Sameh Bakhoum

The association between extracoronary calcification and coronary artery disease in patients with type 2 diabetes mellitus

Cardiovascular complications are the major cause of diabetes-associated morbidity and mortality. However, not all patients with diabetes are at increased risk for cardiovascular disease (CVD). Coronary artery calcification was found to be a powerful predictor of coronary artery disease (CAD). The presence of extracoronary cardiac calcification as a useful predictor of CAD is not yet established, especially in type 2 diabetes mellitus (T2DM). The aim of this study was to evaluate the relation between extracoronary calcification and extent of CAD in a group of T2DM patients who were scheduled for computed tomographic coronary angiography (CTCA). We prospectively studied 380 patients (151 had T2DM) under the age of 60 years who were scheduled for CTCA because of suspected CAD. Severity of CAD was assessed by Gensini score. Coronary artery calcium score (CACS) as well as calcium score in the aortic valve, mitral annulus, ascending aorta, and descending aorta were measured by a 256-row multidetector computed tomography scanner with dedicated software for calcium calculation. Patients with known CAD were excluded. Diabetic and nondiabetic patients had comparable age and gender distribution. However, the diabetic group had higher Gensini score, CACS, and extracoronary calcium score (ECCS). Logistic regression analyses identified male gender and ECCS as significant predictors for the presence of CAD in diabetic patients. Age, smoking, and ECCS were the significant predictors of CAD in nondiabetic patients. Type 2 diabetic patients had increased coronary and extracoronary calcification. ECCS was found to be a significant predictor of CAD in diabetic and nondiabetic patients only when CACS was not taken into account.

Levels of sCD40 Ligand in Chronic and Acute Coronary Syndromes and its Relation to Angiographic Extent of Coronary Arterial Narrowing

We determined the serum levels of soluble CD40 ligand (sCD40L) in patients with chronic coronary artery disease (CAD) and acute coronary syndrome (ACS). Patients with unstable angina (UA) and myocardial infarction (MI) showed significantly higher levels (P < .001) of sCD40L compared with patients with stable angina (SA) and controls; particularly, high levels occurred in patients with UA (UA: 9.23 ± 2.92, MI: 7.38 ± 1.05, SA: 4.42 ± 1.08; control: 4.01 ± 0.87 ng/mL). There was no significant difference in sCD40L levels between patients with UA and MI or between patients with SA and controls. Levels of sCD40L did not show any significant correlation with peak creatine kinase (CK), CK-MB isoenzyme activity in patients with MI, troponin T serum levels in patients with UA or with culprit vessel (CV) complexity score (CVCS), type of CV lesion, or vessel score in patients with UA or MI. These results suggest that CD40L plays a pathogenic role in triggering ACS.

Comparison of early results of percutaneous metallic mitral commissurotome with Inoue balloon technique in patients with high mitral echocardiographic scores.

We compared the safety, efficacy, and cost of the newly introduced percutaneous metallic commissurotome (PMC) with the results of Inoue balloon mitral valvuloplasty (BMV) in 80 patients with mitral stenosis (MS). The mean increase in mitral valve area (MVA) was 0.95 ± 0.19 to 1.7 ± 0.35 cm2 for PMC and 0.97 ± 0.15 to 1.81 ± 0.36 cm2 for BMV (P = NS). The Wilkins echocardiographic scores before dilatation did not correlate with any difference in MVA after dilatation. Bilateral commissural splitting was significantly more common with PMC than with BMV (30/39 patients, 76.9%, vs. 21/40 patients, 52.5%; P = 0.02). Postprocedural severe mitral regurgitation occurred in 1/39 (2.6%) in the PMC group and in 4/41 (9.8%) in the BMV group. Because the PMC device is resterilizable, we estimated the cost to be one‐fourth the cost of BMV with the Inoue balloon. The estimated device cost ratio of PMC to BMV for each patient was 1 to 4.25. The early results of PMC on the MVA are comparable to BMV. However, PMC had better results not only in patients with high echocardiographic scores, but the PMC device splits commissural calcification better than BMV. Cathet Cardiovasc Intervent 2002;57:312–317.

Feasibility of percutaneous closure of atrial septal defects in adults under transthoracic echocardiography guidance using the Figulla atrial septal defect occluder device

Background Closure of atrial septal defect (ASD) among adults under transthoracic echocardiography (TTE) guidance using devices other than the Amplatzer Septal Occluder has not been extensively tested. Aim of work Assessment of the safety and efficiency of secundum ASD closure using the Occlutech Figulla ASD Occluder under TTE guidance in adult patients with hemodynamically significant secundum ASD. Methods Twenty patients (mean age, 32.9 ± 9.7, 75% of them females) were enrolled in the study. All patients underwent TTE and transoesophageal echocardiography (TEE) to assess the characteristics of the ASD prior to percutaneous closure. Procedures were performed using the Figulla Occluder device under both fluoroscopic and TTE guidance. Follow-up clinical and TTE examinations were done at 1, 3, and 6 months following the procedure. Results TTE estimated mean ASD size was 21.7 ± 7.3 mm with adequate rims except for the aortic rim (deficient in one third of cases). Mean device size was 28.1 ± 8.6 mm with mean procedure and fluoroscopic times of 46.2 ± 16.4 and 15.7 ± 5.4 minutes respectively. ASD was successfully closed in all patients. Two patients showed a small residual shunt immediately after the device placement that disappeared by the end of the 2nd followup TTE examination. Transient complications were detected in 2 patients. All patients were asymptomatic during the follow-up period. Conclusion Transcatheter closure of secundum ASD in adults under TTE guidance using the Occlutech Figulla ASD occluder device is safe and effective when performed in a tertiary center and by expert echocardiographers and interventional cardiologists.

Short term outcome of thoracic endovascular aortic repair in patients with thoracic aortic diseases

Aim and background Open surgical repair for thoracic aortic diseases is associated with a high perioperative mortality and morbidity. Most of type B aortic dissections are uncomplicated and are medically treated which carries a high mortality rate. Thoracic endovascular aortic repair is the first-line therapy for isolated aneurysms of the descending aorta and complicated type B aortic dissection. The aim of this study is to test the safety of early thoracic endovascular aortic repair in patients with uncomplicated type B aortic dissection and patients with thoracic aortic aneurysms. Methods A total of 30 patients (24 men and 6 females; mean age 59 ± 8 years) with uncomplicated type B aortic dissection and descending thoracic aortic aneurysm who underwent endovascular aortic repair in National Heart Institute and Cairo University hospitals were followed up. Clinical follow-up data was done at one, three and twelve months thereafter. Clinical follow-up events included death, neurological deficits, symptoms of chronic mal-perfusion syndrome and secondary intervention. Multi-slice computed tomography was performed at three and six months after intervention. Results Of the 30 patients, 24 patients had aortic dissection, and 6 patients had an aortic aneurysm. 7 patients underwent hybrid technique and the rest underwent the basic endovascular technique in whom success rate was 100%. Two patients developed type I endoleak, however both improved after short term follow up. The total mortality rate was 10% throughout the follow-up. Both death and endoleak occurred in subacute and chronic cases, while using TEVAR in acute AD and aneurysm showed no side effects. Early thoracic endovascular aortic repair showed better results and less complications. Conclusion Along with medical treatment, early thoracic endovascular aortic repair in uncomplicated type B aortic dissections and thoracic aortic aneurysms is associated with better outcome.

Transcatheter closure of atrial septal defect in children using the Occlutech Figulla occluder device

Background Percutaneous transcatheter closure of atrial septal defect (ASD) among children using devices other than the Amplatzer septal occluder has not been extensively tested. Objectives We evaluated the efficiency and safety of secundum ASD closure using the Occlutech Figulla ASD occluder in children and the efficiency and safety of secundum ASD closure under transthoracic echocardiography (TTE) guidance in children with less than 12 kg body weight. Patients and methods Forty-two patients (19 girls and 23 boys; mean age 4.8±2.0 years) were enrolled in a prospective cohort study. All patients underwent TTE and transesophageal echocardiography (TEE) to assess the characteristics of the ASD before transcatheter closure. Procedures were performed under fluoroscopic and TTE or TEE guidance. Follow-up was done at 1, 3, and 6 months following the procedure by clinical and TTE examination. Results The mean defect size was 14.9±4.2 mm on TTE and 16.1±4.7 mm on TEE. The mean device size was 17.9±4.9 mm (range 10.5–27 mm). The mean procedure time was 59.6±19.5 min. Thirty-one cases were performed under general anesthesia and TEE guidance, whereas the other 11 cases were performed under general anesthesia and TTE guidance. The device was placed successfully in all 42 patients. A small residual flow was seen immediately after device placement in three (7.1%) patients, which disappeared at 6 months. No complications occurred during the procedure. All patients were asymptomatic during the follow-up period. Conclusion Transcatheter closure of secundum ASD is generally safe and efficient in children younger than 12 years old, and ASD closure under TTE guidance in children less than 12 kg body weight is considered safe and efficient when performed in a tertiary center in the presence of an expert echocardiographer and interventional cardiologist.