Multivessel coronary stenting versus bypass surgery in patients with multivessel coronary artery disease and normal left ventricular function immediate and six months follow up

The usual goal for CABG is complete revascularization, which may be associated with greater freedom from recurrent angina and better long-term survival. In selected patients with multivessel coronary artery disease and normal left ventricular function, intracoronary stenting may offer an effective alternative to coronary bypass surgery. was to compare the immediate and six months follow up of the results of percutaneous coronary intervention [PCI] and the conventional coronary bypass surgery [CABG] in symptomatic patients with multivessel coronary artery disease and normal left ventricular function. The study included 61 patients who were randomly selected and divided into two groups: group [1]: 33 patients who underwent CABG and group [2]: 28 patients who underwent percutaneous coronary intervention. Both groups were followed up immediately post procedures and for a period of six months after. Stress ECG was done for returning patients during the 6 months follow up. During the immediate post operative follow up, only one patient in group 1 [3%] and 19 patients in group 2 [67.6%] were free of complications [P<0.001] Postoperative angina, acute renal failure, need for inotropic support, blood transfusion and lung atelectasis were significantly higher in group [1] than group [2]. Coronary dissection was found only in the PCI group. Other complications found in both groups were of no statistical significance. Regarding the cost and hospitals stay, it was significantly higher and more in group [1] than group [2]. During the 6 months follow up of the symptoms and the level of activity, there was no statistically significant difference regarding the angina and positive stress test between both groups. There was no statistical difference between the two groups in the composite end points [exercise tolevance, incidence of angina and mortality] during the 6 months follow up after the operation. PCI is relatively safer procedure, less costly and with lower hospital stay than CAVG, but it should be done in the presence of surgical back up because it is not completely free of risk and disadvantages. CABG still will have its role in managing patients with complex lesions not amenable to catheter interventions

Study of the fate of detectable left atrial thrombi at repeated tranesophagealechocardiography in patients with mitral stenosis

Previous studies did not encourage balloon mitral valvuloplasty [BMV] when left atrial and /or LAA thrombi are present. Patients with LA and/or LAA thrombi are considered at high risk for thromboembolic events. So it is considered a major cause of morbidity and mortality in patients with mitral stnosis. To investigate the fate and stability of LA and/or LAA thrombi under the effect of oral anticoagulation this study included thirty patients with mitral stenosis having LA and/or LAA thrombi detected by TEE. They were subjected to full anticoagulation therapy controlled by INR of 2-3. Repeated TEE were done three and six months later. According to the results of this study the patients were grouped into two main groups: Group 1: included sixteen patients who had dissolved LA or LAA thrombi after anticoagulation therapy. It represented [53.33%] of all cases included in this study. In thirteen patients out of all the total sixteen patients representing group I, the thrombi were dissolved after three months therapy as they had clear LA and LAA in the second TEE study. They represented [81.25%] of group I and [43.33%] of all patients included in this study. In three patients the thrombi were dissolved after six month anticoagulation therapy, they represented [18.75%] of group I and [10%] of the whole patients included in this study. Group II: which included eleven patients [36.66%] all of them had non dissolved thrombi in LA and LAA in spite of six months anticoagulation therapy, three patients were excluded from the study. In conclusion: Complete resolution of LA and/or LAA thrombi occurs in a considerable number of patients [53.33%]. Age of the patients, size of the left atrium and size of LAA or LAA thrombi are considered the only significant factors influencing thrombus resolution. No other clinical or echocardiographic parameters could influence thrombus resolution. Majority of LA andyor LAA thrombi dissolve in the first three months with less incidence of resolution in the next months

IV Enoxaparin versus unfractionated heparin in elective percutaneous coronary intervention

The rapid progress in the field of interventional cardiology in the last few years necessitates a continuous search for the most safe and effective methods to gain an optimum results, either equipments or drugs. to examine the use of enoxaparin as an anticoagulant in elective PCI, and compare it with unfractionated heparin regarding the acute procedural complications and the immediate 24-hour post-PCI events. The study was conducted on 84 patients who were classified independently into 2 groups. 50 patients represent group [A], received IV single bolus of enoxaparin in a dose of 0.5mg/kg at the start of the procedure and 34 patients represent group [B], received the usual traditional dose of unfractionated heparin [10000-15000 units].All patients were prepared by clopidogrel or ticlopidin before PCI in addition to aspirin 150 mg daily.Follow up was done for all patients during the immediate 24 hours after PCI for death, myocardial infarction, myocardial ischemia requiring urget coronary intervention and cerobrovascular stroke. There was no statistical significant difference between the two groups regarding the type of vessels treated or number of stents placed. None of the patients of both groups experienced any of the following complications during the procedure or 24 hours after: major bleeding, myocardial infarction, myocardial ischemia requiring urgent surgical or repeat percutaneous coronary revascularization or death. The major difference between the two groups was the immediate sheath removal in the enoxaparin group, without sheath site complication [minor haematoma] which was observed in 9% of the UFH group. Angiographic complications were coronary artery dissection [in one patient in group A [2%] and 3 patients in group B [9%]] and acute closure of the culprit vessel [occurred in one patient in group A [2%] and none in group B. The results were quite encouraging, with no statistical differences between the two arms of the study regarding the acute complications and the clinical outcome. The use of enoxaparin in this reduced dose is feasible in elective PCI with adequate level of anticoagulation without need for monitoring its anticoagulant effect. The early sheath removal in group A necessitates further studies to assess its impact on the duration of hospital stay and the possibility of early discharge of the patients

Diastolic dysfunction in patients with insulin dependent diabetes mellitus: as an early indicator of diabetic cardiomyopathy

Background: Diastolic abnormalities present in diabetic patients without diabetic complications or cardiovascular disease has been suggested as an earliest functional effect of a specific diabetic cardiomyopathy. Various abnormalities in diastolic function, e.g. prolonged isovolumic relaxation period, delayed mitral valve opening impairment in rapid diastolic filling, increased atrial contribution of LV filling, and reduced E/A mitral ratio have been characteristic findings

Aim of Work: To evaluate the left ventricular diastolic function in patients with IDDM and to determine the factors that affect diastolic dysfunction among diabetic patients

Patients and Methods: The study included 40 patients with type I insulin-dependent Diabetes Mellitus as a study group and another 40 normal subjects matched by age and sex as a control group. Exclusion criteria: Ischemic Heart Disease, Hypertension, Any concomitant valvular or congenital heart disease, and Renal or hepatic impairment. All patients included in the study were subjected to: Full history taking, full general and local examination of the heart, chest and abdomen, 12 leads resting ECG, Clinical exercise testing using Bruce protocol to exclude CAD, Laboratory investigations including: Fasting and 2 hours post-prandial blood sugar level, glycated hemoglobin [HBA1c], serum creatinine, and urine analysis for microabumenuria. M-mode, 2- Dimensional and echo Doppler study

Results: There was no significant difference between the studied group and controls regarding the systolic parameters [EDD, ESD, EF% and FS%], [P> 0.05]. There was significant difference between the two groups regarding the E wave, A wave, E/A ratio. TVIE, TVIA, TVIE/TVIA, time A, Time E/Time A and IVRT [P < 0.05]. There was no significant difference between the two groups regarding time E and deceleration time [P> 0.05]. There was significant difference between the group of patients with good glycemic control and those with poor glycemic control regarding the E wave, A wave, E/A ratio, TVIE, TVIA, TVIE/TVIA, time A, Time E/Time A and IVRT [P < 0.05]. There was no significant difference between the two groups regarding time E and deceleration time [P>0.05]. There was significantly higher prevalence of diastolic dyfunction among the studied patients [17 patients, 42.3%] than controls [5 patients, 12.5%] [P< 0.001]. The diastolic mitral flowpattern of the studied patients was significantly more severe among patients than among the controls as 10 patients [25%] had stage I diastolic dysfunction and 7 patients [17.5%] had stage II diastolic dysfunction. In the controls the 5 patients [12.5%] had diastolic dysfunction grade I and no one in this group had grade II diastolic dysfunction [P < 0.001]

Conclusion: Diabetes Mellitus is associated with impaired diastolic function irrespective of the presence of any associated cardiac disease [e.g. hypertension or ischemic heart disease]. Factors contributing to the presence of diastolic dysfunction were poor control of Diabetes Mellitus and duration of diabetes Mellitus

Relation between admission troponin -T level and angiographic severity of coronary artery lesion in patients with non-ST segment elevation acute coronary syndrome

Cardiac troponin T and I are sensitive marker for myocardial injury. Elevation of these markers in patients with ST segment elevation acute ischemic syndrome is associated with more severe coronary artery disease and poor prognosis. In the case of non-ST segment elevation acute ischemic syndrome the condition is not so clear to find out the role of admission troponin T on the prediction of the severity of coronary artery lesion in patients with non-STE acute coronary syndrome. This study is a case-controlled clinical trial that was conducted in the National Heart Institute in order to find out the diagnostic utility of elevated troponin T for prediction of the severity of coronary artery disease in patients with non-ST segment elevation acute coronary syndrome. Forty patients admitted in the ICU of the National Heart Institute with chest pain and non-ST segment elevation acute coronary syndrome were included in the study. Coronary angiography was done to 33 patients [2 patients died and 5 patients refused coronary angiography]. They were divided into 2 groups according to troponin T level: Group I: 15 patients with troponin T +ve and group II: 18 patients with troponin -ve. All Patient Included in the Study Were Subjected To: Full history Taking, full general and local examination, resting twelve-leads ECG, routine laboratory investigation, Troponin testing on admission and coronary angiography before discharge. Male sex was significantly more in the group I than group II patients. Also, patients with group I were significantly older [P < 0.05]. There was no significant difference between the two groups regarding the risk factors for coronary artery disease or the ECG diagnosis of ischemic changes [P > 0.05]. The incidence of in-hospital adverse events were significantly higher among the group I than group II patients [P < 0.05]. The degree of stenosis was significantly more in group I than group II. [87% +/- 10.8 and 76% +/- 9.5 respectively, P < 0.05]. The incidence of multivessel disease was significantly higher in group I than that of group II [P < 0.05]. There was significant difference between the two groups regarding the TIMI flow [P < 0.05]. Angiographic evidence of thrmobus was present in 3 patients [20%] of group I, while it was present in 1 patients [5.6%] of group II. The difference between the two groups was significant [P < 0.05]. Troponin T elevation on admission is associated with a significantly severe form of coronary artery disease, more complex lesion, higher incidence of multivessel disease and visible thrombus in patients with non-ST segment elevation acute ischemic syndrome