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J Mair

Publications and source records attributed to J Mair.

At least 19 recordsLinked to original sources

[Technical feasibility of the implantation of a monorail stent system into the renal arteries without pre-dilatation].

PURPOSE: To evaluate the technical feasibility of the implantation of the monorail RX Herculink system into the renal arteries without pre-dilatation. MATERIALS AND METHODS: Forty-two patients (mean age 71 years) from four centers with a total of 44 renal artery stenoses underwent implantation of the RX Herculink stent. The mean grade of the stenosis was 83.8 %, the mean length 7.5 mm. The stenoses were ostial in 38 cases and in immediate proximity to the ostium in 6 cases. The mean follow-up-period was 57 weeks (24 - 176 weeks). RESULTS: In 42 cases, the implantation was successful without pre-dilatation. In 2 cases, pre-dilatation was carried out. In none of the cases, detachment of the stent from the balloon was observed. In one stenosis with a length of 17 mm, implantation of two stents was performed. In 9 cases, post-dilatation with a larger balloon or higher balloon pressure was necessary. Residual stenoses exceeding 30 % were not observed. Two patients developed local bleeding at the puncture site. During the follow-up, restenoses were observed in 5 stents after 26 to 126 weeks, which necessitated a second intervention in 3 cases (PTA in 2 cases, re-stenting in 1 case). The primary patency rate after 6 and 12 months was 0.92 +/- 0.056 according to Kaplan-Meier, the secondary patency rate after 6 and 12 months was 1.0 +/- 0.0. CONCLUSION: Implantation of the RX Herculink stent system into the renal arteries without pre-dilatation is technically feasible and safe. Even without pre-dilatation, the stent-system can be advanced through the stenosis without detachment. The complication rate is low. Our clinical results are comparable to previous studies.

Aged↗

Clinical applications of B-type natriuretic peptide (BNP) testing.

Many claims have been made in recent years regarding the utility of plasma B-type natriuretic peptide (BNP) concentration measurements in the diagnosis, risk stratification and monitoring of patients with heart failure. This paper summarizes the current evidence and provides guidance for practising clinicians. Overall, plasma BNP testing appears to be of most value in the diagnostic arena, where it is likely to improve the performance of non-specialist physicians in diagnosing heart failure. In clinical practice, BNP testing is best used as a 'rule out' test for suspected cases of new heart failure in breathless patients presenting to either the outpatient or emergency care settings; it is not a replacement for echocardiography and full cardiological assessment, which will be required for patients with an elevated BNP concentration. Although work is ongoing in establishing the 'normal' values of BNP, heart failure appears to be highly unlikely below a plasma concentration of 100 pg/ml. However, as BNP levels rise with age and are affected by gender, comorbidity and drug therapy, the plasma BNP measurement should not be used in isolation from the clinical context.

Ambulatory Care↗

Calpain, calpastatin activities and ratios during myocardial ischemia-reperfusion.

The purpose of this study was to test the hypothesis that myocardial ischemia-reperfusion (I/R) is accompanied by an early burst in calpain activity, resulting in decreased calpastatin activity and an increased calpain/calpastatin ratio, thereby promoting increased protein release. To determine the possibility of a 'calpain burst' impacting cardiac calpastatin inhibitory activity, rat hearts were subjected (Langendorff) to either 45 or 60 min of ischemia followed by 30 min of reperfusion with and without pre-administration (s.c.) of a cysteine protease inhibitor (E-64c). Myocardial function, calpain activities (casein release assay), calpastatin inhibitory activity and release of CK, LDH, cTnI and cTnT were determined (n = 8 for all groups). No detectable changes in calpain activities were observed following I/R with and without E-64c (p > 0.05). Both I/R conditions reduced calpastatin activity (p < 0.05) while E-64c pre-treatment was without effect, implicating a non-proteolytic event underlying the calpastatin changes. A similar result was noted for calpain-calpastatin ratios and the release of all marker proteins (p < 0.05). In regard to cardiac function, E-64c resulted in transient improvements (15 min) for left ventricular developed pressure (LVDP) and rate of pressure development (p < 0.05). E-64c had no effect on end diastolic pressure (LVEDP) or coronary pressure (CP) during I/R. These findings demonstrate that restricting the putative early burst in calpain activity, suggested for I/R, by pre-treatment of rats with E-64c does not prevent downregulation of calpastatin inhibitory activity and/or protein release despite a transient improvement in cardiac function. It is concluded that increases in calpain isoform activities are not a primary feature of l/R changes, although the role of calpastatin downregulation remains to be elucidated.

Animals↗

Head-to-head comparison of N-terminal pro-brain natriuretic peptide, brain natriuretic peptide and N-terminal pro-atrial natriuretic peptide in diagnosing left ventricular dysfunction.

Brain natriuretic peptide (BNP), NT-proBNP and NT-pro-atrial natriuretic peptide (NT-proANP) were measured in blood samples from 57 patients using immunoassays and immunoradiometric assays to evaluate the usefulness as diagnostic markers for the detection of heart failure. For the detection of impaired left ventricular ejection fraction (LVEF), receiver operating characteristic curves showed that BNP had the best diagnostic performance with an area under curve (AUC) of 0.75+/-0.06. However, NT-proBNP (AUC: 0.67+/-0.07) and NT-proANP (AUC: 0.69+/-0.08) showed no significant difference to BNP. In a further analysis for the detection of resting LVEF <40%, BNP again was the best marker with an AUC of 0.83+/-0.06. NT-proBNP showed only a slightly smaller AUC (0.79+/-0.07). The AUC for NT-proANP was significantly smaller (0.65+/-0.08) compared to BNP. Additionally, BNP and NT-proBNP correlated negatively with the resting LVEF (BNP: -0.472, p<0.001; NT-proBNP: -0.306, p=0.026), whereas NT-proANP showed no significant correlation. In summary, BNP was the best marker to detect patients with impaired LVEF compared to NT-proBNP and NT-proANP. However, NT-proBNP showed no significant differences to BNP and it is therefore a new promising alternative marker for the detection of left ventricular dysfunction.

Aged↗

Mouse model of myocardial remodelling after ischemia: role of intercellular adhesion molecule-1.

OBJECTIVE: We studied the effects of temporary myocardial ischemia and reperfusion on myocyte injury and ventricular remodelling in wildtype and intercellular adhesion molecule-1- (ICAM-1) deficient mice. METHODS: ICAM-1-/- and ICAM-1+/+ mice were subjected to 30 min of myocardial ischemia and subsequent reperfusion for 2 h, 1 week and 3 weeks, respectively. The evaluation of tissue damage and scar size was performed with histological sections stained with hematoxilin and eosin. Serum levels of troponin T, creatine kinase and lactate dehydrogenase isoenzyme 1 were evaluated as an index of cardiac cellular damage. Immunohistological analysis was employed to determine cell compositions in ischemic regions. RESULTS: After myocardial ischemia (30 min) and 2 h reperfusion, elevation in serum troponin T, creatine kinase and lactate dehydrogenase isoenzyme 1 were found in both groups, but significantly reduced in ICAM-1-/- mice compared with wildtype mice (P<0.05). Absence of a functional ICAM-1 gene in ICAM-1-/- mice resulted in a marked reduction of ischemia-reperfusion injury at the early stage. The damage score and size of the infarct area were lower in ICAM-1 -/- mice by 30 min of ischemia and 2 h of reperfusion (1.4+/-0.54 vs. 2.4+/-0.47, P<0.05). The percentage of MAC-1-positive cells in the ischemic region and the border zone was also significantly diminished in groups of ICAM-1-/- mice. Surprisingly, the scar size in ventricles in animals 1 or 3 weeks after ischemia was similar between ICAM-1-/- and ICAM-1+/+ mice, although the number of infiltrated MAC-1 positive cells in the scar in wildtype mice was higher. CONCLUSION: Our results demonstrate that the absence of ICAM-1 expression results in less myocardial damage induced by ischemia-reperfusion at the early stage, but does not influence the size of myocardial infarction and scar formation.

Animals↗

Markers of inflammation and myofibrillar proteins following eccentric exercise in humans.

The purpose of this study was to examine the time-course and relationships of technetium-99m (99mTc) neutrophils in muscle, interleukin-6 (IL-6), myosin heavy chain fragments (MHC), eccentric torque, and delayed onset muscle soreness (DOMS) following eccentric exercise in humans. Twelve male subjects completed a pre-test DOMS questionnaire, performed a strength test and had 100 ml blood withdrawn for analysis of plasma IL-6 and MHC content. The neutrophils were separated, labelled with 99mTc, and re-infused into the subjects immediately before the exercise. Following 300 eccentric repetitions of the right quadriceps muscles on an isokinetic dynamometer, the subjects had 10 ml of blood withdrawn with repeated the eccentric torque exercise tests and DOMS questionnaire at 0, 2, 4, 6, 20, 24, 48, 72 h, and 6 and 9 days. Bilateral images of the quadriceps muscles were taken at 2, 4, and 6 h. Computer analysis of regions of interest was used to determine the average count per pixel. The 99mTc neutrophils and IL-6 increased up to 6 h post-exercise (P < 0.05). The neutrophils were greater in the exercised muscle than the non-exercised muscle (P < 0.01). The DOMS was increased from 0 to 48 h, eccentric torque decreased from 2 to 24 h, and MHC peaked at 72 h post-exercise (P < 0.001). Significant relationships were found between IL-6 and 2 h and DOMS at 24 h post-exercise (r = 0.68) and assessment of the magnitude of change between IL-6 and MHC (r = 0.66). These findings suggest a relationship between damage to the contractile proteins and inflammation, and that DOMS is associated with inflammation but not with muscle damage.

Adult↗

Hypoxia induces heat shock protein expression in human coronary artery bypass grafts.

OBJECTIVE: Heat shock proteins (HSPs) are molecular chaperones which are essential for cell survival. Heat shock and hypoxia markedly increase the expression of several HSPs in various tissues, i.e. heart. In our in vitro study, we investigated whether HSPs are inducible in human vessels which are used as coronary artery bypass grafts. METHODS: We used remnants of the saphenous vein and the internal mammary artery from 34 patients undergoing coronary artery bypass surgery. Each vessel was divided into segments, one for control conditions at 37 degrees C (5% CO(2)-95% air), the remaining ones for thermal (30 min at 42 degrees C) or hypoxic treatment (6 h oxygen deprivation with nitrogen). The expression of Hsp60, Hsp72 and Hsp73 was investigated by immunohistochemistry and Western-blot analysis. RESULTS: Compared to controls, segments of the saphenous vein undergoing heat treatment showed significantly increased expression of Hsp72 in the intima (P=0.035) and Hsp73 in the media (P=0.003). In the internal mammary artery, Hsp72 and Hsp73 were expressed in the intima at significantly higher levels (P=0.042 each). A 6 h oxygen deprivation with nitrogen resulted in elevated levels of Hsp60 (media: P=0.048), of Hsp72 (intima: P<0.001 and media: P=0.004) and of Hsp73 (intima: P=0.029) in the saphenous vein. In the internal mammary artery, Hsp73 expression was significantly enhanced (intima: P=0.048 and media: P=0.017). The results were confirmed by Western-blot analysis in representative veins. CONCLUSIONS: These findings demonstrate the common cellular defense mechanism of HSP expression in response to stress in coronary artery bypass grafts. Hypoxia and heat treatment strongly induce Hsp72 and Hsp73 expression in human coronary artery bypass grafts.

Aged↗

Cardiac troponin and beta-type myosin heavy chain concentrations in patients with polymyositis or dermatomyositis.

Cardiac troponin T (cTnT), cardiac troponin I (cTnI), myosin heavy chains (MHC), myoglobin, creatine kinase (CK), and creatine kinase isoenzyme MB (CKMB), were measured in blood samples from 39 polymyositis (PM) or dermatomyositis (DM) patients without clinical evidence for cardiac involvement to evaluate their clinical usefulness in this patient population. MHC, myoglobin, and CKMB were frequently elevated and correlated with each other and with disease severity. Undetectable cTnI in all but one patient indicated that MHC was released from skeletal muscle, thereby providing the first laboratory evidence of frequent slow-twitch muscle fibre-necrosis in patients with PM or DM. CKMB was elevated in 51%, cTnT in 41%, and cTnI in only 2.5% of patients. cTnI did not correlate with other markers or with disease severity scores. The close correlations found between cTnT and skeletal muscle damage markers and the relationship between cTnT with disease severity without clinical evidence for myocardial damage suggest a release of cTnT from skeletal muscle. The relationship of cTnT with disease severity indicates a possible role of the marker for risk stratification. However, the prognostic values of cardiac troponins and other muscle damage markers in PM/DM patients remain to be compared in prospective outcome trials.

Adolescent↗

Release of muscle proteins after downhill running in male and female subjects.

The release of muscle proteins after downhill running, which mainly includes eccentric muscle action, was compared in females (F; n=9) and males (M; n=9). They performed 20 min of downhill treadmill running with 16% decline with a target heart rate of 70% of the individual VO2peak, which was determined two weeks before. Blood samples were drawn before, 6 and 24 h after exercise to measure plasma levels of skeletal troponin I (sTnI), myosin heavy chain fragments (MHC), creatine kinase (CK), and myoglobin (Mb). Baseline levels before exercise were significantly higher in males compared to females for the cytoplasmic proteins CK and Mb, but the difference for MHC and sTnI was not significant. Both groups displayed marked and significant early (6 h) increases (P<0.05) for sTnI (median: F: 8.2 microg/L; M: 22.0 microg/L), Mb (median: F: 86.8 microg/L; M: 407 microg/L), and CK (median: F: 162 U/L; M: 339 U/L). A significant (P<0.05) but delayed (24 h) increase was found for MHC (median: F: 482 microU/L; M: 651 microU/L). The absolute values for all four parameters were significantly (P<0.05) higher in males compared to females; however, no difference was found for the relative increases and the time course of all parameters between females and males. We conclude 1) that there were no significant differences in the basal concentrations of predominantly bound proteins, and 2) that there were no differences in the relative muscle protein release between females and males before and after one bout of high-intensive eccentric exercise. The higher plasma concentrations of all measured muscle proteins in males are probably caused by the higher muscle mass compared to females.

Adult↗

Creatine kinase, myosin heavy chains and magnetic resonance imaging after eccentric exercise.

The aim of this study was to examine the relationship between myosin heavy chain (MHC) release as a specific marker of slow-twitch muscle fibre breakdown and magnetic resonance imaging (MRI) of skeletal muscle injury after eccentric exercise. The effects of a single series of 70 high-intensity eccentric contractions of the quadriceps femoris muscle group (single leg) on plasma concentrations of creatine kinase and MHC fragments were assessed in 10 young male sport education trainees before and 1 and 4 days after exercise. To visualize muscle injury, MRI of the loaded thigh was performed before and 4 days after the eccentric exercise. All participants recorded an increase (P < 0.05) in creatine kinase after exercise. In five participants, T2 signal intensity was unchanged post-exercise compared with pre-exercise and MHC plasma concentration was normal; however, they showed an increase (P < 0.05) in creatine kinase after exercise. For the remaining five participants, there was an increase in T2 signal intensity of the loaded vastus intermedius and vastus lateralis. These changes in MRI were accompanied by an increase in MHC plasma concentration (P< 0.01) as well as an increase in creatine kinase (P < 0.01). We suggest that changes in MRI T, signal intensity after muscle damage induced by eccentric exercise are closely related to damage to structurally bound contractile filaments of some muscle fibres. Additionally, MHC plasma release indicates that this damage affects not only fast-twitch fibres but also some slow-twitch fibres.

Adult↗

The impact of cardiac natriuretic peptide determination on the diagnosis and management of heart failure.

The long-predicted endocrine function of the heart has been proven by the discovery of atrial natriuretic peptide (atrial natriuretic factor, A-type natriuretic peptide; ANP) 20 years ago. This subsequently led to the description of a whole family of structurally similar but genetically distinct peptides, the natriuretic peptide family, which contributes to cardiovascular homeostasis. These looped peptides promote natriuresis and diuresis, act as vasodilators, and exert antimitogenic effects on cardiovascular tissues. Two members, ANP and brain natriuretic peptide (B-type natriuretic peptide; BNP) are secreted by the heart mainly in response to myocardial stretch induced by volume load. The natriuretic peptides are synthesized as preprohormones. The C-terminal endocrinological active peptides (ANP, BNP) and their N-terminal prohormone fragments are found in plasma. The natriuretic peptide system is activated to its highest degree in ventricular dysfunction. However, natriuretic peptides are increased in all patients with edematous disorders which lead to an increase in atrial tension or central blood volume, such as renal failure or ascitic liver cirrhosis. It could be demonstrated that in chronic heart failure patients and during the subacute phase of myocardial infarction, of all tested neurohormones, the cardiac natriuretic peptides were best markers to identify heart failure and the most powerful predictors of morbidity and mortality. Natriuretic peptides are independent markers for risk assessment. In comparative studies BNP was superior to ANP and its N-terminal prohormone fragments in myocardial infarction as well as in chronic heart failure patients. Less data on N-terminal proBNP (NT-proBNP) is available, but BNP and NT-proBNP appear to be equivalent markers. For primary care physicians natriuretic peptide measurement is useful to decide which patient with suspected heart failure warrants further investigation, particularly when assessment of left ventricular function is not readily available. Natriuretic peptides have an excellent negative predictive value, particularly in high risk patients. An increase in BNP is serious enough to warrant follow-up examinations. For the cardiologists the natriuretic peptides are helpful for guidance of therapy and monitoring disease course in heart failure patients and for risk stratification in heart failure and myocardial infarction.

Atrial Natriuretic Factor↗

Clinical and experimental results on cardiac troponin expression in Duchenne muscular dystrophy.

BACKGROUND: Because of controversial earlier studies, the purpose of this study was to provide novel experimental and additional clinical data regarding the possible reexpression of cardiac troponin T (cTnT) in regenerating skeletal muscle in Duchenne muscular dystrophy (DMD). METHODS: Plasma from 14 patients (mean age, 7.5 years; range, 5.7-19.4 years) with DMD was investigated for creatine kinase (CK), the CK MB isoenzyme (CKMB), cTnT and cardiac troponin I (cTnI), and myoglobin. cTnT concentrations were measured by an ELISA (second-generation assay; Roche) using the ES 300 Analyzer. cTnI, myoglobin, and CKMB were measured by an ELISA using the ACCESS System (Beckman Diagnostics). Troponin isoform expression was studied by Western blot analysis in remnants of skeletal muscle biopsies of three patients with DMD and in an animal model of DMD (mdx mice; n = 6). RESULTS: There was no relation of cTnT and cTnI to clinical evidence for cardiac failure. cTnI concentrations remained below the upper reference limit in all patients. cTnT was increased (median, 0.11 microg/L; range, 0.06-0.16 microg/L) in 50% of patients. The only significant correlation was found for CK (median, 3938 U/L; range, 2763-5030 U/L) with age (median, 7.5 years; range, 6.8-10.9 years; r = -0.762; P = 0.042). Western blot analysis of human or mouse homogenized muscle specimens showed no evidence for cardiac TnT and cTnI expression, despite strong signals for skeletal muscle troponin isoforms. CONCLUSIONS: We found no evidence for cTnT reexpression in human early-stage DMD and in mdx mouse skeletal muscle biopsies. Discrepancies of cTnT and cTnI in plasma samples of DMD patients were found, but neither cTnT nor cTnI plasma concentrations were related with other clinical evidence for cardiac involvement.

Adolescent↗

Cardiac natriuretic peptides: new laboratory parameters in heart failure patients.

Natriuretic peptides, atrial natriuretic peptide and brain natriuretic peptide, are key regulators in the homeostasis of salt and water excretion and in the maintenance of blood pressure. During heart failure, these peptides are highly activated because of volume overload and increased myocardial wall tension. Among all natriuretic peptides and neurohormones, brain natriuretic peptide and its N-terminal prohormone fragment have been shown to be the best markers to identify patients with heart failure. They are useful prognostic markers as well. The stability of brain natriuretic peptides and N-terminal prohormones in ethylene-diamine-tetraacetic-acid whole blood is sufficient for routine use. Sensitive and specific assays without the need for plasma extraction are commercially available. The available data indicate that natriuretic peptides are powerful diagnostic and prognostic markers in heart failure patients. First data on treatment guidance are promising.

Aged↗

Stealing the show.

Explore the source record for details and available documents.

Financing, Construction↗

A novel biochemical approach to congestive heart failure: cardiac troponin T.

BACKGROUND: The major structural characteristic of congestive heart failure is myocardial cell death. The aim of our study was to determine whether the level of cardiac troponin T, a protein specific for cardiac necrosis, was increased in patients with congestive heart failure. METHODS AND RESULTS: Plasma samples were obtained from 33 patients and 47 healthy control subjects. Quantitative determination of cardiac troponin T was achieved with a second-generation enzyme immunoassay without cross-reactivity with the skeletal muscle troponin T. The mean circulating level of cardiac troponin T was 0.140 +/- 0.439 ng/mL in patients with heart failure and 0.0002 +/- 0.001 ng/mL in the healthy controls (P =. 0001). To evaluate the relation between structural degradation and functional impairment, patients in heart failure were categorized according to their radionuclide left ventricular ejection fraction (LVEF). In the 23 patients with LVEF </=45%, cardiac troponin T was 0.163 +/- 0.50 ng/mL, a level significantly higher than that in patients with LVEF >45% (P =.04). There was also a negative correlation between cardiac troponin T and LVEF (R = -0.41, P =.01). CONCLUSIONS: These data show that cardiac troponin T is increased in patients with congestive heart failure and that the level parallels the severity of the disease. We conclude that cardiac troponin T is a suitable candidate-marker molecule to monitor congestive heart failure from a structural perspective.

Adult↗

Relationship between natriuretic peptides and hemodynamics in patients with heart failure at rest and after ergometric exercise.

Sixteen patients with heart failure who underwent right heart catherization were studied with regard to plasma natriuretic peptide levels and hemodynamic parameters at rest and immediately after symptom-limited ergometry. Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) were measured and correlated with left ventricular ejection fraction (LVEF), mean pulmonary arterial pressure (MPAP), pulmonary arterial wedge pressure (PAWP) and cardiac index (CI). Compared to normal controls, ANP and BNP were elevated at rest. During exercise ANP and BNP increased. BNP was highly significantly correlated with LVEF (P = 0.005) at rest, whereas ANP did not (P = 0.082). BNP significantly correlated with MPAP and PAWP after exercise and showed a significant inverse correlation with CI. Our data provide evidence that BNP might be a better indicator for LVEF at rest than ANP. In addition, BNP correlates very well with MPAP and PAWP, after exercise. This close correlation is likely to reflect a correlation of BNP with left ventricular enddistolic pressure in heart failure when patients are exposed to physical exercise.

Atrial Natriuretic Factor↗

Effects of a leucocyte depleting arterial line filter on perioperative proteolytic enzyme and oxygen free radical release in patients undergoing aortocoronary bypass surgery.

BACKGROUND: Proteolytic enzymes and oxygen free radicals released from activated leucocytes contribute significantly to the organ dysfunction associated with cardiopulmonary bypass. Leucocyte depletion during extracorporeal circulation should reduce the release of these toxic compounds and thereby improve postbypass myocardial and pulmonary function. Recently, a leucocyte-specific arterial line filter to achieve leucocyte depletion during clinical perfusion has become commercially available. The aim of this study, therefore, was to evaluate the influence of the leucocyte depleting arterial line filter on proteolytic enzyme release, oxygen free radical release and postbypass pulmonary and myocardial function in patients undergoing bypass surgery. METHODS: Forty patients undergoing elective aortocoronary bypass surgery were included into this prospective, randomized clinical study, 20 in the leucocyte depletion (LG-6 group, leucocyte-specific arterial line filter) and 20 in the control group (AV-6 group, standard arterial line filter). White cell count, differential white cell count, plasma elastase concentration, plasma malondialdehyde concentration and C-reactive protein were determined before, twice during and immediately after cardiopulmonary bypass, at the end of surgery and 6 and 20 h thereafter. RESULTS: White cell count, differential white cell count, malondialdehyde and C-reactive protein were not significantly different between LG-6 and control patients. Plasma elastase concentrations were significantly (P < or = 0.03) higher during and immediately after extracorporeal circulation in LG-6 group patients. Need for inotropic support, arterial pO2 after extracorporeal circulation and perioperative CK MB mass and troponin I release were not different between the two groups of patients. CONCLUSION: The use of a leucocyte depleting arterial line filter is associated with an increased release of the proteolytic enzyme elastase, but does not reliably and consistently achieve effective leucocyte depletion during clinical perfusion. In contrast to previous studies, we could not demonstrate any significant difference in postbypass pulmonary or myocardial function between patients perfused with the leucocyte-specific arterial line filter and control patients. Our data do not support the routine use of a leucocyte depleting arterial line filter during clinical perfusion in patients undergoing elective aortocoronary bypass surgery.

Aged↗