Spontaneous Remission Without Steroid Therapy in Isolated Cardiac Sarcoidosis with Severe Left Ventricular Systolic Dysfunction.

Spontaneous remission is often observed in extracardiac cases of sarcoidosis, such as skin sarcoidosis. However, for cardiac sarcoidosis (CS), the prognosis is unfavorable. Although corticosteroids are the first-line treatment for CS, data regarding the natural history of isolated CS are limited. We describe a rare case of isolated CS with severe left ventricular systolic dysfunction that improved without steroid therapy.

Two cases of idiopathic pulmonary fibrosis evaluated by dynamic digital radiography for diaphragmatic motion and disease progression.

Forced vital capacity has been utilized as a parameter of disease progression in idiopathic pulmonary fibrosis (IPF); however, its measurement is difficult when patients do not understand or cooperate. Dynamic digital radiography (DDR) enables sequential chest X-ray imaging during breathing, with lower radiation doses compared to conventional fluoroscopy or computed tomography. There is accumulating evidence showing that parameters obtained from DDR, particularly those related to diaphragmatic dynamics, are correlated with pulmonary function parameters, and are useful for pathophysiological evaluation. We herein present two cases that suggest parameters obtained from DDR during supine normal tidal breathing may predict disease progression of IPF.

Safety and potential usefulness of sequential intracoronary acetylcholine and ergonovine administration for spasm provocation testing.

BACKGROUND: Although guidelines recommend intracoronary acetylcholine (ACh) and ergonovine (ER) provocation testing for diagnosis of vasospastic angina, the feasibility and safety of sequential (combined) use of both pharmacological agents during the same catheterization session remain unclear. OBJECTIVES: In this study, we investigated the feasibility and safety of sequential intracoronary ACh and ER administration for coronary spasm provocation testing. METHODS: The study included 235 patients who showed positive results on ACh and ER provocation testing. Initial intracoronary ACh administration was followed by ER administration for left coronary artery (LCA) spasm provocation testing. Subsequently, the right coronary artery (RCA) was subjected to sequential ACh and ER administration for provocation testing. The primary outcome of the study was the safety of sequential intracoronary ACh and ER provocation testing, which was assessed based on a composite of all-cause death, sustained ventricular tachycardia and fibrillation, and cardiogenic shock. RESULTS: Even in patients with negative results on sequential intracoronary ACh and ER provocation testing in the LCA and only ACh administration into the RCA, additional administration of ER into the RCA showed a positive provocation test result in 33 of 235 (14.0%) patients; three (1.3%) patients developed adverse effects (cardiogenic shock occurred in all cases) during LCA provocation testing. We observed no deaths attributable to spasm provocation testing. CONCLUSION: Sequential administration of intracoronary ACh and ER was associated with a relatively low major complication rate and may be safe and potentially useful for diagnosis of vasospastic angina.

Safety and potential usefulness of novel coronary spasm provocation testing protocolCoronary spasm represents a subtype of ischemic heart disease, potentially leading to heart attack. Although guidelines recommend intracoronary administration of different pharmacological agents, acetylcholine (ACh) and ergonovine (ER), for coronary spasm provocation testing, the feasibility and safety of sequential (combined) use of both drugs are unclear. In the present study, we showed that sequential administration of intracoronary ACh and ER was associated with a relatively low major complication rate and may be safe and potentially useful for diagnosis of coronary vasospasm.

Coexistence of Spontaneous Coronary Artery Dissection, Takotsubo Cardiomyopathy, and Myocardial Bridge.

We report a case of spontaneous coronary artery dissection located next to a myocardial bridge in a patient with concomitant takotsubo cardiomyopathy. A fusion image with multidetector-row computed tomography and single-photon emission computed tomography played an important role in the diagnosis of these lesions. (Level of Difficulty: Advanced.).

[The Mid-term Results of Transapical Transcatheter Aortic Valve Implantation for Aortic Stenosis].

We aimed to evaluate the results of transapical transcatheter aortic valve implantation (TAVI) for aortic stenosis. Thirty patients who had aortic stenosis and underwent transapical TAVI between 2016 and 2020 were enrolled. Medical records were reviewed, and the following data were retrieved and analyzed:basic demographic data, and intraoperative data and postoperative outcomes. Mean age was 85.8 years. There were 3 intraoperative complications (1 apex bleeding, 1 coronary stenosis and 1 mitral regurgitation). Extracorporeal membrane oxygenation was initiated due to unstable hemodynamics in two patients. One patient was converted to mitral valve replacement due to severe mitral regurgitation. There were 2 in-hospital complications (1 with sick sinus syndrome and 1 with cerebral infarction). One patient died of cerebral infarction and eventually, the 30-day mortality was 3%. Median observational period was 1.3 years. Three-year survival was 87.3%. Left ventricular ejection fraction increased by six months after the procedure and then, reached plateau. Left ventricular mass index decreased constantly throughout the observational period. Both parameters at one year after the procedure were significantly higher than preoperative ones. In conclusion, survival after transapical TAVI was favorable because of the low critical complication rate. Both left ventricular functional improvement and reverse remodeling were obtained.

The interference with transapical transcatheter aortic valve implantation by the anterior chordae tendineae preserved at previous mitral valve replacement.

Preserved anterior chordae tendineae is a possible risk factor for disturbing delivery of a transcatheter heart valve. Inserting a sheath just below the aortic valve for delivery of the transcatheter heart valve might be proposed as an alternative to avoid the chordae tendineae.

The Role of Saline and Sodium Bicarbonate Preprocedural Hydration to Prevent Mid-term Renal Insufficiency in Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention.

Objective Persistent renal damage (RD) three months after exposure to contrast media is associated with contrast-induced acute kidney injury (CI-AKI) and poor clinical outcomes. Little is known about the role of preprocedural hydration on persistent RD in patients with chronic kidney disease [CKD; estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2] undergoing percutaneous coronary intervention (PCI). We therefore examined the use of preprocedural hydration to decrease the incidence of persistent RD. Methods Between 2012 and 2015, 1,230 consecutive patients undergoing PCI, except for patients with an eGFR ≥60 mL/min/1.73 m2, on dialysis, having acute myocardial infarction, or recently having started renin-angiotensin inhibitors, were screened (n=333). Before their index PCI, the 12-h saline group (n=103) received 1 mL/kg/h 0.9% sodium chloride for 12 hours, and the 1-h bicarbonate group (n=63) received 3 mL/kg 154 mEq/L sodium bicarbonate for 1 hour. The control group (n=167) received no pre-procedural hydration. The study outcome of kidney function decline was investigated using the percent-change (%-change) of the calculated creatinine clearance between the baseline value and the lowest value recorded three to six months after index PCI. Results There was less renal function deterioration in the saline group than in the control group, and the bicarbonate group showed deterioration similar to the other groups (%-change; 12-h saline 2.0±11.3% vs. control -5.6±12.6%, p<0.001; vs. 1-h bicarbonate -1.8±14.1%, p=0.18; 1-h bicarbonate vs. control, p=0.14 ANOVA). A multiple regression analysis adjusted for risk factors for persistent RD showed that saline hydration correlated independently with a higher %-change (r=0.262, p<0.001). Conclusion Preprocedural 12-h saline may be better than no preprocedural hydration in preventing mid-term renal insufficiency in CKD patients undergoing PCI.

Impact of Chronic Kidney Disease on Outcomes After Percutaneous Coronary Intervention for Chronic Total Occlusions (from the Japanese Multicenter Registry).

The impact of chronic kidney disease (CKD) and potential pharmacologic intervention on clinical outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) remains unknown. A total of 1,463 patients underwent successful CTO-PCI between August 2004 and December 2014. Major adverse cardiovascular events (MACE) defined as the composite of all-cause death, myocardial infarction and target lesion revascularization, cardiac death, and stent thrombosis were compared between patients with and without CKD (555 and 908 patients, respectively). The results demonstrated higher risks of MACE (log-rank p = 0.015), all-cause death (log-rank p <0.001), and cardiac death (log-rank p <0.001) in the CKD group compared with the non-CKD group. Multivariable analyses demonstrated that CKD was an independent predictor for MACE (hazard ratio 1.23, 95% confidence interval 1.02 to 1.47, p = 0.03). With regard to pharmacotherapy, statin use was associated with significantly lower rates of MACE in the CKD group (log-rank p = 0.003). In conclusion, the presence of CKD would be an important predictor of long-term clinical outcomes in patients who underwent CTO-PCI, and use of statin may influence in reducing the adverse clinical outcomes.

Impact of target vessel on long-term cardiac mortality after successful chronic total occlusion percutaneous coronary intervention: Insights from a Japanese multicenter registry.

BACKGROUND: The impact of successful chronic total occlusion (S-CTO) percutaneous coronary intervention (PCI) on cardiac mortality may differ depending on target CTO vessel; however, to date this has not yet been adequately evaluated. The aim of this study was to investigate the impact of target vessel on cardiac mortality after S-CTO PCI. METHODS: From January 2004 to December 2011, 1517 CTO PCIs were performed in 4 Japanese centers and enrolled in a multicenter registry. Cases were retrospectively analyzed and divided per target vessel treated. The primary endpoint was cardiac mortality during the follow-up period. RESULTS: During the study period, 1424 CTOs with 1 main vessel CTO per patient were analyzed (left anterior descending artery [LAD]: 487, right coronary artery [RCA]: 599, left circumflex [LCx]: 338). 92.3% (n=1314) of cases were S-CTO PCIs. The median follow-up period was 1677 (interquartile range; 811-2463) days. In LAD and RCA CTOs, S-CTO PCI was associated with a lower cardiac mortality rate at 5-year follow-up when compared with unsuccessful CTO (U-CTO) (2.6% vs 9.7%, p=0.01, 2.6% vs 27.3%, p<0.01, respectively). This finding was not present with LCx CTO PCI (2.2% vs 0.0%, p=0.53). Cox regression analysis demonstrated that LAD and RCA S-CTO PCI were independent predictors of a lower cardiac mortality rate (LAD; HR: 0.18, 95% CI: 0.06-0.56; p<0.01; RCA; HR: 0.24, 95% CI: 0.09-0.65; p<0.01). CONCLUSIONS: S-CTO LAD and RCA PCI were associated with a lower long-term cardiac mortality after CTO PCI. This finding was not observed with LCx CTO PCI.

Effect of remote ischemia or nicorandil on myocardial injury following percutaneous coronary intervention in patients with stable coronary artery disease: A randomized controlled trial.

BACKGROUND: The effect of remote ischemic preconditioning (RIPC) and nicorandil on periprocedural myocardial injury (pMI) in patients with planned percutaneous coronary intervention (PCI) remains controversial. The aim of this randomized trial was to evaluate the effect of RIPC or nicorandil on pMI following PCI in patients with stable coronary artery disease (CAD) compared with a control group. METHODS: Patients with stable CAD who planned to undergo PCI were assigned to a 1:1:1 ratio to control, RIPC, or intravenous nicorandil (6mg/h). Automated RIPC was performed by a device, which performs intermittent arm ischemia through three cycles of 5min of inflation and 5min of deflation of a pressure cuff. The primary outcome was the incidence of pMI, determined by an elevation in high-sensitive troponin T or creatine kinase myocardial band at 12 or 24h after PCI. The secondary outcomes were ischemic events during PCI and adverse clinical events at 8months after PCI. RESULTS: A total of 391 patients were enrolled. The incidence of pMI following PCI was not significantly different between the control group (48.9%) and RIPC group (39.5%; p=0.14), or between the control group and nicorandil group (40.3%; p=0.17). There were no significant differences in ischemic events during PCI or adverse clinical events within 8months after PCI among the three groups. CONCLUSIONS: This study demonstrated moderate reductions in biomarker release and pMI by RIPC or intravenous nicorandil prior to the PCI consistently, but may have failed to achieve statistical significance because the study was underpowered.

Expansion in calcific lesions and overall clinical outcomes following bioresorbable scaffold implantation optimized with intravascular ultrasound.

OBJECTIVES: This study aimed to investigate clinical outcomes following bioresorbable scaffold (BRS) optimized with intravascular ultrasound (IVUS), and furthermore expansion of BRS in calcific lesions. BACKGROUND: Although IVUS use has contributed to improved clinical outcomes with metallic stent implantation, it is unclear if this is also true with regards to BRS, especially in calcified lesions. METHODS: Between May 2012 and April 2015, 291 lesions in 198 patients were treated with BRS with IVUS use. We evaluated overall clinical outcomes at 1-year and investigated the expansion and eccentricity index of BRS amongst quadrants categorized by calcium arc (CA) every 90-degrees. RESULTS: The rates of major adverse cardiac events were 5.4% (at 6 months) and 10.7% (at 12 months). TLR was observed in 3.1% at 6-month and 7.5% at 12-month follow up. Although there was a significant difference among quadrants regarding to eccentricity of calcium (0°â‰¦CA < 90°: 0.82 ± 0.09, 90°â‰¦CA < 180°: 0.75 ± 0.12, 180°â‰¦CA < 270°: 0.78 ± 0.11, and 270°â‰¦CA≦360°: 0.79 ± 0.09, ANOVA P = 0.002), the BRS expansion index [minimal scaffold area (MSA) divided by BRS area expanded at a nominal pressure] was comparable between quadrants. CONCLUSIONS: The use of IVUS to optimize BRS implantation results in favorable clinical outcomes even for complex lesions. Although eccentric calcium distribution resulted in asymmetric expansion of BRS, the final MSA was comparable irrespective of calcium distribution. © 2016 Wiley Periodicals, Inc.

Clinical outcomes of a real-world cohort following bioresorbable vascular scaffold implantation utilising an optimised implantation strategy.

AIMS: It has become apparent that, in comparison to metallic stents, bioresorbable vascular scaffolds (BVS) require specific implantation techniques. The aim of this study was to investigate outcomes following BVS implantation using a dedicated strategy for optimal deployment. METHODS AND RESULTS: Four hundred consecutive lesions (264 patients) treated with the Absorb BVS were analysed. All procedures were performed based on the following principles: 1) aggressive lesion preparation; 2) high-pressure post-dilation; and 3) a low threshold for intravascular imaging. The majority of target lesions (74.8%) were type B2 or C lesions. Predilation (97.3%) and post-dilation (99.8%) were performed in almost all cases. The mean post-dilation pressure was 21±5 atm, and the total scaffold length per patient was 53.2±32.5 mm. Intravascular imaging was performed in the majority of cases (85.8%) and, when utilised after post-dilatation, a further intervention was required in 24.5% of lesions. The cumulative target lesion failure rates were 7.9% at one year and 11.6% at two years. Definite/probable scaffold thrombosis occurred in three patients (1.2% at one and two years). CONCLUSIONS: Clinical outcomes following implantation of current-generation BVS, in a real-world population with a high prevalence of complex lesions, were acceptable when utilising our optimised implantation strategy.

Clinical Outcomes After Implantation of Overlapping Bioresorbable Scaffolds vs New Generation Everolimus Eluting Stents.

INTRODUCTION AND OBJECTIVES: There is limited evidence on procedural and clinical outcomes in patients treated with overlapping bioresorbable scaffolds vs overlapping everolimus-eluting stents. We evaluated the outcomes of propensity-matched patients treated with overlapping scaffolds vs everolimus-eluting stents. METHODS: After propensity matching, 70 consecutive stable angina patients treated with overlapping bioresorbable scaffolds and 70 patients treated with overlapping new generation everolimus stents were included in this study. The primary outcome was the 1-year rate of major adverse cardiovascular events, defined as the composite of all-cause mortality, nonprocedural myocardial infarction, and target-vessel revascularization. RESULTS: Patients in the 2 groups had similar age (scaffold vs stent: 64.5 ± 10.3 vs 66 ± 9.7 years; P=.381), sex, diabetes, previous cardiovascular history, and SYNTAX score (scaffold vs stent: 18.6 ± 9.2 vs 19.4 ± 10.4; P=.635). Postprocedural acute gain was significantly lower in patients treated with scaffolds (1.82±0.66 vs 2.03±0.68mm; P=.033). At 1-year follow up, the estimated major adverse cardiovascular event rate was not significantly different between the 2 groups (scaffold vs stent: 14.5% vs 14.6%; Plog-rank=.661). Similarly, no significant differences were seen in 1-year rates of target vessel (scaffold vs stent: 14.5% vs 10%; Plog-rank=.816) or target lesion revascularization (scaffold vs stent: 9.7% vs 8.3%; Plog-rank=.815). CONCLUSIONS: Treating long lesions with overlapping scaffolds is feasible with acceptable 1-year outcomes.

The use of a scoring balloon for optimal lesion preparation prior to bioresorbable scaffold implantation: a comparison with conventional balloon predilatation.

AIMS: Meticulous lesion preparation prior to bioresorbable vascular scaffold (BVS) implantation has been strongly recommended. The aim of this study was to investigate if there was a benefit associated with scoring balloon use in lesion preparation in comparison to conventional balloons prior to implantation of a BVS. METHODS AND RESULTS: Of the lesions treated with BVS between May 2012 and July 2014, 155 lesions in the conventional balloon group and 29 lesions in the scoring balloon group were included. Procedures without predilatation and those which utilised cutting balloon or rotational atherectomy devices were excluded. Complex (B2/C lesion: 76.1% vs. 93.1%; p=0.028), restenotic (5.2% vs. 17.2%; p=0.036) and calcified (36.1% vs. 79.3%; p<0.001) lesions were more common in the scoring balloon group. Compared to the conventional balloon group, the scoring balloon group demonstrated better procedural IVUS outcomes with regard to both expansion index (defined as scaffold lumen area divided by final post-dilatation balloon cross-sectional area, 0.71 vs. 0.86; p<0.001) and eccentricity index (defined as minimal scaffold diameter divided by maximal scaffold diameter, 0.78 vs. 0.84; p<0.001). The occurrence of ischaemia-driven target lesion revascularisation at one year was similar (6.1% vs. 7.1%; p=0.87). CONCLUSIONS: Lesion preparation for complex lesions using a scoring balloon appeared to facilitate optimal sizing and radially concentric expansion of BVS.

Procedural outcomes of patients with calcified lesions treated with bioresorbable vascular scaffolds.

AIMS: To compare the feasibility, procedural and clinical outcomes after implantation of bioresorbable vascular scaffolds (BVS) in patients with calcified lesions. METHODS AND RESULTS: We assessed the feasibility of BVS implantation and procedural outcomes in patients with and without calcific lesions. The primary outcome was angiographic and procedural success. Secondary outcomes included major adverse cardiovascular events (MACE). Of 163 patients, 62 (38%) had calcified lesions. Patients with calcific lesions had a higher prevalence of diabetes (35.5% vs. 22.8%, p=0.078) and chronic kidney disease (31.1% vs. 13.9%, p=0.008), and higher SYNTAX scores (18.9±9.7 vs. 15.1±9.0, p=0.017). Calcific lesions required longer procedures (126.4±39.8 vs. 106.9±37.1 min, p=0.015), more frequent use of dedicated devices and IVUS. Acute gain (1.83±0.6 vs. 1.86±0.6, p=0.732) and angiographic success were similar (98% non-calcific vs. 95.2% calcific, p=0.369), whereas procedural success was reduced in patients with calcific lesions (94.1% vs. 83.9%, p=0.034) due to higher rates of periprocedural myocardial infarction (MI) (5% vs. 13.1%, p=0.067). During the median follow-up time of 14 months MACE rates (10.9% non-calcific vs. 12.9% calcific, plog-rank=0.546) were similar. CONCLUSIONS: Treating calcific lesions with BVS is feasible with high angiographic success rates, at the expense of longer procedure times, aggressive lesion preparation and increased rates of periprocedural MI.

Evaluation of the Safety of Everolimus-Eluting Bioresorbable Vascular Scaffold (BVS) Implantation in Patients With Chronic Total Coronary Occlusions: Acute Procedural and Short-Term Clinical Results.

AIMS: The bioresorbable vascular scaffold (BVS) (Abbott Vascular) provides temporary scaffolding while eluting everolimus. There are limited data on its use in daily practice, especially in patients with stable angina pectoris referred for elective percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). The current study aims to investigate the safety and efficacy of BVS implantation in a selected patient cohort with CTO. METHODS: A total of 70 consecutive patients, who underwent successful recanalization of CTO with BVS between September 13, 2012 and September 20, 2014 in three cardiac centers (Department of Cardiology, Bezmialem Vakif University, Istanbul, Turkey; Department of Interventional Cardiology, San Raffaele Hospital, Milan, Italy; and EMO-GVM Centro Cuore Columbus, Milan, Italy) were included in this CTO registry. Endpoints analyzed included: (1) the composite of all-cause death and non-fatal myocardial infarction (MI); and (2) the composite safety endpoint of major adverse cardiovascular events (MACEs), including death, MI and symptom-driven target lesion revascularization (TLR). RESULTS: Clinical data were obtained for 70 patients (mean age, 56.9 ± 9.4 years; 90.0% male) with a total number of 76 CTOs. At a median follow-up of 11.0 months (interquartile range, 7-18 months), both MACE and TLR rates were 4.3%. Two patients suffered from ischemia-driven TLR (1 patient at 6 months and 1 patient at 9 months after implantation). No death, MI, or stent thrombosis was observed during the follow-up period. CONCLUSION: Treatment of CTOs with BVS seems to be safe and effective, with a high technical success rate and acceptable MACE at short-term follow-up.

Early Outcomes With Direct Flow Medical Versus First-Generation Transcatheter Aortic Valve Devices: A Single-Center Propensity-Matched Analysis.

OBJECTIVES: To compare early outcomes between Direct Flow Medical (DFM) and 1(st) -generation transcatheter aortic valve replacement (TAVR) devices. BACKGROUND: The effectiveness of new-generation TAVR devices compared with earlier generations is unclear. METHODS AND RESULTS: Overall, 496 patients treated between November 2007 and March 2014 were included: 44 (8.7%) treated with DFM, 179 (36.9%) with Medtronic CoreValve (MCV) and 273 (54.4%) with Edwards Sapien / Sapien XT (SXT) valve. Because of differences in baseline characteristics, propensity-score matching among patients treated in the same time span (March 2012-March 2014) was performed. The primary objective was the VARC-2 device success composite endpoint. Propensity-score matching identified 41 patients in each group. A higher device success composite endpoint was observed in DFM (DFM 97.6% vs. MCV 65.9% vs. SXT 92.7%; P < 0.001). This was attributed to a significantly lower incidence of moderate-to-severe post-procedural aortic regurgitation (AR; 2.4% vs. 22% vs. 7.3%; P < 0.001), lower rate of valve embolization (0% vs. 7.3% vs. 0%; 0.041) and need for a 2nd valve implantation (0% vs. 7.3% vs. 0%; P = 0.041). CONCLUSIONS: DFM was associated with higher rates of device success and a lower incidence of post-procedural AR. New generation devices appear to address several of the limitations of earlier generation devices.