Troponin I, troponin T, or creatine kinase-MB to detect perioperative myocardial damage after coronary artery bypass surgery

The anatomy of the labiomandibular fold was evaluated in a series of 12 fresh hemifacial cadaver dissections. The techniques of methylene blue dye injection, histologic evaluation, and gross dissection all confirm that the labiomandibular fold has distinct anatomic boundaries. The superior boundary is formed by the cutaneous insertion of the depressor anguli oris muscle at the labiomandibular crease. The inferior boundary is determined by the mandibular ligament, which has been previously described. The cutaneous insertion of the depressor muscle and the mandibular ligament act as relative points of fixation. The dynamic forces of both aging and facial animation act about these two points to create the typical appearance of the labiomandibular fold. This anatomy is consistent with that seen in other areas of the face such as the nasolabial and nasojugal folds, where the dermal insertion of muscle and/or fascia defines an anatomically distinct region. Clinically, this anatomy may suggest that a subcutaneous plane of dissection during the face lift procedure may allow manipulation and reduction of the fat that was noted lateral to the dermal insertion of the depressor anguli muscle. Subcutaneous dissection also avoids lateral pull on the platysma muscle, which may tend to accentuate and distort the labiomandibular crease due to its intimate association with the overlying depressor muscle.     

Cardiac markers in the early hours of acute myocardial infarction: clinical performance of creatine kinase, creatine kinase MB isoenzyme (activity and mass concentration), creatine kinase MM and MB subform ratios, myoglobin and cardiac troponin T

We compared early markers of acute myocardial infarction (AMI) in the first 6 h from the onset of symptoms in 133 non-traumatized patients arriving at the emergency department with chest pain suggestive of AMI. Clinical performance parameters were calculated on the basis of 45 patients with AMI and 88 patients with a non-AMI diagnosis. At admission and in the first 0-3 h after the onset of chest pain the creatine kinase-MB (CK-MB) subform ratio was the most sensitive test at a comparable specificity level of 0.95. In the time interval of 3-5 h, myoglobin, the CK-MB mass concentration and the CK-MB subform ratio were associated with the greatest areas under receiver operating characteristic (ROC) curves, but differences between these tests were small and non-significant. At 6 h from the onset of pain, differences in clinical performance between the same three tests were even smaller whether or not samples drawn after the start of thrombolytic treatment were included in the test comparison. For confirmation of AMI at 6 h after onset of pain, CK-MB (activity and mass concentration) demonstrated the highest positive likelihood ratio, and for exclusion of AMI at 6 h the CK-MB subform ratio was associated with the highest negative likelihood ratio. However, differences between the CK-MB subform ratio, CK-MB mass concentration and myoglobin were not significant as estimated by the substantial overlap between the confidence intervals of the likelihood ratios and the ROC areas at 6 h. Cardiac troponin T (cTnT) demonstrated an ROC area equal to the CK-MB isoform ratio and myoglobin at 6 h. However, the likelihood ratio for ruling out AMI was lower, mostly due to the elevated cTnT in unstable coronary disease not defined as AMI. We conclude that the CK-MB subform ratio, CK-MB mass concentration and myoglobin do not demonstrate any significant differences in clinical performance for ruling in or ruling out acute myocardial infarction at 6 h after the onset of chest pain.     

Comparison of myoglobin, creatine kinase-MB, and cardiac troponin I for diagnosis of acute myocardial infarction

Serial plasma concentrations of myoglobin, creatine kinase MB (CK-MB) isoenzyme, and cardiac troponin I (cTnI) were measured in 25 patients with a confirmed diagnosis of acute myocardial infarction (AMI), and 74 patients who were suspected of AMI but were subsequently ruled out for this diagnosis. The cutoff concentration for the cTnI assay was optimally determined to be 2.5 ng/mL. Of the three markers, myoglobin had the highest clinical sensitivity (50 percent) when blood was collected between 0 to 6 h after the onset of chest pain. Assays for all serum markers used had high clinical sensitivity (> 93 percent) 6 to 24 h after onset. The CK-MB remained highly sensitive for 48 h, while cTnI was sensitive for up to 72 h. Between 72 and 150 h, cTnI had a clinical sensitivity of 70 percent as compared to 21 percent and 18 percent for myoglobin and CK-MB, respectively. The clinical specificity of cTnI for non-AMI patients was equivalent to CK-MB and significantly higher than for myoglobin. The clinical efficiency of cTnI for all samples was better than either CK-MB or myoglobin, owing mainly to the wider diagnostic window. The specificity of cTnI for 59 patients with chronic renal failure, skeletal muscle trauma and disease was better than all of these markers including cardiac troponin T (cTnT). Results of this study show that cTnI is an effective marker for the retrospective diagnosis of AMI, and consideration should be given to its use in place of CK-MB.     

Comparison of serum myoglobin and creatine kinase MB isoenzyme in early diagnosis of acute myocardial infarction

We compared the clinical usefulness of serum myoglobin and creatine kinase MB (CK MB) isoenzyme determinations in the early diagnosis of acute myocardial infarction in 109 consecutive patients admitted to a coronary care unit. Of these, 37 patients were diagnosed as having definite infarction, three possible infarction, and 69 no infarction, using World Heath Organisation criteria. Blood samples were taken on admission and two to four hours later, Both CK MB and myoglobin were raised in the initial serum samples in 24 of the 37 patients with definite infarction. In an additional seven patients both CK MB and myoglobin were negative in the first specimen though both were detected in the second sample. In five patients CK MB preceded the appearance of myoglobin while in the remaining patient myoglobin appeared before CK MB. We conclude that the detection of serum myoglobin does not offer any clinical advantage over CK MG as an early indicator of myocardial infarction.     

Analysis of reperfusion by thrombolysis of the artery responsible for acute myocardial infarction

OBJECTIVE: To analyze the role of the culprit coronary artery in myocardial infarction, its evolution and mortality. And to correlate with clinical criteria of reperfussion. MATERIALS AND METHODS: We included patients with clinical diagnosis of acute myocardial infarction (MI) treated with thrombolytic therapy, and coronariography. We used the TIMI study angiographic scale to evaluate the level of permeability of the culprit artery. RESULTS: Of 473 patients with of acute MI; coronariography was made in 377. The most frequent culprit vessel was anterior descending artery in 168 patients (45%) and right coronary artery in 139 patients (36%). In 276 patients the culprit vessel was permeable (73%). Of them in 30 patients, had TIMI 1 alterations, TIMI 2 in 97 patients, had TIMI 3 in 148 patients, only 102 patients had TIMI 0. In anterior MI the most frequent reperfussion arrhythmia was ventricular ectopic beats followed by slow ventricular tachycardia and ventricular tachycardia in 54%, ventricular fibrillation was observed only in six patients, of whom TIMI scale was 2 and 3 in five patients. In inferior MI, ventricular ectopic beats and slow ventricular tachycardia was seen in 25% of patients. In patients with permeable culprit artery we observed significant depression of ST segment, (159 patients, 42%), and significant increase in CK-MB levels, seen in 191 patients (51%). In the group of patients with total occlusion of the culprit artery, twenty-one (30%) had left ventricular disfuntion, and only six of them were in cardiogenic shock. In the group of patients with permeable culprit artery only two percent had cardiogenic shock. Therefore the analysis of the clinical evolution is the maia marker to take into consideration to send patients to early coronary arteriography with the objective to look for other therapeutic alternatives.     

Serum levels of cardiac troponin I and troponin T in estimating myocardial infarct size soon after reperfusion

BACKGROUND: Cardiac troponin I (TnI) and troponin T (TnT) are highly specific myocardial markers. OBJECTIVE: To determine whether their serum levels can be used to estimate myocardial infarct size soon after reperfusion. METHODS: We measured the serum levels of TnI, TnT, and creatine kinase every 3 h, and the serum cardiac myosin light chain I (MLCI) every 24 h, in 42 patients with acute myocardial infarction in whom reperfusion therapy had successfully been performed. We calculated the severity of regional hypokinesis by analyzing the follow-up ventriculograms with the centerline method. RESULTS: The time from reperfusion to the peak level for TnI was 6.1 +/- 3.5 h, significantly shorter than those for creatine kinase (7.5 +/- 4.1 h) and MLCI (55 +/- 28 h). The time to peak level for TnT (6.8 +/- 4.0 h) differed significantly from that for MLCI but not from that for creatine kinase. There was a significant correlation between the peak levels of TnI and TnT (r = 0.86). The peak TnI and TnT levels were correlated well to the peak creatine kinase level (r = 0.67 and 0.69, respectively), total creatine kinase release (r = 0.66 and 0.66), and the peak MLCI level (r = 0.71 and 0.80). We observed excellent correlations between the peak levels of TnI and TnT, and regional hypokinesis (r = -0.84 and -0.85, respectively). These were comparable to the correlations between regional hypokinesis and the peak creatine kinase level (r = 0.75), total creatine kinase release (r = -0.72), and the peak MLCI level (r = -0.76). CONCLUSIONS: These results suggest that the peak serum levels of TnI and TnT in patients with successful reperfusion are accurate and early indices of infarct size.     

Comparative sensitivities and specificities of the mass measurements of CK-MB2, CK-MB, and myoglobin for diagnosing acute myocardial infarction

We evaluated the clinical utility of the mass measurement of the tissue isoform of creatine kinase MB isoenzyme (CK-MB2) in the diagnosis of an acute myocardial infarction (AMI) by determining its sensitivity, specificity, and predictive value relative to those of CK-MB mass and myoglobin. Samples were obtained at 0, 4, 8, and 16 h postpresentation from 100 patients (41% with AMI). The order of sensitivity for the sample proportions taken at 0-2 h from the onset of symptoms was myoglobin > CK-MB2 > CK-MB. At all other time points, the sensitivity of CK-MB2 either equaled or surpassed that of both CK-MB and myoglobin, although the 95% confidence intervals for the population proportions each of these markers overlapped. Of the 41 AMI patients, 31 (76%) exhibited concurrent abnormal increases of CK-MB and %CK-MB2; the other 10 (24%; 8 non-Q wave, 2 Q wave) exhibited abnormal values for %CK-MB2 before their CK-MB exceeded the upper limit of normal. The specificity of myoglobin was statistically lower than that for either CK-MB2 or CK-MB at all time points.     

Female sex is associated with increased mortality and morbidity early, but not late, after coronary artery bypass grafting

OBJECTIVE: To describe mortality and morbidity during a period of 2 years after coronary artery bypass grafting in relation to gender. DESIGN: Prospective follow-up study. SETTING: Two regional cardiothoracic centres which performed all the coronary artery bypass operations in western Sweden at the time. SUBJECTS: A total of 2129 (1727 (81%) men and 402 (19%) women) consecutive patients undergoing coronary artery bypass surgery between June 1988 and June 1991 without concomitant procedures. RESULTS: Females were older and more frequently had a history of hypertension, diabetes mellitus, congestive heart failure, renal dysfunction and obesity. In a multivariate analysis, taking account of age, history of cardiovascular diseases and renal dysfunction, female sex appeared as a significant independent predictor of mortality during the 30 days after coronary artery bypass grafting (P < 0.05), but not thereafter. Various postoperative complications including neurological deficit, hydro- and pneumo-thorax, perioperative myocardial damage and the need for assist devices and prolonged reperfusion were more common in females than males. CONCLUSION: Females run an increased risk of early death and the development of postoperative complications after coronary artery bypass surgery as compared with males. Late mortality does not appear to be influenced by gender and the long-term benefit of the coronary artery bypass graft operation is similar in men and women.     

Comparison of transesophageal coronary sinus and left anterior descending coronary artery Doppler measurements for the assessment of coronary flow reserve

Genetic variation in correlations among size-related traits of head, thorax, and wings was examined in Drosophila buzzatii, by comparing the pattern of the Phenotypic Correlation Matrix (Rp) between inversion karyotypes of the second chromosome. No similarity in Rp was observed between some karyotypes in a natural population. The pattern of Rp in wild-reared heterokaryotypes, but not in homokaryotypes, was similar to the whole population represented by laboratory-reared flies. While phenotypic correlations in wild-reared flies were found to be larger than in laboratory-reared flies, similarity in the pattern of Rp was very high for one homokaryotype reared in both environments: the relatively homogeneous lab environment and the more variable field environment. While no such a similarity across environments was detected between different karyotypes, the pattern of Rp was similar for a same homokaryotype in different populations. Thus, the lack of karyotypic similarity in Rp is, at least partially, genetic. These results indicate that chromosomal inversions are factors affecting genetic correlations among traits known to be phenotypically correlated with adult fitness components in this species.     

Diabetes mellitus, internal thoracic artery grafting, and risk of an elevated hemidiaphragm after coronary artery bypass surgery

The elevated hemidiaphragm after coronary artery bypass grafting (CABG) that occurs in some patients is associated with internal thoracic artery (ITA) grafting as well as with the use of topical cardiac hypothermia. An increased incidence of elevated hemidiaphragm after CABG surgery in diabetic patients was observed. To determine the incidence and risk factors of elevated hemidiaphragm after CABG surgery and the relationship to preoperative diabetes, 200 consecutive patients undergoing CABG were studied; 29 (14.5%) had hemidiaphragm elevation postoperatively (25 on the left, 1 on the right, 3 bilateral). In the remaining 171 there was no hemidiaphragm elevation. Factors analyzed were age, gender, preoperative diabetes, duration of cardiopulmonary bypass (CPB) and aortic cross-clamping, minimum esophageal temperature during CPB, and use of the ITA graft. Univariate analysis showed a significant association between elevated hemidiaphragm and diabetes (P < 0.05), left ITA grafting (P < 0.01), and age (P < 0.05). Right ITA was not used for any patient. Multivariate analysis ruled out age, whereas preoperative diabetes and the use of the ITA remained the independent factors associated with elevated hemidiaphragm (odds ratio, 3.41; 95% confidence interval 1.41 to 8.18, and 2.86; 1.01 to 8.06, respectively). The relative risk of an elevated hemidiaphragm was 9.75 in diabetic patients with the ITA graft, as compared with nondiabetic patients without this graft. All 3 patients with bilateral diaphragm paralysis and a patient with a right hemidiaphragm elevation were diabetic. In conclusion, both diabetes and use of the ITA graft appear to be important risk factors for the development of elevated hemidiaphragm following CABG.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of reperfusion on arrhythmias and death after coronary artery occlusion in the rat: increased electrical stability independent of myocardial salvage

OBJECTIVES: This study sought to delineate salvage-dependent from salvage-independent coronary reperfusion in acute myocardial infarction and the effects on spontaneously occurring arrhythmias and arrhythmic death in rats. BACKGROUND: Reperfusion of the infarct-related artery might increase electrical stability independently of salvage of ischemic myocardium. METHODS: In 98 conscious rats the electrocardiogram was monitored by telemetry for 48 h after MI, and all episodes of ventricular tachycardia (VT) and ventricular fibrillation (VF) were analyzed. Reperfusion at 45 min (RP45) (n = 15), 90 min (RP90) (n = 18) and 180 min (RP180) (n = 30) min was compared with permanent coronary artery occlusion (CAO) (n = 35) with respect to the post-reperfusion periods. RESULTS: RP45, RP90 and RP180 reduced the incidence of VT by 93%, 98% and 88% and VF by 89%, 97% and 92%, respectively (all p < 0.01 vs. CAO). The all-cause mortality rate was reduced from 47% (CAO) to 8% (RP45, p < 0.05) and 0% (RP90, p < 0.01); after RP180 it was 17% (CAO 42%, p = 0.08). All reperfusion regimens reduced arrhythmic deaths: 47% to 8% (RP45, p < 0.05), 47% to 0% (RP90, p < 0.01) and 42% to 8% (RP180, p < 0.05). Infarct size was identical to that during CAO (49 +/- 10% [mean +/- SD]) and RP180 (49 +/- 10%), whereas preferentially epicardial salvage occurred at RP45 (36 +/- 8%, p < 0.001) and RP90 (38 < 10%, p < 0.001). CONCLUSIONS: Early and late reperfusion reduce the incidence and duration of VT and VF in conscious rats with acute MI. Thereby, arrhythmia-related mortality is improved through the prevention of fatal VF episodes. Thus, reperfusion increases the electrical stability of the heart independently of myocyte salvage, as proposed by the open artery hypothesis.     

Early clinical, electrocardiographic and biological criteria of reperfusion after intravenous fibrinolysis during the acute phase of myocardial infarction

Between May 1991 and February 1992, 31 consecutive patients were included in a prospective study, the aims of which were to determine the criteria of early coronary revascularisation after intravenous thrombolysis in the acute phase of myocardial infarction. The rise in serum myoglobin, the ST segment elevation, accelerated idioventricular rhythm and the evolution of chest pain were analysed. All patients underwent coronary angiography. Twenty-six were revascularized and 5 remained with coronary occlusion. Two types of serum myoglobin curves were demonstrated. Those with a sudden , decrease and a well defined peak in the first 4 hours were specific for revascularisation and easily identified (Group A: 16 patients). The graphs with a progressively rising slope to a peak after the 4th hour were observed in patients with coronary occlusion, but also in 10 patients with recanalized arteries (Group B). No significant difference was demonstrated with regards to the clinical and coronary angiographic parameters between patients in Group A and Group B. On the other hand, the time between the onset of chest pain and peak myoglobin was shorter in Group A (298 +/- 81 min) than in recanalised patients in Group B (380 +/- 54 min) (p < 0.05). The difference in the profile of the serum myoglobin could therefore reflect restoration of arterial flow in myocardial cells which had not suffered the same period of ischemia. ST segment elevation may increase, decrease of remain stable at 120 minutes in patients revascularised and those remaining occluded. In 9 patients, the ST elevation increased compared with the initial electrocardiogram .(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of EGb 761, a ginkgo biloba extract, on early arrhythmia induced by coronary occlusion and reperfusion in dogs

EGb 761 is a preparation of Ginkgo biloba extract, which has complex biologic actions including free radical scavenging activity. To examine the anti-arrhythmic effect of EGb 761, a canine preparation of coronary artery occlusion-reperfusion was tested. Under intravenous anesthesia and open chest conditions, 32 dogs were subjected to 30 min of coronary occlusion, followed by reperfusion. Twelve received EGb 761 by intravenous injection, 1 mg/kg five minutes before coronary occlusion, followed by a continuous infusion of 0.1 mg/kg/min until five minutes after reperfusion. Immediately prior to reperfusion, an additional bolus dose of EGb 761 (1 mg/kg) was again injected (group A). The remaining 20 dogs received saline injection, and served as the control (group B). The electrocardiographic changes were recorded during the whole experimental course. The results showed that, during coronary occlusion, group A dogs had a lower count of ventricular premature beats than group B dogs. However, there was no difference in the incidence of ventricular tachycardia (VT) between the two groups. The duration of VT of the treated dogs was similar to that of the control dogs. The incidence of ventricular fibrillation (VF) was also similar. Upon reperfusion, the treated dogs were shown to be protected from VF. The duration of VT was also shorter in the treated group, although the incidence of VT was not different between the two groups. EGb 761 is effective in preventing early VF induced by coronary reperfusion while ineffective in protecting the ischemic VT and VF.     

Expression and functional assessment of a truncated cardiac troponin T that causes hypertrophic cardiomyopathy. Evidence for a dominant negative action

Mutations in the beta-myosin heavy chain gene are believed to cause hypertrophic cardiomyopathy (HCM) by acting as dominant negative alleles. In contrast, a truncated cardiac troponin T (TnT) that causes HCM implies that altered stoichiometry of contractile proteins may also cause cardiac hypertrophy. Wild-type and HCM-mutant (truncated) TnT were studied in a novel quail myotube expression system. Unexpectedly, antibody staining demonstrated incorporation of both forms of human cardiac TnT into the sarcomeres of quail myotubes. Functional studies of wild type and mutant transfected myotubes of normal appearance revealed that calcium-activated force of contraction was normal upon incorporation of wild type TnT, but greatly diminished for the mutant TnT. These findings indicate that HCM-causing mutations in TnT and beta-myosin heavy chain share abnormalities in common, acting as dominant negative alleles that impair contractile performance. This diminished force output is the likely stimulus for hypertrophy in the human heart.     

Patient perceived health status, hospital length of stay, and readmission after coronary artery bypass surgery

This study evaluates the effect of length of stay and baseline health status on health status and readmission rates 3 months after coronary artery bypass graft surgery. Baseline health status showed a trend toward worse scores for patients who were readmitted. Readmitted patients had longer lengths of stay, and worse 3-month health status scores, and women and patients with heart failure had higher readmission rates. It may be possible to identify patients at risk for readmission using clinical variables, length of stay, and health status. If a predictive model can be developed, then interventions can be developed and tested to decrease the rate of unplanned readmissions.     

Aprotinin does not decrease early graft patency after coronary artery bypass grafting despite reducing postoperative bleeding and use of donated blood

Forty-five male patients with planned coronary artery bypass operation were randomized in a double blind fashion to receive either 6 million kallikrein inactivator units of aprotinin (high-dose group), 2 million kallikrein inactivator units of aprotinin (low-dose group), or placebo (control group). Postoperative bleeding was significantly decreased in both aprotinin groups in comparison to that in the control group (590 ml [290 to 1800 ml] high-dose group and 650 ml [280 to 1900 ml] low-dose group versus 920 ml (350 to 2700 ml) control group, p < 0.001). There was no difference between the two aprotinin groups. The need for postoperative blood transfusion was significantly lower in the aprotinin groups (1.46 [0 to 4] blood units high-dose group and 1.65 [0 to 5] blood units low-dose group versus 2.43 [0 to 7] blood units control group, p < 0.05). All patients underwent coronary angiography between the seventh and twelfth postoperative day. No difference was found among the three groups in patency of vein grafts-93.8% in the high-dose group, 94.5% in the low-dose groups, and 93.3% in the control group. Therefore, aprotinin significantly reduced postoperative bleeding and transfusion requirement after coronary artery bypass grafting without influencing early graft patency.     

Incidence, consequences, and risk factors of early reocclusion after primary and/or rescue percutaneous transluminal coronary angioplasty for acute myocardial infarction

We recently experienced a 43-year-old man with a large, multiloculated, cystic tumor that appeared on the pelvis. The tumor was composed of glands and cysts lined by prostatic-type epithelium and attached microscopically to the prostate by a pedicle. The prostatic nature of the lesions was confirmed by immunohistochemical staining of epithelium for prostate specific antigen (PSA). Our review of literature disclosed nine similar cases in men of various ages, originated from the prostate and grew to massive proportions. The lesions in these reported cases did not invade contiguous structures but they can adhere to viscera in their proximity. The multilocular prostatic cystadenoma is a pathologically benign entity, and they can be definitively treated by a carefully planned complete surgical excision. This lesion should be included in the differential diagnosis of retroperitoneal cystic tumors in man. We report a rare case of multilocular prostatic cystadenoma that did not invade adjacent organs and showed no evidence of recurrence after complete surgical excision.