient's CRP level (a non-invasive, safe and inexpensive test), independently predicts CAV and GFDCAV. Adding CRP to a previously established AT model improves its predictive power.

Value of the first post-transplant biopsy for predicting long-term cardiac allograft vasculopathy (CAV) and graft failure in heart transplant patients.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the principal cause of long-term graft failure following heart transplantation. Early identification of patients at risk of CAV is essential to target invasive follow-up procedures more effectively and to establish appropriate therapies. We evaluated the prognostic value of the first heart biopsy (median: 9 days post-transplant) versus all biopsies obtained within the first three months for the prediction of CAV and graft failure due to CAV. METHODS AND FINDINGS: In a prospective cohort study, we developed multivariate regression models evaluating markers of atherothrombosis (fibrin, antithrombin and tissue plasminogen activator [tPA]) and endothelial activation (intercellular adhesion molecule-1) in serial biopsies obtained during the first three months post-transplantation from 172 patients (median follow-up = 6.3 years; min = 0.37 years, max = 16.3 years). Presence of fibrin was the dominant predictor in first-biopsy models (Odds Ratio [OR] for one- and 10-year graft failure due to CAV = 38.70, p = 0.002, 95% CI = 4.00-374.77; and 3.99, p = 0.005, 95% CI = 1.53-10.40) and loss of tPA was predominant in three-month models (OR for one- and 10-year graft failure due to CAV = 1.81, p = 0.025, 95% CI = 1.08-3.03; and 1.31, p = 0.001, 95% CI = 1.12-1.55). First-biopsy and three-month models had similar predictive and discriminative accuracy and were comparable in their capacities to correctly classify patient outcomes, with the exception of 10-year graft failure due to CAV in which the three-month model was more predictive. Both models had particularly high negative predictive values (e.g., First-biopsy vs. three-month models: 99% vs. 100% at 1-year and 96% vs. 95% at 10-years). CONCLUSIONS: Patients with absence of fibrin in the first biopsy and persistence of normal tPA in subsequent biopsies rarely develop CAV or graft failure during the next 10 years and potentially could be monitored less invasively. Presence of early risk markers in the transplanted heart may be secondary to ischemia/reperfusion injury, a potentially modifiable factor.

Biomarkers of heart transplant rejection: the good, the bad, and the ugly!

Acute cellular rejection (ACR), antibody-mediated rejection (AMR), and cardiac allograft vasculopathy (CAV) are important limitations for the long-term survival of heart transplant recipients. Although much progress has been made in reducing ACR with modern immunosuppressive treatments and continuous biopsy surveillance, there is still a long way to go to better understand and treat AMR, to enable early detection of patients at risk of CAV, and to reduce the development and sustained progression of this irreversible disease that permanently compromises graft function. This review considers the advances made in ACR detection and treatment allowing a more prolonged survival and the risk factors leading to endothelial injury, dysfunction, inflammation, and subsequent CAV, as well as new treatment modalities for CAV. The review also evaluates the controversies around the definition, pathogenesis, and treatment of AMR. To date, much progress is still needed to significantly reduce post-transplant complications and increase graft and patient survival.

Longitudinal cohort study on the effectiveness of lipid apheresis treatment to reduce high lipoprotein(a) levels and prevent major adverse coronary events.

BACKGROUND: We investigated in a longitudinal, multicenter, cohort study whether combined lipid apheresis and lipid-lowering medication can reduce extremely high levels of lipoprotein(a) (Lp[a]) and thus prevent major adverse coronary events (MACE) more efficaciously than lipid-lowering medication alone. METHODS: Eligible patients had coronary artery disease and Lp(a) levels > or =2.14 micromol/l (95th percentile). All patients received lipid-lowering medications alone until maximally tolerated doses were no longer effective, followed by combined lipid apheresis and lipid-lowering medication. The rates of the primary outcome, MACE, were recorded for both periods. RESULTS: A total of 120 patients were included. The mean duration of lipid-lowering therapy alone was 5.6+/-5.8 years, and that of apheresis was 5.0+/-3.6 years. Median Lp(a) concentration was reduced from 4.00 micromol/l to 1.07 micromol/l with apheresis treatment (P<0.0001); the corresponding mean annual MACE rate per patient was 1.056 versus 0.144 (P<0.0001). CONCLUSIONS: Lowering of Lp(a) levels by apheresis was efficacious and safe, and we recommend this therapy for patients in whom maximally tolerated doses of medication alone have failed to control coronary artery disease-associated events.

The German Lipid Apheresis Registry - remaining to be established.

BACKGROUND: The target-oriented distribution of increasingly limited health care resources demand data, which support the benefit of established treatment procedures such as lipid apheresis. In recent years, the Federal Joint Committee (G-BA), a paramount decision-making body of the German Health Care System, warrants reassessment of the approval of chronic lipid apheresis therapy for regular reimbursement. Therefore, in 2005, an interdisciplinary German apheresis working group has been established by members of both German Societies of Nephrology. The goal of this working group has been to revise 1.) the indication for lipid apheresis according to current guidelines and recommendations for the treatment of lipid disorders and 2.) to transfer recent advances of our understanding of the impact of lipoproteins for atherogenesis and thrombosis into these recommendations. In addition, the working group developed standardized report forms, which could be implemented in a software solution to establish a German Lipid Apheresis Registry. METHODS AND RESULTS: From 2005 to 2009 the working group met on a regular basis to substantiate the first defined goals. The indication for lipid apheresis was critically revised with respect to cardiovascular guidelines and actual scientific evidence and was accepted by the members of the apheresis working group. The first draft of report forms for the German Lipid Apheresis Registry was validated. Various software solutions were discussed, but proved not feasible because of the lack of financial sponsoring. CONCLUSIONS: There is consensus between the medical societies and health care authorities that there is a need for a German Lipid Apheresis Registry. The advantage of such a registry is to substantiate prospective long-term data on clinical outcome of chronic lipid apheresis treatment and to support additional clinical research activities in that field. In addition, this registry should comply with requests of the Federal Joint Committee (G-BA). The necessary terms for this registry are well defined, but financial support is an issue.

Smoking cessation and subclinical atherosclerosis--results from the Heinz Nixdorf Recall Study.

BACKGROUND: Smoking accounts for more than 5 million years of potential life lost per year in the US alone. Leading causes of smoking attributable mortality are acute atherothrombotic complications of coronary heart disease (CHD). Smoking cessation is a key issue in preventive medicine, but quantitative data on its benefit for the coronary arteries are sparse. METHODS: The Heinz Nixdorf Recall Study is an ongoing population-based, prospective cohort study, with 4814 participants aged 45-74 years (49.8% men). Baseline data of 4078 participants without history of established coronary heart disease or stroke are included in this report. Electron beam-computed tomography allows for non-invasive quantification of coronary artery calcium (CAC). We estimate the risk-related ageing of coronary arteries from multivariable regression of CAC on smoking behavior, sex, age and risk factors. RESULTS: Smoking 20 cigarettes per day since the age of 16 is associated with a CAC burden which is found in a person 10 years older who has never smoked (both sexes). Smoking cessation at 45, 55 or 65 leads to CAC at the age of 75 that would have been reached 9, 6 or 3 years earlier, respectively, had smoking been continued. CONCLUSIONS: In individuals without overt CHD, present smokers are about 10 years older in 'coronary artery age' than never smokers. The accumulation of CAC is accelerated by smoking and slows down after smoking cessation, but advanced CAC is persistent for a long period. These quantitative findings strongly support smoking cessation measures as early as possible, to prevent accelerated arterial ageing.

Lipid-lowering effect of preoperative statin therapy on postoperative major adverse cardiac events after coronary artery bypass surgery.

OBJECTIVE: Statins are powerful lipid-lowering drugs that have been proved effective in the prevention of coronary artery disease, clearly reducing the risk of mortality and cardiovascular events. Whether hyperlipidemic patients undergoing coronary artery bypass grafting profit from the lipid-lowering beneficial effects of statins is as yet uncertain. We sought to determine whether preoperative statin therapy may have an effect on outcome among hyperlipidemic patients undergoing coronary artery bypass grafting. METHODS: From January 2000 through March 2006, prospectively recorded clinical data from 3346 consecutive patients undergoing isolated first-time elective coronary artery bypass grafting were analyzed for major adverse cardiac events and all-cause in-hospital mortality. Of these, 167 patients had preoperative statin-untreated hyperlipidemia (group 1), 2592 had statin-treated hyperlipidemia (group 2), and 587 had statin-untreated normolipidemia (group 3). RESULTS: Risk-adjusted multivariate logistic regression analysis revealed statin-treated hyperlipidemia (odds ratio, 0.42; 95% confidence interval, 0.26-0.69; P = .0007) and statin-untreated normolipidemia (odds ratio, 0.42; confidence interval, 0.26-0.69; P = .0007) to be independently associated with reduced in-hospital major adverse cardiac events but not with in-hospital mortality. To further control for selection bias, a computed propensity score matching based on 14 major preoperative risk factors was performed. After propensity matching, conditional logistic regression analysis confirmed statin-treated hyperlipidemia and statin-untreated normolipidemia to be strongly related to reduced in-hospital major adverse cardiac events (odds ratio, 0.41; 95% confidence interval, 0.24-0.71 [P = .0013] and odds ratio, 0.23; 95% confidence interval, 0.11-0.48 [P = .0001]) but not with in-hospital mortality (odds ratio, 1.18; 95% confidence interval, 0.36-3.87 [P = .79] and odds ratio, 1.10; 95% confidence interval, 0.32-4.41 [P = .80]) after coronary artery bypass grafting surgery. CONCLUSIONS: Hyperlipidemic, but not normolipidemic, patients have an increased risk for in-hospital major adverse cardiac events and therefore clearly benefit from preoperative statin therapy before coronary artery bypass grafting surgery.

Molecular identification and differentiation of Brevibacterium species and strains.

Amplified ribosomal DNA restriction enzyme analysis (ARDRA), pulsed field gel electrophoresis (PFGE) and ribotyping were used to differentiate among 24 strains of Brevibacterium linens, Brevibacterium casei and Brevibacterium epidermidis obtained from type culture collections or isolated from various smear ripened cheeses. ARDRA was applied to the 16S rDNA. B. linens was shown to be a quite heterogenic group with 2 to at least 4 copies of rrn operons per strain with aberrant nucleotide sequences. AccI gave genus specific restriction patterns and was used to separate Brevibacterium from Corynebacterium species. The expected species specificity of TaqI applied to B. linens type culture strains, but not to all strains isolated from cheese. By AvaI restriction, B. casei and B. linens were differentiated from B. epidermidis and the orange pigmented Arthrobacter casei, a new species of coryneform bacteria; by XmnI restriction, B. linens and B. epidermidis were differentiated from B. casei. One of 4 B. linens genotypes could not be distinguished from B. casei by this method. Here, the typical orange B. linens pigments were used for classification, which was confirmed by partial sequencing of the 16S rDNA.

Emergency re-revascularization with percutaneous coronary intervention, reoperation, or conservative treatment in patients with acute perioperative graft failure following coronary artery bypass surgery.

OBJECTIVE: Perioperative graft failure following coronary artery bypass grafting (CABG) results in acute myocardial ischemia/infarction (PMI), which may necessitate an acute secondary revascularization procedure to salvage myocardium, in order to preserve ventricular function and improve patient outcome. Whether acute percutaneous coronary (re)intervention (PCI), emergency reoperation, or conservative intensive care treatment should be applied, is currently unknown. METHODS: In order to identify the source of PMI and to pursue the appropriate re-revascularization strategy, coronary repeat angiography was emergently performed in 118 among 5427 consecutive isolated CABG patients with evidence of PMI. As a result, patients immediately underwent acute PCI (group 1), emergency reoperation (group 2), or were treated conservatively (group 3). Primary study endpoint was postoperative myocardial infarct size, as measured by peak cardiac troponin I (cTnI) serum levels. Secondary endpoints were perioperative left ventricular ejection fraction (LVEF%), assessed by transesophageal echocardiography, major adverse cardiac events, and short- and midterm mortality. RESULTS: Repeat coronary angiography revealed early perioperative bypass graft failure in 67 among 118 patients and 84 among 214 bypass grafts after CABG. The number and type of failing bypass grafts were comparable between groups 1 and 2, but significantly different to that of group 3 (P<0.007). Acute PCI was applied in 25 patients, redo-CABG in 15 patients, and conservative treatment in 27 patients. Procedural peak cTnI serum levels were significantly different between groups 1 and 2 (81+/-18 ng/ml vs 178+/-62 ng/ml; P<0.001). Global LVEF was reduced during the acute ischemic event when compared with preoperative values (P<0.01). Thereafter, LVEF improved during follow-up within each group (P<0.001), but did not differ between the three groups. In-hospital and 1-year mortality were 12.0% and 20.0% in group 1, 20.0% and 27% in group 2, and 14.8% and 18.5% in group 3, respectively (P=NS). CONCLUSIONS: Re-revascularization with emergency PCI may limit the extent of myocardial cellular damage compared with the surgical-based treatment strategy in patients with acute perioperative myocardial ischemia due to early graft failure following CABG.

Changes in myocardial vasoreactivity after drastic reduction of plasma fibrinogen and cholesterol: a clinical study in long-term heart transplant survivors using positron emission tomography.

BACKGROUND: Given the central importance of the microvasculature in heart transplant recipients, we investigated the possibility of increasing cardiac perfusion after reduction of low-density lipoprotein (LDL)-cholesterol, lipoprotein (a), C-reactive protein (CRP) and fibrinogen plasma levels after apheresis treatment in transplanted patients. METHODS: Ten long-term heart transplant recipients were examined with positron emission tomography (PET) to measure myocardial perfusion before and after a single heparin-mediated extracorporeal LDL/fibrinogen precipitation (HELP)-apheresis treatment. PET studies were performed the mornings before and after the apheresis treatment. Myocardial blood flow at rest and during adenosine-induced hyperemia was measured using (13)N-ammonia. RESULTS: HELP-apheresis reduced the plasma levels of LDL-cholesterol, lipoprotein (a) and C-reactive protein by 48% (p < 0.001), fibrinogen by 42% (p = 0.02), plasma viscosity by 14% (p = 0.004) and erythrocyte aggregation by 28% (p < 0.02). Osmolality (<1%) and hematocrit (<2%) remained stable. A single apheresis treatment increased median corrected rest flow by 17.5% (p = 0.007) and median hyperemic flow by 27% (p = 0.02). Median coronary flow reserve increased by 8.1% (p = 0.09). Hyperemic flow after adenosine infusion increased plasma vascular endothelial growth factor levels only before HELP-apheresis (+60%), indicating better ischemic tolerance after apheresis (p = 0.01). CONCLUSIONS: Myocardial perfusion in transplanted hearts increases significantly after single HELP-apheresis treatment. The present study is only a proof of concept, providing complementary evidence to clinical long-term studies showing that cholesterol reduction either with statins and/or apheresis improves heart transplant outcome.

Heparin-mediated extracorporeal LDL precipitation treating a peripheral arterial disease patient suffering from repeated postoperative bypass occlusion.

Acute occlusion of a peripheral artery is a serious complication in peripheral arterial disease (PAD). Traditionally open surgical intervention in combination with antithrombotic therapy is the choice for treatment but the beneficial effects of both strategies are limited often by the patient's situation and therapeutic side effects. Heparin-mediated extracorporeal low-density lipoprotein precipitation (H.E.L.P.) apheresis efficiently removes circulating atherogenic lipoproteins, fibrinogen and C-reactive proteins as well as various proinflammatory and procoagulatory factors. We first report H.E.L.P. apheresis treating a PAD patient suffering from repeated postoperative femoropopliteal bypass graft occlusion, first, intensively, followed by weekly intervals. Limb amputation was avoided and the patient is doing well now. Angiography revealed bypass graft remained patent half a year after operation. This case report might help to design the regime for preventing postoperative bypass occlusion in patients with hyperlipidemia or hyperfibrinogenemia.

[Fibrinogen and atherothrombosis: vulnerable plaque or vulnerable patient?]. / Fibrinogen und Atherothrombose: vulnerable Plaque oder vulnerabler Patient?

Fibrinogen is far more important as a risk factor for acute cardiovascular syndromes than generally recognized. Evidence from a recent metaanalysis (including 22 studies of 63,736 subjects and 5,717 events [1] suggests that the risk for myocardial infarction and stroke almost doubles if the fibrinogen level exceeds 3.03 g/l (measured according to Clauss) with an odds ratio of 1.99 and a 95% confidence interval of 1.85-2.13. The predictive value of fibrinogen levels equally applies to men and women, young and old, primary and secondary prevention. Repeated fibrinogen measurements are particularly helpful with emphasis on high risk patients: concentrations of the upper tertile indicate a 92% higher risk of impending acute cardiovascular syndromes, as evidenced by a metaanalysis evaluating five prospective studies with 9,639 participants and 671 events [1]. Together with other risk factors such as hypertension, hypercholesterolemia, or diabetes, the risk of fatal and nonfatal acute cardiovascular syndromes may further increase by 6-12- fold, while fibrinogen remains an independent risk factor for both cardiac and extracardiac atherothrombotic complications, as well as for iatrogenic complications like restenosis following PTCA or stenting. Fibrin(ogen) and his effector thrombin substantially determine the extent and outcome of atherothrombotic complications, because they are the molecules linking the mutually dependent events of atherogenesis, coagulation/fibrinolysis, rheology/vasotonus, and inflammation. Interventional studies on fibrinolytic and defibrinating substances, as well as GpIIb/IIIa-inhibitors for treatment of acute cardiovascular syndromes have confirmed the benefit of fibrinogen reduction and extended the experimental evidence for the relevance of fibrin(ogen) in the pathogenesis of these syndromes. Accordingly, the preventive use of fibrates leading to moderate reductions in plasma cholesterol and fibrinogen diminished significantly the rate of reinfarction. The emerging possibilities from a more than 50% fibrinogen reduction (by studies using H.E.L.P. apheresis) strengthened the therapeutic concept to free the blood from all risk factors-as effective as it can be-in order to achieve an optimal plaque regression, since changes in the blood composition strongly affect the fragility and stability of the atherosclerotic plaques.