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Biomedical subjects

A E Abdelmeguid

Publications and source records attributed to A E Abdelmeguid.

10 recordsLinked to original sources
PubMed1998

Myonecrosis after revascularization procedures.

The detection of elevated cardiac enzyme levels and the occurrence of electrocardiographic (ECG) abnormalities after revascularization procedures have been the subject of recent controversy. This report represents an effort to achieve a consensus among a group of researchers with data on this subject. Creatine kinase (CK) or CK-MB isoenzyme (CK-MB) elevations occur in 5% to 30% of patients after a percutaneous intervention and commonly during coronary artery bypass graft surgery (CABG). Although Q wave formation is rare, other ECG changes are common. The rate of detection is highly dependent on the intensity of enzyme and ECG measurement. Because most events occur without the development of a Q wave, the ECG will not definitively diagnose them; even the ECG criteria for Q wave formation signifying an important clinical event have been variable. At least 10 studies evaluating > 10,000 patients undergoing percutaneous intervention have demonstrated that elevation of CK or CK-MB is associated not only with a higher mortality, but also with a higher risk of subsequent cardiac events and higher cost. Efforts to identify a specific cutoff value below which the prognosis is not impaired have not been successful. Rather, the risk of adverse outcomes increases with any elevation of CK or CK-MB and increases further in proportion to the level of intervention. This information complements similar previous data on CABG. Obtaining preprocedural and postprocedural ECGs and measurement of serial cardiac enzymes after revascularization are recommended. Patients with enzyme levels elevated more than threefold above the upper limit of normal or with ECG changes diagnostic for Q wave myocardial infarction (MI) should be treated as patients with an MI. Patients with more modest elevations should be observed carefully. Clinical trials should ensure systematic evaluation for myocardial necrosis, with attention paid to multivariable analysis of risk factors for poor long-term outcome, to determine the extent to which enzyme elevation is an independent risk factor after considering clinical history, coronary anatomy, left ventricular function and clinical evidence of ischemia. In addition, tracking of enzyme levels in clinical trials is needed to determine whether interventions that reduce periprocedural enzyme elevation also improve mortality.

Angioplasty, Balloon, Coronary↗
PubMed1997

New technique for stent jail: another niche for the rotablator.

We report the treatment of a jailed side branch using the Rotablator. Initial attempts at passing various low profile balloons in the jailed branch were unsuccessful. The Rotablator allowed access to the side branch, which was stented with a single Palmaz-Schatz stent, providing excellent angiographic and 9 months follow-up results.

Angioplasty, Balloon, Coronary↗
PubMed1996

Significance of mild transient release of creatine kinase-MB fraction after percutaneous coronary interventions.

BACKGROUND: The clinical significance of minor elevations in creatine kinase-myocardial band isoenzyme (CK-MB) after coronary interventions has not been systematically evaluated. METHODS AND RESULTS: We examined 4484 patients who underwent successful percutaneous transluminal coronary angioplasty or directional coronary atherectomy and whose peak CK levels did not exceed twice the upper limit of laboratory normal. Group 1 (3776 patients) had no CK or MB elevation after the procedure (ie, CK < or = 180 IU/L, with MB fraction < or = 4%). Group 2 (450 patients) had a peak CK level between 100 and 180 IU/L, with MB fraction > 4%, and group 3 (258 patients) had a peak CK level between 181 and 360 IU/L, with MB fraction > 4%. The strongest correlate of postprocedure CK-MB elevation was the performance of directional coronary atherectomy (odds ratio, 4.1; P < .0001), followed by the development of > or = 1 in-1ab minor procedural complication (odds ratio, 2.6; P < .0001). Clinical follow-up was available in 4461 patients (99.5%), with a mean duration of 36 +/- 22 months. Survival analysis, adjusted with Cox proportional hazards regression model, showed that the groups with elevated CK-MB had a significantly higher incidence of cardiac death (risk ratio, 1.3; P = .04) and myocardial infarction (risk ratio, 1.3; P = .03). Major ischemic complications (death, myocardial infarction, and coronary revascularization) occurred more frequently in the groups with increased CK-MB (groups 1 versus 2 versus 3, 37.3% versus 43.3% versus 48.9%; P = .01). CONCLUSIONS: This study shows that minor elevations of CK-MB after successful coronary interventions identify a population with a worse long-term prognosis compared with patients with no enzyme elevations and appear to have an adverse effect on long-term prognosis. Future studies of percutaneous coronary revascularization should include routine measurements of biochemical cardiac markers as important predictors of long-term prognosis.

Angioplasty, Balloon, Coronary↗
PubMed1996

Defining the appropriate threshold of creatine kinase elevation after percutaneous coronary interventions.

The threshold of creatine kinase elevation after coronary interventions has been set at levels ranging in different studies from 2 to > 5 times the laboratory's upper limit of normal. This high variability is caused by the absence of any systematic evaluation of the prognostic implications of cardiac-enzyme elevation in this setting. This study was undertaken to evaluate the clinical, morphologic, and procedural correlates, and the long-term follow-up of two commonly used thresholds of creatine kinase (CK) elevation after successful percutaneous coronary interventions, in an attempt to define the level of postprocedural cardiac enzymes that correlates with adverse clinical outcome. We examined 4664 consecutive patients who underwent successful coronary angioplasty or directional atherectomy at the Cleveland Clinic. Group I (4480 patients) had CK > or = 2 times control levels after the procedure (i.e., < or = 360 IU/L). Group II (123 patients) had a peak level between 361 and 900 IU/L, and group III (61 patients) had a peak level >900 IU/L with positive myocardial isoenzymes (CK-MB > 4%). Elevation of cardiac enzymes was associated with distinct clinical, morphologic, and procedural characteristics, including coronary embolism, recent infarction, transient in-laboratory closure, hemodynamic instability, vein graft procedures, and large dissections. Clinical follow-up was available in 4644 (99.6%) patients, with a mean follow-up of 36 +/- 22 months. Kaplan-Meier survival analysis adjusted with Cox proportional hazards regression model showed that cardiac-enzyme elevation was an important correlate of cardiac death (risk ratio, 2.19; p < 0.0001). The groups with elevated cardiac enzymes had a higher incidence of cardiac death compared with group I (p < 0.0001). There was also a trend toward more cardiac hospitalizations in the same groups (p = 0.15). The incidence of cardiac death and cardiac hospitalization on follow-up was not different between groups II and III, This study shows that CK elevations between 2 and 5 times control values after successful coronary interventions are associated with an adverse long-term outcome. The findings suggest that an appropriate CK threshold that has prognostic implications would be twice the upper limit of normal.

Angioplasty, Balloon, Coronary↗
PubMed1995

Long-term outcome of transient, uncomplicated in-laboratory coronary artery closure.

BACKGROUND: Successful reversal of abrupt vessel closure without resultant major ischemic complications (death, Q-wave myocardial infarction, or coronary artery bypass graft surgery) is achieved in nearly half of all cases of abrupt vessel closure. The long-term outcome of these patients has not been previously addressed, and it is not clear whether they have a different prognosis than that of patients who have a successful procedure not associated with transient vessel closure. METHODS AND RESULTS: We examined 4863 consecutive patients who underwent successful percutaneous transluminal coronary angioplasty (PTCA) or directional coronary atherectomy (DCA). Eighty-eight patients had an uncomplicated, successfully reversed transient in-laboratory vessel closure (group 2) and were compared with 4775 patients who had a successful procedure not associated with transient in-laboratory closure (group 1). Clinical follow-up was available in 4839 patients (99.5%), with a mean duration of 41 +/- 23 months (range, 1 to 104 months). Survival analysis showed that successfully treated, uncomplicated transient vessel closure per se does not have an adverse effect on long-term prognosis (death, myocardial infarction, or coronary interventions). However, when the procedure (PTCA or DCA) was associated with an increase in creatine kinase-MB (CK-MB), there was a significant adverse effect on long-term outcome. By multivariate logistic regression, an increase in postprocedure CK-MB was the most significant correlate for cardiac death (risk ratio, 1.25; P < .0001). An increase in CK-MB was also the most important correlate for major ischemic complications (death, infarction, or coronary interventions) on follow-up (risk ratio, 1.08; P = .0005). CONCLUSIONS: Transient, uncomplicated in-laboratory vessel closure per se does not have an adverse long-term effect. However, a concomitant elevation of postprocedure cardiac enzymes has an important and significant adverse effect on long-term outcome. This study suggests that periprocedural creatine kinase isoenzyme determination in patients experiencing in-laboratory coronary closure has important prognostic implications.

Angioplasty, Balloon, Coronary↗
PubMed1994

Directional coronary atherectomy in unstable angina.

OBJECTIVES: To determine whether excision of complex, ulcerated plaque improves the risk of patients with unstable angina to the level of those with stable angina, the results of directional coronary atherectomy were compared in patients with these two syndromes. BACKGROUND: The procedural results of angioplasty in the setting of unstable angina are not as favorable as those observed for chronic stable angina, presumably because thrombus-associated plaque augments the risk of abrupt closure. METHODS: Two hundred eighty-seven consecutive patients who had undergone directional atherectomy for a single new stenosis were studied. Seventy-seven patients had stable angina (Group I); 110 patients had progressively worsening angina in the absence of rest or postinfarction angina (Group II); and 100 patients had rest or postinfarction angina, or both (Group III). RESULTS: Major ischemic complications (death, Q wave infarction, emergency bypass surgery) occurred more frequently in Group III (1.3% [Group I] vs. 0.9% [Group II] vs. 7% [Group III], p = 0.036). This difference was largely due to a higher incidence of emergency surgery in Group III (1.3% [Group I] vs. 0% [Group II] vs. 5% [Group III], p = 0.05). Clinical follow-up was obtained in 97% of successful procedures for a mean follow-up period of 22 months (range 9 to 52) and revealed a higher incidence of hospital admission for angina (p = 0.05) and a trend toward more bypass surgery (p = 0.09) and myocardial infarction (p = 0.16) in Group III. There was no difference in repeat percutaneous interventions among the three groups (range 19% to 24%, p = 0.75). CONCLUSIONS: These results show that the definition of unstable angina is important in determining the immediate outcome of directional atherectomy. In the absence of rest or postinfarction angina, the immediate results are not significantly different from those obtained in stable angina. Our results also suggest that both the immediate and short-term outcome in unstable angina are not greatly influenced by atherectomy but more so by the pathophysiology of unstable angina, which increases the complications of percutaneous interventions.

Analysis of Variance↗
PubMed1994

Temporary stents: the ACS RX flow support catheter.

Although permanent stents have been successfully used as bail-out devices in the treatment of abrupt occlusion, the risk of stent thrombosis and of bleeding complications, as well as the cost of a prolonged hospitalization, have been deterrents to their universal acceptance. Temporary stents were conceived to provide internal scaffolding of the coronary arteries, which could stabilize occlusive dissections, yet still allow the stent to be removed before the time of peak incidence of subacute thrombosis. The ACS RX flow support catheter is a prototype temporary stent which has been recently evaluated in phase I and II clinical trials. The device is effective in improving angina score, coronary flow, and decreasing residual stenosis when used in cases of suboptimal percutaneous interventional results. However, the incidence of major complications and the need for adjunctive percutaneous interventions remain significant. Further studies are needed to define the optimal time of cage expansion as well as the clinical, anatomical, and procedural factors that predict efficacy and safety of this new device.

Aged↗
PubMed1994

Effect of low perfusate [Ca2+] and diltiazem on cardiac sarcoplasmic reticulum in myocardial stunning.

The ability of low perfusate Ca2+ concentration ([Ca2+]) or diltiazem to improve sarcoplasmic reticulum (SR) function and mechanical performance after ischemia-reperfusion was investigated using an isovolumic Langendorff preparation. SR function was evaluated by the oxalate-supported Ca2+ uptake rates of ventricular homogenates. Influx of Ca2+ was estimated from the rate of Ca2+ uptake in the presence of high concentrations of ryanodine (500 microM) to close the Ca2+ efflux channel. Ca2+ efflux under the assay conditions was estimated as the difference in Ca2+ uptake rate in the presence and absence of ryanodine. Ten and fifteen min of global, normothermic ischemia decreased the Ca2+ uptake rate in the presence of ryanodine, suggesting that Ca2+ influx was decreased. The effect of ischemia on Ca2+ influx was not altered by preperfusion with low [Ca2+] (0.2 mM) or with 1.0 microM diltiazem. Ischemia decreased SR Ca2+ uptake rate twice as much in the absence of ryanodine as in its presence, indicating an increased efflux of Ca2+. This increased efflux was reduced by preperfusion with either low [Ca2+] or diltiazem. The decreased Ca2+ influx was completely reversed by 15 min of reperfusion, whereas the increased Ca2+ efflux was only partially reversed. These results indicate that ischemia exerts independent effects on the SR Ca2+ influx and efflux pathways. The results also suggest that one site of cardiac protection by low [Ca2+] or diltiazem is the ryanodine-sensitive Ca2+ efflux pathway of the SR, rather than the Ca2+ influx pathway.

Animals↗
PubMed1992

Effect of perfusate [Ca2+] on cardiac sarcoplasmic reticulum Ca2+ release channel in isolated rat hearts.

The effect of perfusate [Ca2+] on the function of cardiac sarcoplasmic reticulum (CSR) was assessed by the oxalate-supported Ca2+ uptake rate of ventricular homogenates of isolated rat hearts maintained in a modified Langendorff preparation. The total Ca2+ pumping activity of the CSR was determined by using 20 microM ruthenium red or 625 microM ryanodine to close the CSR Ca2+ release channel. The homogenate Ca2+ uptake rate in the absence of ruthenium red or ryanodine decreased progressively with increasing perfusate [Ca2+] (25.7 +/- 1.2, 21.4 +/- 1.5, 17.2 +/- 1.1, and 16.3 +/- 1.2 [mean +/- SEM] nmol Ca2+.min-1.mg-1 for hearts perfused for 5 minutes with 0.2, 1.4, 2.8, and 5.6 mM Ca2+, respectively; p = 0.0001; n = 8). This depression was not observed when Ca2+ uptake was assayed in the presence of ryanodine or ruthenium red. Since the Ca2+ uptake in the presence of ryanodine or ruthenium red is determined by the Ca(2+)-ATPase, this result suggests that perfusion with varying [Ca2+] did not affect the Ca(2+)-ATPase. The observed decrease in Ca2+ uptake in the absence of ryanodine or ruthenium red is caused by an increased efflux through the ryanodine-sensitive Ca2+ release channel. When hearts perfused for 5 minutes with 0.2 or 5.6 mM Ca2+ were reperfused for 10 minutes with 1.4 mM Ca2+, homogenate Ca2+ uptake rates were restored to near control levels. These effects of perfusate Ca2+ were not direct effects, because changes in the [Ca2+] of the homogenization medium did not alter the homogenate Ca2+ uptake activity in either the presence or absence of ryanodine. The homogenate Ca2+ uptake rates were unaffected by prior active loading of the CSR with Ca2+. These results suggest a regulatory role of perfusate Ca2+ in increasing the open state of the ryanodine-sensitive Ca2+ release channel that is distinct from the beat-to-beat regulation of Ca2+ release from the CSR by Ca2+ (Ca(2+)-induced Ca2+ release).

Adenosine Triphosphate↗