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Heeding the Sign
of Increased CK-MB Level After Bypass Surgery
Background: Although it has been suggested that elevation of CK-MB after percutaneous
coronary intervention is associated with adverse clinical outcomes, limited data
are available in the setting of coronary bypass grafting. The aim of the present
study was to determine the incidence, predictors, and prognostic significance of
CK-MB elevation following multivessel coronary bypass grafting (CABG).
Methods and Results: The population comprises 496 patients with multivessel
coronary disease assigned to CABG in the Arterial Revascularization Therapies Study
(ARTS). CK-MB was prospectively measured at 6, 12, and 18 hours after the procedure.
Thirty-day and 1-year clinical follow-up were performed. Abnormal CK-MB elevation
occurred in 61.9% of the patients. Patients with increased cardiac-enzyme levels
after CABG were at increased risk of both death and repeat myocardial infarction
within the first 30 days (P = .001). CK-MB elevation was also independently related
to late adverse outcome (P = .009, OR=0.64).
Conclusions: Increased concentrations of CK-MB, which are often dismissed
as inconsequential in the setting of multivessel CABG, appear to occur very frequently
and are associated with a significant increase in both repeat myocardial infarction
and death beyond the immediate perioperative period.
Costa MA, Carere RG, Lichtenstein SV, et al. Incidence, predictors, and significance
of abnormal cardiac enzyme rise in patients treated with bypass surgery in the Arterial
Revascularization Therapies Study (ARTS). Circulation. 2001;104:2689-2693.
Full text article available at: circ.ahajournals.org
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T-Cell Flow Cytometry Crossmatch Strongly Linked to Allograft Rejection
Background: Acute allograft
rejection (AR) in solid organ transplantation is generally regarded to develop through
cell-mediated immune response following activation of helper T cells. Since production
of antibodies is also mediated by helper T cells, humoral immunity may play some
roles in AR. Although flow cytometry crossmatch (FCXM) is reported as a useful method
for the detection of antibodies against donor antigen, specific role of T- or B-cell
FCXM and its sensitivity for AR is controversial.
Methods: T- and B-cell FCXM using fresh donor peripheral lymphocytes were
performed before and after blood-type compatible living donor liver transplantation
in 47 patients. IgM and IgG anti-donor antibodies were analyzed in relation to clinical
AR. Results: Positive pre-transplant T-cell FCXM was associated with a high incidence
of positive post-transplant T-cell FCXM (P = .017). Four of five cases (80%) with
positive pre-transplant T-cell FCXM experienced earlier AR (day 8.0+/-4.4, mean+/-SD)
than 16 of 42 cases (31%) with negative pre-transplant T-cell FCXM (17.3+/-6.8; P
= .016). In addition, higher dose of steroids was given to treat AR episodes in cases
with positive pre-transplant T-cell FCXM (79.9+/-10.3 mg/kg/month) than in those
with negative pre-transplant T-cell FCXM (47.1+/-26.6; P = .039). In the first month
after transplantation, 13 episodes of positive post-transplant T-cell FCXM were all
concomitant with or preceded clinical AR compared with seven ARs in T-cell FCXM-negative
cases (P < .0001). T-cell FCXM between positive sera and third parties revealed
some crossreactions. In contrast, detection of antibodies by B-cell FCXM in pre-
and post-transplant phases was scarcely associated with AR, and no correlation was
found between T- and B-cell FCXM before and after transplantation.
Conclusions: Positive T-cell FCXM is closely related with AR and that before
transplantation is a predictor of early and refractory AR as well as post-transplant
FCXM. In contrast, not a few detections of antibodies irrelevant to AR are observed
in B-cell FCXM, suggesting its low specificity.
Takakura K, Kiuchi T, Kasahara M, et al. Clinical implications of flow cytometry crossmatch with T or B cells in living donor liver transplantation. Clin Transplant. 2001;15:309-316.
Full text article available at:
www.blackwell-synergy.com
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Combined Surgical Technique
Shows Promise for Coexisting Carotid/Coronary Artery Disease
Background: Controversy remains regarding the optimal surgical management
of patients with coexisting significant carotid and coronary artery disease. The
debate has deepened by the evolution of new approaches for the treatment of both
coronary and carotid disease. We report our early experience with combined off-pump
coronary artery bypass (OPCAB) and carotid endarterectomy (CEA) for the treatment
of patients with coexisting coronary and carotid disease.
Methods: Our computer database was examined to obtain patients and their demographics
and clinical profiles. Operative reports were reviewed. Telephone interviews were
conducted to assess follow-up status. Results: Thirteen patients underwent combined
OPCAB and CEA. Average age was 71 years. The CEA was performed with intraluminal
shunting and patch reconstruction. On average, 3.6 bypass grafts were performed.
There were no gross neurologic complications or myocardial infarctions. Excluding
an outlier, mean length of hospital stay was 8.2 days. All patients were well on
follow-up (2 weeks to 16 months).
Conclusions: A combined OPCAB and CEA strategy appears safe and effective.
Further follow-up and experience is warranted before conclusions regarding potential
benefits of this approach for staged or conventional OPCAB/CEA procedures can be
made.
Youssuf AM, Karanam R, Prendergast
T, et al. Combined off-pump myocardial revascularization and carotid endarterectomy:
early experience. Ann Thorac Surg. 2001;72:
1542-1545.
Full text article available at:
ats.ctsnetjournals.org
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Risk for Hypertension Postoperatively Increased With Eversion Endarterectomy
Objective: The incidence
of postoperative hypertension (HTN) after eversion carotid endarterectomy (e-CEA)
was compared with that after standard carotid endarterectomy (s-CEA). Methods: In
a retrospective analysis from January 1998 to January 2000, 217 patients underwent
219 CEAs for symptomatic (68) or asymptomatic (151) high-grade (>80%) carotid
artery stenosis by either standard (137) or eversion (82) techniques. The eversion
technique involves an oblique transection of the internal carotid artery at the carotid
bulb and a subsequent endarterectomy by everting the internal carotid artery over
the atheromatous plaque. All procedures were done under general anesthesia, and somatosensory-evoked
potentials were used for cerebral monitoring. Patients with s-CEA were compared with
those with e-CEA for postoperative hemodynamic instability, carotid sinus nerve block,
requirement for intravenous vasodilators or vasopressors, stroke, and death.
Results: Patients who underwent e-CEA had a significantly (P < .005) increased
postoperative blood pressure and required more frequent intravenous antihypertensive
medication (24%), compared with patients having an s-CEA (6%). Furthermore, postoperative
vasopressors were required after 10% of s-CEAs, but after none of the e-CEAs. No
statistically significant difference was noted in the morbidity or mortality of patients
after s-CEA and e-CEA.
Conclusion: e-CEA is a substantial risk factor for HTN in the immediate postoperative
period, when compared with the s-CEA. This difference would be even more remarkable
in the absence of antihypertensive medications in the e-CEA group and vasopressors
in the s-CEA group. Therefore, particular attention should be focused on diagnosing
and controlling postoperative HTN in patients after e-CEA.
Mehta M, Rahmani O, Dietzek AM, et al. Eversion technique increases the risk for post-carotid endarterectomy hypertension. J Vasc Surgery. 2001;34:839-845.
Full text article available at: www.harcourthealth.com
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