Martin Möckel

Value of cardiac troponin I and T for selection of heart donors and as predictors of early graft failure.

Background. Cardiac troponin I and T (cTnI and cTnT) are sensitive andspecific markers of myocardial damage. We evaluated them for the selection ofheart donors and as predictors of early graft failure after hearttransplantation. Methods. cTnI, cTnT, myoglobin, and creatine kinase (CK) levels andits isoenzyme MB (CKMB) activity and mass were measured in serum samplesimmediately before opening the pericardium from 126 consecutive brain-deadmulti-organ donors over 10 years of age inspected by our harvesting team.Donors with serum creatinine >2.0 mg/dL (n=6) were excluded from theanalysis. Donors for high-urgency status recipients (n=2) were alsoexcluded. The remaining donors were retrospectively divided into three groups:group I (n=68), grafts with good function; group II (n=11),grafts with impaired function; and group III (n=39), grafts notaccepted fortransplantation. Results. No differences in donor and recipient characteristics werefound among the groups. The mean values of cTnI (0.36±0.88 &mgr;g/L,4.45±3.28 &mgr;g/L, and 3.02±7.88 &mgr;g/L, respectively) andcTnT (0.016±0.029 &mgr;g/L, 0.134±0.114 &mgr;g/L, and0.123±0.245 &mgr;g/L, respectively) were lower in group I when comparedwith groups II or III (cTnI:P <0.0001, P =0.018; cTnT:P <0.0001, P =0.012). The cTnI value washigher in group II compared with group III(P =0.023). The cTnT values weresimilar in groups II and III. A cTnI value >1.6 &mgr;g/L as a predictor ofearly graft failure had a specificity of 94%, and a cTnT value of >0.1&mgr;g/L had a specificity of 99%. The odds ratio for the development of acutegraft failure after heart transplantation was 42.7 for donors with cTnI>1.6 &mgr;g/L and 56.9 for donors with cTnT >0.1 &mgr;g/L. Nodifferences of myoglobin, CKMB activity, or CKMB/CK ratio were found among thegroups. Conclusions. Significantly higher cTnI and cTnT values were found inperipheral blood at the time of explantation in donors of hearts withsubsequently impaired graft function and in not accepted donors. cTnI and cTnTare useful as additional parameters for heart donorselection.

Stent-supported recanalization of chronic Iliac artery occlusions

PURPOSE Iliac artery occlusions that are more than a few centimeters in length are normally treated with surgical bypass grafting. The aim of this study was to evaluate the results of primary stent implantation after Excimer laser-assisted recanalization of iliac artery occlusions. SUBJECTS AND METHODS We studied 212 consecutive patients with chronic unilateral iliac artery occlusions (mean [+/- SD] length 8.9 +/- 3.9 cm) who were treated with Excimer laser-assisted recanalization and stent implantation. Based on the criteria of the Society of Cardiovascular and Interventional Radiology, lesions were graded as class III occlusions (<5 cm) in 46 patients and as class IV (> or =5 cm) in 166 patients. A total of 527 stents (Palmaz stent, 346; Wallstent, 94; Strecker stent, 38; covered stents, 49) were implanted. RESULTS Technical success was achieved in 190 (90%) patients. There was a clinical improvement of three grades in 112 (53%) patients and of two grades in 67 (32%) patients. The rate of major complications was 1.4%, which included arterial rupture (1) and embolic events (2). Primary patency rates were 84% at 1 year, 81% at 2 years, 78% at 3 years, and 76% at 4 years. Secondary patency rates were 88% at 1 year, 88% at 2 years, 86% at 3 years, and 85% at 4 years. CONCLUSION Stent-supported angioplasty is an effective treatment for iliac artery occlusions, with less morbidity and mortality than is associated with surgery. However, reported long-term patency rates after bypass surgery are greater than those we observed with interventional treatment. The value of primary stenting as compared with angioplasty alone should be evaluated in a randomized trial.

Diagnostic and Prognostic Role of Myoglobin in Patients With Suspected Acute Coronary Syndrome

diagnostic efficiency of cardiac troponin I and troponin T for acute myocardial infarction. Acad Emerg Med 1997;4:13–21. 15. Zimmerman J, Fromm R, Meyer D, Boudreaux A, Wun CC, Smalling R, Davis R, Habib G, Roberts R. Diagnostic markers cooperative study for the diagnosis of myocardial infarction. Circulation 1999;99:1671–1677. 16. Panteghini M, Apple FS, Christenson RH, Dati F, Mair J, Wu AH. Proposals from IFCC committee on standardization of markers of cardiac damage (C-SMCD): recommendations on use of biochemical markers of cardiac damage in acute coronary syndromes. Scan J Clin Lab Invest 1999; 59(suppl 230):103–112. 17. Hamm CW, Goldmann BU, Heeschen C, Kreymann G, Berger J, Meinertz T. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I. N Engl J Med 1997;337:1648–1653.

The acute coronary syndrome diagnosis and prognostic evaluation by troponin I is influenced by the test system affinity to different troponin complexes.

It was suggested recently that cardiac troponins are released as T-I-C complexes and then further degraded to T and I-C. It is not known whether the various affinity to the T-I-C and I-C complex of different troponin I test systems influence the diagnostic and prognostic value of the test results in clinical practice. We studied 162 patients (61.3 S.D. 11.1 years) with suspected acute myocardial infarction (AMI) in a single center study. AMI was confirmed in 109 patients. Blood samples were taken at admission, after 1, 2, 4, 8, 12 and 24 h. Troponin I (TnI) was measured using the OPUS plus (TnI-O, cut-off 1.6 microg/l) and the Stratus II (TnI-S, cut-off 1.5 microg/l) analyzers. TnI-O has high affinity to the binary (I-C) and TnI-S to the ternary (T-I-C) troponin complex. A 6-month follow-up with respect to death and recurrent AMI was performed. The sensitivity (SE) and specificity (SP) for AMI diagnosis were 82.6 and 86.8% for TnI-S; 75.2 and 92.5% for TnI-O 0-2 h after admission. The ROC analysis showed a slightly better curve for TnI-S at 4 h (P<0.05). Logistic regression analysis shows prediction of 6 months outcome by 0-24 h serial TnI-S measurements (odds ratio 5.21, P=0.0356), and serial TnI-O measurements (odds ratio 4.92, P=0.0186). High affinity to the ternary troponin complex enhances the diagnostic but not the prognostic value of a test system. Indeed, the resulting differences are small but underline the need for standardization of biochemical markers.

Ischemia-Modified Albumin, Free Fatty Acids, Whole Blood Choline, B-Type Natriuretic Peptide, Glycogen Phosphorylase BB, and Cardiac Troponin

There is increasing need to make accurate early diagnosis and rule out acute coronary syndromes (ACS) in patients who present to the emergency department (ED) with chest pain. Accurate diagnosis will reduce the number of inappropriate management decisions, and the number of malpractice lawsuits relating to these decisions. Early diagnosis will facilitate faster entry to treatment protocols such as anticoagulant and antiplatelet therapies resulting in reduced morbidity, mortality, and hospital length of stay. Rapid rule-out of ischemia will facilitate discharge of patients at no or low risk for cardiovascular complications and alleviate the diminishing resources available to EDs. Although the presence of ST-segment depressions on the electrocardiogram (ECG) is evidence of ischemia, the ECG is nondiagnostic in the majority of unstable angina patients. Radionuclide imaging is a sensitive marker for ischemia, but is expensive and requires a high degree of technical expertise.

Persistent myocardial sinusoids of the left ventricle

T first description of a rightsided persistent sinusoid dates from 1964, whereas only 1 publication from 1984 is known on leftsided persistent ventricular sinusoids. In a 56-year-old woman with angina at rest, a coronary 2-vessel disease (in the right coronary artery and left anterior descending artery [stenosis of 50% each]) was diagnosed on coronary angiography. Ventriculography of the left ventricle showed 4 distinct persistent myocardial sinusoids of the left anterior wall (Figures 1 and 2). Dimensions and function as well as intracavitary pressures were within normal ranges. Because the incidence of persistent myocardial sinusoids of the left ventricle is very rare, no report exists on the clinical relevance of this phenomenon. Yet in our patient, maximal dobutamine-atropine stress echocardiography did not reveal any hint of abnormal wall motion or ischemia in the region of interest.

Biomarker strategies: the diagnostic and management process of patients with suspected AMI

Abstract Security standards of our times largely exclude a discharge of patients with chest pain from the emergency departments (EDs) based on clinical assessment alone. Given the increasing use and consequently crowding of EDs worldwide and the large proportion of patients who present to the EDs with, however vague, signs and symptoms of acute coronary syndrome, there is a strong clinical and public health need to achieve a faster but safe rule-in and rule-out of acute myocardial infarction (AMI) to direct patients onto the correct management pathway. A number of approaches for a faster rule-in and rule-out of AMI are currently under research and evaluation and some have already been integrated into current guidelines and/or implemented into the clinical routine in selected centers. This article summarizes these different diagnostic strategies for patients with suspected AMI, using cardiac troponin alone or in combination with copeptin.