Stephan Willems

University of Hamburg, Hamburg, Hamburg, Germany

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Publications (288)1144.42 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Different follow-up methods have been used to report success rates after AF ablation. Recent studies have shown that intermittent rhythm monitoring underestimates the actual AF recurrence rate. We therefore report our experience with continuous rhythm monitoring by implantable loop recorder (ILR) in a large patient cohort. Between 09/2008 and 12/2012, 343 cardiac surgical patients underwent concomitant surgical AF ablation. ILR implantation was performed in 206 patients. ILR interrogation was accomplished at 3, 6 and 12 months postoperatively. Successful ablation was defined as AF Burden <0.5 %. Primary outcome of the study was freedom from AF at 12-month follow-up. Mean patient's age was 70.5 ± 7.4 years. No major ablation- or ILR-related complications occurred. In 4 patients (1.9 %) ILR had to be explanted due to ILR-related wound infection (n = 2) or chronic pain (n = 2). Survival rate at 1-year follow-up was 96.6 %. Freedom from AF rate after 1-year follow-up was 68.5 and 63.6 % off antiarrhythmic drugs, respectively. Statistically significant predictors for successful ablation at 1-year follow-up were smaller LA diameter, shorter duration of AF and preoperative paroxysmal AF. Demographic data, indication for surgery, lesion set and used energy source had no impact on freedom from AF after 1 year. Continuous ILR monitoring after concomitant surgical AF ablation was safe and feasible, with registered freedom from AF rate of 68.5 % at 1-year follow-up. Thus continuous rhythm monitoring provides reliable outcome data and helps to guide antiarrhythmic therapy.
    Heart and Vessels 08/2015; DOI:10.1007/s00380-015-0735-4 · 2.11 Impact Factor
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    ABSTRACT: Catheter ablation is increasingly used to manage atrial fibrillation, but arrhythmia recurrences are common. Adenosine might identify pulmonary veins at risk of reconnection by unmasking dormant conduction, and thereby guide additional ablation to improve arrhythmia-free survival. We assessed whether adenosine-guided pulmonary vein isolation could prevent arrhythmia recurrence in patients undergoing radiofrequency catheter ablation for paroxysmal atrial fibrillation. We did this randomised trial at 18 hospitals in Australia, Europe, and North America. We enrolled patients aged older than 18 years who had had at least three symptomatic atrial fibrillation episodes in the past 6 months, and for whom treatment with an antiarrhythmic drug failed. After pulmonary vein isolation, intravenous adenosine was administered. If dormant conduction was present, patients were randomly assigned (1:1) to additional adenosine-guided ablation to abolish dormant conduction or to no further ablation. If no dormant conduction was revealed, randomly selected patients were included in a registry. Patients were masked to treatment allocation and outcomes were assessed by a masked adjudicating committee. Patients were followed up for 1 year. The primary outcome was time to symptomatic atrial tachyarrhythmia after a single procedure in the intention-to-treat population. The trial is registered with ClinicalTrials.gov, number NCT01058980. Adenosine unmasked dormant pulmonary vein conduction in 284 (53%) of 534 patients. 102 (69·4%) of 147 patients with additional adenosine-guided ablation were free from symptomatic atrial tachyarrhythmia compared with 58 (42·3%) of 137 patients with no further ablation, corresponding to an absolute risk reduction of 27·1% (95% CI 15·9-38·2; p<0·0001) and a hazard ratio of 0·44 (95% CI 0·31-0·64; p<0·0001). Of 115 patients without dormant pulmonary vein conduction, 64 (55·7%) remained free from symptomatic atrial tachyarrhythmia (p=0·0191 vs dormant conduction with no further ablation). Occurrences of serious adverse events were similar in each group. One death (massive stroke) was deemed probably related to ablation in a patient included in the registry. Adenosine testing to identify and target dormant pulmonary vein conduction during catheter ablation of atrial fibrillation is a safe and highly effective strategy to improve arrhythmia-free survival in patients with paroxysmal atrial fibrillation. This approach should be considered for incorporation into routine clinical practice. Canadian Institutes of Health Research, St Jude Medical, Biosense-Webster, and M Lachapelle (Montreal Heart Institute Foundation). Copyright © 2015 Elsevier Ltd. All rights reserved.
    The Lancet 07/2015; DOI:10.1016/S0140-6736(15)60026-5 · 45.22 Impact Factor
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    ABSTRACT: Marfan syndrome (MFS) is associated with a substantial risk for ventricular arrhythmia and sudden cardiac death (SCD). We used heart rate turbulence (HRT) and deceleration capacity (DC), to evaluate the risk stratification for these patients. We enrolled 102 patients [45 male (44.1 %), age 40.5 ± 14.6 years] with MFS. Blood samples were obtained to determine N-terminal pro-brain natriuretic peptide (NT-proBNP) levels. Transthoracic echocardiography studies were conducted to evaluate heart function parameters and a 24-h holter ECG was performed. An analysis of two HRT parameters, turbulence onset (TO) and turbulence slope (TS), and DC was performed. Therefore, optimal cut-off values were calculated. Primary endpoint was the combination of SCD, ventricular arrhythmia and arrhythmogenic syncope. Secondary endpoint was total mortality. During a follow-up of 1145 ± 491 days, 12 (11.7 %) patients reached the primary and 8 (7.8 %) patients the secondary endpoint. Patients reaching the primary were significantly older, had a higher burden of premature ventricular complexes and NT-proBNP levels and lower values of LVEF, DC and HRT TS. Multivariate analysis identified NT-proBNP (HR 1.25, 95 % CI 1.01-1.56, p = .04) and the abnormal HRT (abnormal TS and/or TO (HR 7.04, 95 % CI 1.07-46.27, p = .04) as independent risk predictor of arrhythmogenic events. Patients with Marfan syndrome are at risk for severe ventricular arrhythmias and SCD. Abnormal HRT parameters and NT-proBNP values are independent risk factors for arrhythmogenic events and SCD. The assessment of these tools may help predicting SCD patients with MFS.
    Clinical Research in Cardiology 06/2015; DOI:10.1007/s00392-015-0873-9 · 4.56 Impact Factor
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    ABSTRACT: Dual atrioventricular nodal non-re-entrant tachycardia (DAVNNT), also known as 'double fire', has recently received more attention since it was demonstrated to mimic more common arrhythmias such as atrial premature beats, atrial fibrillation, and ventricular tachycardia. This is important, since mistaken differential diagnoses and the resulting therapeutic decisions have severe consequences for affected patients. DAVNNT is characterized by conduction characteristics of the atrioventricular (AV) node that leads to a double antegrade conduction of one sinoatrial nodal activity via the slow and fast AV nodal pathways. As a result, the most significant hint from an electrocardiogram (ECG) is a P wave followed by two narrow QRS complexes. Although DAVNNT is rather a rare arrhythmia, it now appears to be more common than previously thought. To date, 68 cases including 3 small single-centre observational studies accumulated over the last 5 years have demonstrated the feasibility and safety of radiofrequency catheter ablation for DAVNNT. Catheter ablation treats this arrhythmia effectively by modifying or eliminating slow pathway function. Here, we review the current state of DAVNNT knowledge systematically and address current challenges presented by this 'ECG chameleon from the AV node'. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.
    Europace 04/2015; DOI:10.1093/europace/euv056 · 3.05 Impact Factor
  • The Journal of Heart and Lung Transplantation 04/2015; 34(4):S206. DOI:10.1016/j.healun.2015.01.565 · 5.61 Impact Factor
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    ABSTRACT: Recently, a new image integration module (IIM, CartoUnivu™ Module) has been introduced to combine and merge fluoroscopy images with 3-dimensional-(3D)-electroanatomical maps (Carto® 3 System) into an accurate 3D view. The aim of the study was to investigate the influence of IIM on the fluoroscopy exposure during pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) in a prospective randomized trial. Between June and November 2014, a total of 60 patients with PAF (73.3% male, 64.0 ± 9.2 years), who underwent PVI with the endpoint of unexcitability of the ablation line, were randomized to either a conventional 3D mapping system (Carto® 3 System) or to an additional IIM on the basis of an assumed reduction of fluoroscopy exposure by the use of IIM. There were no significant differences in baseline characteristics. The median ablation procedure time was identical in both groups (140.7 ± 27.8 vs. 140.8 ± 39.5 minutes; P = 0.851). A significant decrease of mean fluoroscopy time from 11.9 ± 2.1 to 7.4 ± 2.6 minutes (P < 0.0006) and median fluoroscopy dose from 882.9 to 476.5 cGycm(2) (P < 0.001) was achieved. The main reduction of radiation could be realized during creation of the 3D-map. No major complications occurred during the procedures. After a median follow-up of 125.7 ± 45.6 days 80% of the patients were free from any atrial arrhythmias. CartoUnivu™ module easily integrates into the workflow of PVI with the endpoint of unexcitability of the ablation line without prolonging the procedure time. It is associated with a marked reduction in fluoroscopic dose when compared to a conventional 3D mapping system. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    Journal of Cardiovascular Electrophysiology 03/2015; 26(7). DOI:10.1111/jce.12673 · 2.88 Impact Factor
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    ABSTRACT: -In the meantime, catheter ablation (CA) is widely used for the treatment of persistent (pers) atrial fibrillation (AF). There is a paucity of data regarding long-term outcomes. This study evaluates (1) 5 year -single and multiple procedure success and (2) prognostic factors for arrhythmia recurrences after CA of persAF using the "stepwise approach" aiming at AF termination. -549 patients (pts) with persAF underwent de novo CA using the "stepwise approach" (2007-2009). 493 pts were included (holter-ecgs≥every 6 mo). Mean FU was 59±16 mo with 2.1±1.1 procedures/pt. Single and multiple procedure success rates were 20.1% and 55.9%, respectively (80% off AAD). AAD free multiple procedure success was 46%. Long-term recurrences (n=171) were paroxysmal AF in 48 pts (28%) and persAF/atrial tachycardia in 123 pts (72%). Multivariable recurrent event analysis revealed the following factors favoring arrhythmia recurrence: failure to terminate AF during index procedure (HR: 1.279; 95%CI [1.093-1.497]; p=0.002), number of procedures (HR: 1.154; 95% CI [1.051-1.267]; p=0.003), female sex (HR: 1.263; 95% CI [1.027-1.553]; p=0.027) and presence of a structural heart disease (HR: 1.236; 95% CI [1.003-1.524]; p=0.047. AF termination, was correlated with a higher rate of consecutive procedures due to AT recurrences (p=0.003, HR 1.71 95% CI [1.20-2.43] CONCLUSIONS: -CA of persAF using the "stepwise approach" provides limited long term freedom of arrhythmias often requiring multiple procedures. AF termination, the number of procedures, gender and the presence of structural heart disease correlate with outcome success. AF termination is associated with consecutive AT procedures.
    Circulation Arrhythmia and Electrophysiology 03/2015; 8(2). DOI:10.1161/CIRCEP.114.001672 · 5.42 Impact Factor
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    ABSTRACT: Catheter ablation (CA) of ventricular tachycardia (VT) is an important treatment option in patients with structural heart disease (SHD) and implantable cardioverter defibrillator (ICD). A subset of patients requires epicardial CA for VT.
    International Journal of Cardiology 03/2015; 182. DOI:10.1016/j.ijcard.2014.12.003 · 6.18 Impact Factor
  • M Antz · S Willems · B A Hoffmann
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    ABSTRACT: In addition to treatment with drugs to control the rate and rhythm, the method of catheter ablation is a cornerstone in the treatment of atrial fibrillation. Another crucial part in treating patients with atrial fibrillation is an adequate oral anticoagulation. Apart from the vitamin K antagonists (VKA) phenprocoumon and warfarin, the direct oral anticoagulants (DOAC) apixaban, dabigatran and rivaroxaban have been approved for oral anticoagulation of patients with atrial fibrillation. As a result there are different potential treatment possibilities for pre-interventional, peri-interventional and post-interventional anticoagulation in the setting of catheter ablation for atrial fibrillation. Due to increasing clinical experience with DOAC and the increasing number of atrial fibrillation ablations worldwide, peri-interventional treatment strategies are continuously changing. Therefore, the current article discusses current standards and gives practical guidance.
    Herz 02/2015; 40(1). DOI:10.1007/s00059-014-4196-9 · 0.91 Impact Factor
  • The Thoracic and Cardiovascular Surgeon 01/2015; 63(S 01). DOI:10.1055/s-0035-1544273 · 1.08 Impact Factor
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    The Thoracic and Cardiovascular Surgeon 01/2015; 63(S 01). DOI:10.1055/s-0035-1544301 · 1.08 Impact Factor
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    ABSTRACT: Atrial fibrillation (AF) is the most common cause of ischemic stroke. Recent data suggest that AF patients after successful ablation have the same risk for thromboembolic events (TE) as patients without AF. Despite current guideline recommendations it is still under debate if oral anticoagulation (OAC) can be safely discontinued after ablation. We analyzed follow-up (FU) after ablation of paroxysmal AF (PAF) in a high- (previous stroke; group 1) and a low-risk group (no previous stroke; group 2) based on data from the German Ablation Registry to reveal real-life prescription behavior. Overall 29 centers in Germany participated by performing AF-ablation. Between April 2008 and April 2011, 83 patients in group 1 and 377 patients in group 2 with a first ablation of PAF were included in the registry. Mean CHA2DS2-VASc-Score was 4.2 ± 1.4 (group 1) vs. 1.6 ± 1.2 (group 2) (p < 0.0001). No peri-interventional TE was observed. Arrhythmia recurrence was seen in 47.4 vs. 48.4 % (p = 0.79) during a median FU of 489 (453-782) days, resulting in a repeat procedure in 20.0 vs. 20.7 % (p = 0.88), respectively. OAC was discontinued in 38.6 % in group 1 vs. 66.3 % in group 2 (p < 0.0001) during FU. TE during FU occurred more often in group 1 than in group 2 (4.3 vs. 0.3 %, p < 0.05). Even in patients with previous stroke, OAC was frequently discontinued during FU after PAF ablation in this observational study. However, TE occurred significantly more frequent in these high-risk patients. These data argue against OAC discontinuation after ablation in patients with previous stroke.
    Clinical Research in Cardiology 12/2014; 104(6). DOI:10.1007/s00392-014-0804-1 · 4.56 Impact Factor
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    ABSTRACT: Atrial arrhythmias lower the biventricular pacing percentage in cardiac resynchronization therapy (CRT) treated patients (pts) and have a high prevalence in this population. External electrical cardioversion (ECV) is commonly performed to restore sinus rhythm. There is a paucity of data on the safety and efficacy of ECV in pts with CRT devices. Forty-three pts with CRT devices undergoing ECV at two centers were included prospectively. Devices were interrogated immediately prior to and after ECV, as well as after 4 weeks. Devices (CRT-D in 38 and CRT-P in 5) were all implanted in left pectoral position, with predominantly bipolar left ventricular (LV) leads. Sixty-one shocks were delivered, all biphasic. Arrhythmia had recurred in 36 % of pts at follow-up (FU). There was a significant increase in LV lead threshold voltage and drop in bipolar LV lead impedance after ECV, which returned to normal at FU. An at least twofold increase in pacing threshold voltage at FU was seen in 2 LV leads and a 0.5 V increase in threshold in 3 LV leads. Overall, biventricular pacing significantly increased during FU. ECV in CRT pts was safe and effective in this two-center study. A transient increase in LV lead pacing threshold was observed. Relevant changes in pacing threshold at FU occurred in five LV leads-identification and regular FU of these pts are necessary. Restoring SR through ECV significantly increased the biventricular pacing percentage but arrhythmia recurrence was frequent. CRT pts with atrial arrhythmias require close FU after ECV.
    Clinical Research in Cardiology 12/2014; 104(5). DOI:10.1007/s00392-014-0800-5 · 4.56 Impact Factor
  • The American Journal of Cardiology 10/2014; 115(1). DOI:10.1016/j.amjcard.2014.10.002 · 3.43 Impact Factor
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    ABSTRACT: Aims: The FREEZE-cohort study (NCT 01360008) is a prospective observational, multicenter and multinational study to evaluate safety and effectiveness of cryoballoon ablation for pulmonary vein isolation as compared to radiofrequency ablation in patients with paroxysmal or persistent atrial fibrillation (lasting <one year) under the conditions of clinical routine. Methods and Results: The study started in 2011 and anticipates inclusion up to 2000 patients in each of the two treat-ment groups. A total of 37 centers from 8 countries worldwide, all experienced in at least one of the two ablation techniques, participate in the study. The primary outcome parameter of the study is defined as atrial fibrillation recurrence rate during twelve months of follow-up. Secondary out-come parameters include primary success rates, complication rates in general, specific complica-tions with respect to phrenic nerve palsy and pulmonary vein stenosis, radiation exposure, clinical course including death and repeat ablation. Finally specific procedural aspects will be evaluated in a descriptive manner. Preliminary data of the first 1882 patients show that in clinical practice cryoablation is preferentially performed in patients with paroxysmal atrial fibrillation, whereas application of radiofrequency ablation is equally distributed between patients with persistent and paroxysmal atrial fibrillation. Conclusion: Based on multi-center and multi-national data the FREEZE-cohort study will provide important information on long-term efficacy, clinical effective-ness, complication rates and procedural differences between atrial fibrillation patients treated with either cryoablation or radiofrequency ablation.
    International Journal of Clinical Medicine 10/2014; 5(19):1161-1172. DOI:10.4236/ijcm.2014.519149
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    ABSTRACT: Background: Catheter ablation (CA) for atrial fibrillation (AF) is an effective therapeutic option for the treatment of symptomatic drug-refractory AF. According to current guidelines, the prevention of stroke and embolism is the most important therapeutic goal in AF and the recommendations for anticoagulation (OAC) after successful CA are based upon the CHA2DS2-VASc-Score 3. The aim of this study was to evaluate the use of OAC in patients with a high risk for thromboembolic events 1 year after CA and to identify predictor variables for discontinuation of OAC. Methods: Between January 2007 and January 2010 13092 patients were enrolled in the study. A total of 52 German electrophysiological centers agreed to participate in this prospective multicenter registry. 41 centers included patients undergoing CA for AF. Analysis included patients who were discharged with OAC after CA and had a CHA2DS2-VASc-Score ≥ 2. A centralized 1 year follow-up (FU) was conducted via telephone. Results: 1300 patients fulfilled the inclusion criteria. One year after CA 51.8 % of these patients were on OAC. Factors significantly associated with discontinuation of OAC included no AF recurrence in FU (adjusted odds ratio (OR): 2.14, [95 % confidence interval (CI): 1.73-2.66], P < 0.001) and paroxysmal AF (OR: 1.53 [95 % CI: 1.29-1.81], P < 0.001). Factors associated with continuation of OAK were patient age (OR per 10 years: 0.79 [95 % CI: 0.68-0.91], P = 0.002), valvular heart disease (OR: 0.67 [95 % CI: 0.48-0.92], P = 0.013), an implanted pacemaker, defibrillator or a cardiac resynchronization therapy system (OR: 0.55 [95 % CI: 0.41-0.74], P < 0.001) and neurological events in hospital or during FU (OR: 0.40 [95 % CI: 0.18-0.88], P < 0.022). Conclusion: Almost half of the patients with an indication for OAC are not adequately anticoagulated one year after CA for AF. Paroxysmal AF or freedom from AF is significantly associated with discontinuation of OAC.
    DMW - Deutsche Medizinische Wochenschrift 09/2014; 139(39):1923-1928. DOI:10.1055/s-0034-1387316 · 0.55 Impact Factor
  • A Sultan · J Lüker · S Willems · D Steven
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    ABSTRACT: History and admission findings: A 62-year-old woman presented with history of repeat syncope and palpitations. She experienced aggravation of symptoms within the last few months. At referring hospital a ventricular tachycardia was already inducible during electrophysiological study. The patient was transferred to our hospital for VT ablation vs. ICD implantation. Investigation: No evidence for structural heart disease was revealed during TTE nor was a coronary heart disease detectable during coronary angiography, only hypertension was verifiable. No ICD implantation so far. Treatment and course: The patient underwent repeat EP study at our facility with induction of VT. Pace-mapping and mapping for earliest ventricular activation was performed. The middle-cardiac vein was revealed as site of earliest ventricular activation (50 ms) and good pace-map. Therefore, radiofrequency ablation at this site terminated successfully VT into sinus rhythm. Conclusion: Ablation of epicardial VT foci is successfully feasible via coronary sinus. With regard to typical ECG parameters an epicardial foci may be assumed precociously. The great cardiac vein is one of the most common sites of origin for epicardial foci, however, VT partially may originate from the crux cordis which is accessible for ablation via the middle cardiac vein with good ablation results.
    DMW - Deutsche Medizinische Wochenschrift 09/2014; 139(39):1929-1931. DOI:10.1055/s-0034-1387311 · 0.55 Impact Factor
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    ABSTRACT: Vascular reflex mechanisms contribute to vasovagal syncope. However, the alterations in central haemodynamics in patients with vasovagal syncope are unknown. 30 consecutive patients (36.5 ± 15 years, 14 females) with recurrent vasovagal syncope (VVS) and a positive tilt table test were compared to 39 age- and sex-matched controls (36.9 ± 16 years, 15 females) with a negative tilt table result and no history of syncope. Central aortic pressure parameters including augmentation index and central pulse pressure as markers of aortic stiffness were generated non-invasively by applanation tonometry of the radial artery and use of a validated mathematical transfer function. No difference in aortic augmentation index was observed between groups. (VVS 9 ± 2.6 vs. Control 11 ± 2.4, p = 0.8). However, in patients with vasovagal syncope the aortic pressure waveform significantly differed from healthy controls. A prolonged time to the peak of aortic pressure wave (aortic T2) was observed in patients with vasovagal syncope (226 ± 24 vs. 208 ± 21 ms, p = 0.001). Furthermore time to the first shoulder of the aortic pressure wave (aortic T1) was slightly shorter compared to healthy controls, but did not reach statistical significance (106 ± 22 vs. 110 ± 12 ms, p = 0.33). Patients with vasovagal syncope have an altered aortic pressure waveform at rest, but no signs of elevated aortic stiffness. The underlying mechanisms for these findings may potentially result from a complex imbalance of the autonomic nervous system with a continuous deregulation of the sympathetic and parasympathetic reflex arcs.
    Heart and Vessels 08/2014; DOI:10.1007/s00380-014-0576-6 · 2.11 Impact Factor
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    ABSTRACT: Background Ablation of premature ventricular contractions (PVC) can be challenging due to infrequent spontaneous ectopy and the limitations subjective pacemapping (PM). Activation mapping (AM) provides an objective parameter, but relies on spontaneous ectopic activity. Objectives The objective of the study was to evaluate the correlation of automated template matching (TM) with activation timing and to investigate potential implications towards ablation success. Methods Forty Patients undergoing catheter ablation of idiopathic outflow tract VT or PVC in 47 procedures were included. PVC/VT origin was determined by PM and AM. A percentage value for PM was calculated using TM software and correlated with corresponding activation timing. Overall, 126 TM and corresponding AM values were analysed. All patients were followed (313 ± 158 days after ablation) including a 24-hour Holter ECG. Results A correlation between TM and activation timing (r = 0.66, p < 0.0001) could be shown. Success rate at follow up was 77%. No statistically significant coherence of TM percentage and relapse was observed. Conclusions Template matching correlates with activation timing in the process of mapping idiopathic focal PVC/VT. TM helps to objectify the process of PM and may therefore be helpful to guide successful ablation in the absence of spontaneous ectopy.
    IJC Heart and Vessels 08/2014; 4. DOI:10.1016/j.ijchv.2014.08.006
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    ABSTRACT: Atrial fibrillation is the most common form of arrhythmia worldwide and is associated with potentially severe complications. Apart from antiarrhythmic drug therapy, interventional treatment by catheter ablation has emerged as an effective and safe alternative notably for the paroxysmal form. The pulmonary veins (PV) have been identified as a major source in the setting of paroxysmal atrial fibrillation. Circumferential wide area PV isolation, optimization of procedural techniques and the positioning of an ablation line deep in the left atrium have contributed to the increased success rates; however, the procedure is still associated with potentially severe complications and should therefore be carried out in centers with sufficient case numbers and operators with corresponding training and experience.
    Herzschrittmachertherapie & Elektrophysiologie 07/2014; DOI:10.1007/s00399-014-0332-8

Publication Stats

3k Citations
1,144.42 Total Impact Points

Institutions

  • 2007–2015
    • University of Hamburg
      • • Department of Cardiology, Electrophysiology
      • • University Heart Center
      Hamburg, Hamburg, Germany
  • 1997–2015
    • University Medical Center Hamburg - Eppendorf
      • • Department of Cardiology, Electrophysiology
      • • Department of Cardiovascular Surgery
      Hamburg, Hamburg, Germany
  • 2011
    • CHU de Québec
      Quebec City, Quebec, Canada
    • Johannes Gutenberg-Universität Mainz
      Mayence, Rheinland-Pfalz, Germany
    • Institut für Interdisziplinäre Medizin Hamburg
      Hamburg, Hamburg, Germany
  • 2010
    • Ludwig-Maximilian-University of Munich
      • Department of Internal Medicine I
      München, Bavaria, Germany
  • 2009
    • Universitätsklinikum Münster
      • Department für Kardiologie und Angiologie
      Muenster, North Rhine-Westphalia, Germany
  • 1994–2007
    • University of Münster
      • Department of Cardiology and Angiology
      Muenster, North Rhine-Westphalia, Germany