Differences of side branch jailing between left main-left anterior descending artery stenting and left main-left circumflex artery stenting with Nobori biolimus-eluting stent.

The aim of this study is to indicate differences of side branch jailing between the left main (LM)-left anterior descending artery (LAD) stenting and the LM-left circumflex artery (LCx) stenting. Thirty-one patients who underwent single-stenting using a two-link ten-crowns biolimus-eluting stent (Japanese design of BES, J-BES) and subsequent kissing balloon dilation (KBD) on an LM bifurcation with optical coherence tomography (OCT) were divided into two groups according to the stented vessel. Bifurcation angles were measured by three-dimensional (3D) quantitative coronary analysis. The jailing pattern on a side branch ostium was evaluated by stent-enhanced 3D-OCT. Incomplete stent apposition (ISA) after KBD was compared between the stented vessels. The to-be-stented angle of the LM-LCx stenting (n = 11) was significantly steeper than that of the LM-LAD stenting (n = 20) (132.6° ± 16.9° vs. 150.7° ± 10.6°, p < 0.01). The incidence of the free carina type, which has no stent links bridging from a carina, in the LM-LCx stenting was significantly higher than that in the LM-LAD stenting (90.9 vs. 45.0 %, p = 0.02). The percentage of ISA at the bifurcation segment in the LM-LCx stenting was significantly smaller than that in the LM-LAD stenting (4.4 ± 8.2 vs. 12.7 ± 9.2 %, p = 0.0003). This study showed, by higher incidence of the favorable configuration, that the LM-LCx stenting achieved a smaller percentage of ISA than the LM-LAD stenting. These insights may help guide LM bifurcation stenting with J-BES.

A Rare Case of Complete Stent Fracture, Coronary Arterial Transection, and Pseudoaneurysm Formation Induced by Repeated Stenting.

This report describes a rare asymptomatic case of complete stent fracture, coronary arterial transection, and pseudoaneurysm formation in response to repeated stenting. The proximal and distal ends of transected coronary artery were closed, and distal bypass was performed. Coronary arterial transection can occur in patients with repeated stenting as a long-term adverse event.

Association of apixaban therapy and prothrombin time in patients with atrial fibrillation.

BACKGROUND: This study evaluated whether measuring prothrombin time (PT) using particular reagents of interest predicted apixaban-associated anticoagulant activity in Japanese patients with non-valvular atrial fibrillation (NVAF). METHODS AND RESULTS: Two reagents, Shinplastin Excel S and Coagpia PT-N, were used to evaluate PT under apixaban therapy. From June 2013 to February 2014, 103 NVAF patients were recruited, and PT was measured at 3 time points: (1) anytime in the outpatient clinic, (2) at peak, and (3) at trough. In spike-in experiments using pooled citrated normal human platelet-poor plasma with these PT reagents, apixaban prolonged PT values in a concentration-dependent manner. PT values significantly correlated between both reagents (r=0.97) in outpatients. PT values in outpatients taking 5-mg apixaban bid were significantly prolonged and had wide inter- and intraindividual variability. Peak values were significantly higher than trough values, with both values higher than normal. The dose change of apixaban from 5 mg bid to 2.5 mg bid in outpatients halved the degree of PT prolongation in each NVAF patient. CONCLUSIONS: The PT value measured by these specific reagents can predict apixaban-associated anticoagulant activity, although there is significant interpatient variability.

Guide wire shadow assessed by shading index is reduced in sparse spring coil wire in optical coherence tomography.

One of the major problems of a Fourier-domain optical coherence tomography (FD-OCT) is the guide wire (GW) shadow which disturbs precise coronary assessment. If two or more GWs are used in a bifurcation PCI, the GW shadow becomes larger. In FD-OCT, GWs were usually observed as a crescent shape, but GWs with the sparse spring coil were observed as either round or crescent shape. The measured angle making GW shadow of GW without the sparse spring coil was similar to its theoretical angle (30.4 ± 1.7° vs. 30.1 ± 0.7°, p = 0.21); however, the measured angle of GW with the sparse spring coil was significantly smaller than its theoretical angle (16.8 ± 4.8° vs. 28.7 ± 1.5°, p < 0.01). For standardization of shading-effect of GW, a virtual diameter of GW which was calculated from a measured angle, an actual diameter of GW, and a distance between an imaging catheter and GW was defined as the shading index. The shading index of GW with the sparse spring coil was significantly smaller than that of GW without the sparse spring coil (0.008 ± 0.002 vs. 0.014 ± 0.001, p < 0.01). Shading indices of GWs with the sparse spring coil were smaller than their actual diameters. The sparse spring coil structure could contribute to the reduction of the GW shadow in FD-OCT. Also, we proposed the new and useful shading index to indicate the shading-effect of GW.

Japanese patients with Fabry disease predominantly showing cardiac and neurological manifestation with novel missense mutation: R220P.

BACKGROUND: Fabry disease, an X-linked lysosomal sphingolipid storage disorder caused by mutation of the α-galactosidase A (GLA) gene, results in systemic organ damage. However, the age of onset of clinical manifestations and course of the disease are variable even within the same family. OBJECTIVE: In this study, we evaluated the clinical phenotype and the molecular lesions associated with the GLA gene in a Japanese family with Fabry disease that predominantly showed cardiac and neurological manifestations. METHODS: A genetic analysis of the GLA gene using conventional genomic sequencing was performed in all seven members of this family, including four hemizygous males and three heterozygous females. Endomyocardial biopsy was performed in two patients with severe left ventricular (LV) hypertrophy. RESULTS: A novel missense mutation was identified at codon 220 in exon 5, thus resulting in an arginine to proline substitution (R220P) in all seven family members. The three adult hemizygous males had LV hypertrophy and developed neurological manifestations in their 50s. One of the adult hemizygotes developed complete atrioventricular block. On the other hand, we could not find any organ damage in a young hemizygous male or the three heterozygous females. CONCLUSION: We identified a novel missense mutation in a Japanese family with Fabry disease showing cardiac and neurological manifestations. In patients with Fabry disease, advanced organ damage in the heart and brain can be life-threatening, even if renal failure is lacking.

Novel and quick coronary image analysis by instant stent-accentuated three-dimensional optical coherence tomography system in catheterization laboratory.

In order to confirm the relation between stent struts and the jailed side branch (SB), the actual wire re-crossing position and the optimal wire re-crossing position during a bifurcation stenting, we developed the instant stent-accentuated three-dimensional optical coherence tomography (iSA 3D-OCT) system based on a novel algorithm. Stent struts in two-dimensional optical coherence tomography (2D-OCT) are represented as high-intensity line segments or spots in low-intensity background. Stent struts disappear and a vessel image is created by the mean filter followed by the minimum filter. A strut image is created by subtracting a vessel image from an original image, and accentuated. By adding a vessel image to a strut image, iSA 2D-OCT is created. It took only 3 s to accentuate stent struts of 100 frames by ImageJ with its macro program. By the iSA 3D-OCT system which consists of the console of OCT, the USB selector, USB cables, the USB flash drive, the computer, and three freeware programs, it took about 65 s from an export of the image data to an observation of iSA 3D-OCT semi-automatically. During a bifurcation stenting procedure, we could confirm the relation between stent struts and the jailed SB, the actual wire re-crossing position and the optimal wire re-crossing position. Using the iSA 3D-OCT system, a detailed process during a bifurcation PCI can be observed in very short waiting time, about 65 s. It is expected to improve the outcome of a complicated bifurcation PCI by the iSA 3D-OCT system.

A case of a concealed type of Brugada syndrome with a J wave and mild ST-segment elevation in the inferolateral leads.

We report a patient with a concealed type of Brugada syndrome. The electrocardiogram in the emergency department revealed atrial fibrillation with an almost normal ST segment. Slight electrocardiogram abnormalities of the J wave and mild ST-segment elevation appeared in the inferolateral leads a few days later. Although the ST segment in the right precordial leads, including that recorded from the high intercostal space recording sites, was completely normal, a drug challenge test using pilsicainide revealed a coved-type ST-segment elevation only in a modified V2 lead placed 1 or 2 intercostal spaces higher.

Different effect of the pure Na+ channel-blocker pilsicainide on the ST-segment response in the right precordial leads in patients with normal left ventricular function.

BACKGROUND: The response of the ST-segment in the right precordial leads to Na+ channel blockers in patients without structural heart disease and a typical Brugada-type ECG has not been fully elucidated. METHODS AND RESULTS: A pilsicainide challenge test was performed in 161 patients and according to recently established ECG criteria and an organized computer algorithm, the ST morphology was classified and the maximum increase in the J wave amplitude (maxDeltaJ) from the standard and high right precordial leads V1-3 was examined. Before the test, subjects exhibiting type 1 ECG in the standard leads were excluded. After administering pilsicainide, type 1 ECGs in the standard leads were observed in 31 cases and a maxDeltaJ of >or=200 microV was observed in 29 cases (23 type 1, 2 type 2/3 and 4 normal ECGs). In the additional higher right precordial leads, type 1 ECGs were observed in 55 cases and a maxDeltaJ of >or=200 microV was observed in 45 cases (42 type 1 and 3 type 2/3 ECGs). CONCLUSIONS: A maxDeltaJ>or=200 microV induced by pilsicainide, including that measured in the high right precordial leads, was associated with a change mainly to a type 1 ECG.

Novel mutation of plakophilin-2 associated with arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a disease characterized by dilatation and akinesis of the right ventricle, and causes life-threatening ventricular arrhythmia. Mutations of plakophilin-2 (PKP2) have recently been identified as one causative abnormality in ARVC. A case of ARVC with a mutation of PKP2 is reported here. Direct sequencing of the patient's DNA revealed an insertion mutation in exon 8 of PKP2 (1728_1729insGATG). The mutation caused the frameshift and the premature termination of translation (R577DfsX5). This is the first case report of PKP2 mutation found in Japanese ARVC patients.

Differentiation of the electrophysiological effects on the atrial myocardium between the pure Na channel blocker, pilsicainide, and flecainide.

UNLABELLED: The purpose of this study was to identify the difference between the pure Na channel blocker, pilsicainide and Ic-antiarrhythmic drug, flecainide, on the atrial electrophysiological characteristics. METHODS: The subjects consisted of 24 patients (48 +/- 12 years-old: P-group) in whom pilsicainide was administrated intravenously (1 mg/kg/10 min) and 31 patients (47 +/- 15 years-old: F-group) in whom flecainide was administrated intravenously (2 mg/kg/10 min). The atrial effective refractory period (ERP-A), intra-atrial conduction time (CT), max intra-atrial conduction delay (Max CD), repetitive atrial firing zone (RAFZ), fragmented atrial activity zone (FAZ) and intra-atrial conduction delay zone (CDZ) were measured before and after the drugs. RESULTS: Pilsicainide and flecainide significantly prolonged the ERP-A (211 +/- 27 msec to 246 +/- 39 msec; p < 0.001, 217 +/- 25 msec to 244 +/- 33 msec; p < 0.001, respectively) and CT (121 +/- 33 msec to 149 +/- 43 msec; p < 0.001, 122 +/- 22 msec to 153 +/- 27 msec; p < 0.001, respectively) to the same degree. However, the Max CD was shortened by pilsicainide, but not by flecainide. The RAFZ, FAZ and CDZ decreased in the P-group (21 +/- 25 msec to 4 +/- 10 msec; p < 0.01, 24 +/- 24 msec to 14 +/- 18 msec; p < 0.05, 56 +/- 29 msec to 43 +/- 32 msec, p < 0.05, respectively), but not in the F-group. CONCLUSIONS: The effects of atrial conduction delays may differ between pilsicainide and flecainide. Further examination will be needed to explain this mechanism.

Decrease in the spatial dispersion at the termination of atrial fibrillation by intravenous cibenzoline.

Atrial electrograms were recorded from the high right atrium, coronary sinus, and right lateral wall in 15 patients with induced atrial fibrillation (AF). Intravenous cibenzoline terminated AF in 8 patients (T group), but not in 7 patients (non-T group). The cycle length of the AF (AFCL) obtained by the autocorrelation function was measured every 5 s during the 30 s prior to the cibenzoline administration, and just before the termination of AF or at the end of the cibenzoline infusion in the non-T group. The mean AFCL, and spatial and temporal dispersion of the AFCL were then compared between the 2 groups (dispersion = standard deviation x 100 /mean AFCL). Cibenzoline significantly increased the mean AFCL and decreased the spatial dispersion in both groups. No significant difference in either the mean AFCL or temporal dispersion before or after cibenzoline was observed between the 2 groups. In addition, no significant difference in the spatial dispersion before the cibenzoline was observed, but the spatial dispersion after the cibenzoline was significantly smaller in the T group than in the non-T group. The mean AFCL, and the spatial and temporal dispersion before the cibenzoline did not predict the termination of AF. The decrease in the spatial dispersion may be the most important mechanism by which intravenous cibenzoline terminates AF.

New method of determining the atrial fibrillation cycle length during human atrial fibrillation.

INTRODUCTION: The aim of this study was to investigate the usefulness of the autocorrelation function (reversed fast Fourier transform analysis) in determining the atrial fibrillation cycle length (AFCL) during human atrial fibrillation (AF). METHODS AND RESULTS: From 30 episodes of atrial electrograms recorded for 30 seconds from the high right atrium during type I AF in 16 patients, the mean, 5th percentile (p5), and 95th percentile (p95) of the AFCLs were measured by using a computer-picked activation time. The peak, minimum, and maximum AFCLs also were measured by using the autocorrelation function. The mean AFCL was retrieved at the point of the maximum peak of the coefficient of the first positive autocorrelogram. The minimum AFCL (min AFCL) was chosen as the point where the first positive autocorrelogram crossed the baseline from negative to positive, and the maximum AFCL (max AFCL) was chosen as the point where the first positive autocorrelogram crossed the baseline from positive to negative. There was a significantly strong correlation between the mean and peak AFCLs (r = 0.995, P < 0.0001), p5 and min AFCLs (r = 0.953, P < 0.0001), and p95 and max AFCLs (r = 0.98, P < 0.0001). CONCLUSION: The autocorrelation function was useful in determining the AFCLs, at least during type I AF. The min AFCL may be used as an index of the refractory period during AF when the p5 AFCL approximates the refractory period.