918-7 Limitations of Percutaneous Interventions in the Treatment of Bifurcation Lesions Involving the Left Anterior Descending Coronary Artery

Serious complications may occur when intervention is unsuccessful in bifurcation lesions involving the left anterior descending (LAD) and first major diagonal (D), because of the large amount of involved myocardium. To determine this complication rate, we reviewed 82 consecutive cases, over a 3 year period, in which these lesions were attempted. Sixty-six percent of the subjects were male, and 37% had unstable angina. The mean age was 59 and the mean ejection fraction was 56%. Digital calipers were used to measure vessel minimum lumen (MLD) and reference diameters. For the LAD the final MLD was 1.81mm and for the 0 1.32mm. The final percent mean diameter stenoses for the LAD and D were 41% and 45%, respectively. There were no significant differences in the rates of success or complication between groups treated with angioplasty only (N=68) or directional atherectomy (N=14). The in-hospital event-free success rate was 55%. The in-hospital complication rates were:Recurrent Ischemia16%Ventricular Tachycardia2%Myocardial Infarction14%Stroke2%Bypass Surgery12%Death1%Repeat Procedure4%Composite34%ConclusionLAD bifurcation lesion intervention is associated with a high in-hospital complication rate. Since these lesions are not amenable to stent placement or atherectomy with simultaneous protection of both vessels, these cases should be carefully evaluated before intervention, and bypass surgery should be considered as a treatment option

Approaches for advancing scientific understanding of macrosystems

The emergence of macrosystems ecology (MSE), which focuses on regional- to continental-scale ecological patterns and processes, builds upon a history of long-term and broad-scale studies in ecology. Scientists face the difficulty of integrating the many elements that make up macrosystems, which consist of hierarchical processes at interacting spatial and temporal scales. Researchers must also identify the most relevant scales and variables to be considered, the required data resources, and the appropriate study design to provide the proper inferences. The large volumes of multi-thematic data often associated with macrosystem studies typically require validation, standardization, and assimilation. Finally, analytical approaches need to describe how cross-scale and hierarchical dynamics and interactions relate to macroscale phenomena. Here, we elaborate on some key methodological challenges of MSE research and discuss existing and novel approaches to meet them

Clinical outcomes after detection of elevated cardiac enzymes in patients undergoing percutaneous intervention

AbstractObjectives. We examined the relations of elevated creatine kinase (CK) and its myocardial band isoenzyme (CK-MB) to clinical outcomes after percutaneous coronary intervention (PCI) in patients enrolled in Integrilin (eptifibatide) to Minimize Platelet Aggregation and Coronary Thrombosis-II (trial) (IMPACT-II), a trial of the platelet glycoprotein IIb/IIIa inhibitor eptifibatide.Background. Elevation of cardiac enzymes often occurs after PCI, but its clinical implications are uncertain.Methods. Patients undergoing elective, scheduled PCI for any indication were analyzed. Parallel analyses investigated CK (n = 3,535) and CK-MB (n = 2,341) levels after PCI (within 4 to 20 h). Clinical outcomes at 30 days and 6 months were stratified by postprocedure CK and CK-MB (multiple of the site’s upper normal limit).Results. Overall, 1,779 patients (76%) had no CK-MB elevation; CK-MB levels were elevated to 1 to 3 times the upper normal limit in 323 patients (13.8%), to 3 to 5 times normal in 84 (3.6%), to 5 to 10 times normal in 86 (3.7%), and to >10 times normal in 69 patients (2.9%). Elevated CK-MB was associated with an increased risk of death, reinfarction, or emergency revascularization at 30 days, and of death, reinfarction, or surgical revascularization at 6 months. Elevated total CK to above three times normal was less frequent, but its prognostic significance paralleled that seen for CK-MB. The degree of risk correlated with the rise in CK or CK-MB, even for patients with successful procedures not complicated by abrupt closure.Conclusions. Elevations in cardiac enzymes, including small increases (between one and three times normal) often not considered an infarction, are associated with an increased risk for short-term adverse clinical outcomes after successful or unsuccessful PCI