Surgical techniques using an attached patch for large left ventricular pseudoaneurysm after inferior acute myocardial infarction.

We report a case of large left ventricular pseudoaneurysm after inferior acute myocardial infarction. Patch repair is commonly performed; however, only a few studies have described specific surgical techniques for left ventricular pseudoaneurysm repair of the inferior left ventricular wall. As an optimal repair technique for left ventricular pseudoaneurysm of the inferior left ventricular wall is lacking, we believe our technique is safe and effective in repairing this pathology.

Impact of stent strut link location in proximal balloon edge dilation technique for bifurcation percutaneous coronary intervention.

The single-stent strategy has generally been accepted as the default approach to bifurcation percutaneous coronary intervention. We have proposed the proximal balloon edge dilation (PBED) technique to prevent stent deformation during side branch (SB) dilation. This bench study aimed to evaluate the impact of stent link location and stent design on stent deformation, obstruction by stent struts at a jailed SB ostium, and incomplete stent apposition in the proximal optimization technique (POT)-PBED procedure. A coronary bifurcation model was used. We intentionally set the absence or presence of stent link on the carina (link-free or link-connect) under videoscope observation and compared stent parameters between 3- and 2-link stents (n = 5 each, n = 20 total). In the link-free group, the SB jailing rate of 3-link stents was significantly higher than that of 2-link stents (15.5 ± 5.1% vs. 6.6 ± 1.2%, p = 0.009). In the link-connect group, the SB jailing rate of 3-link stents was significantly lower than that of 2-link stents (30.0 ± 4.5% vs. 39.0 ± 2.6%, p = 0.009). In the bifurcation segment, the rate of incomplete stent apposition was significantly lower for 3-link stents of the link-connect group than for 2-link stents of the link-connect group (3.3 ± 4.2% vs. 19.0 ± 7.8%, p = 0.009). For both stent designs, ellipticity ratio was higher for link-connect group than link-free group. Link location as well as stent cell design greatly impacted stent deformation during the POT-PBED procedure.

Efficacy of Optical Coherence Tomography-Guided Primary Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome.

Background: Optical coherence tomography (OCT) is currently used as a guide for percutaneous coronary intervention (PCI), however its clinical benefit in comparison with intravascular ultrasound (IVUS) remains unclear in patients with acute coronary syndrome (ACS). Objectives: The purpose of this study was to evaluate the clinical efficacy of OCT-guided PCI in comparison with IVUS-guided PCI in patients with ACS. Methods: The study participants comprised 280 consecutive ACS patients who underwent primary PCI for de novo culprit lesions under OCT or IVUS guidance. Results: Compared with the IVUS-guided group, the OCT-guided group had lower Killip classification (p < 0.001) and lower creatinine level at baseline (0.80 ± 0.37 mg/dl vs. 1.13 ± 1.29 mg/dl, p = 0.004). Fluoroscopy time and total procedure time were significantly shorter in the OCT-guided group than in the IVUS-guided group (32 ± 13 min vs. 41 ± 19 min, p < 0.001, and 98 ± 39 min vs. 127 ± 47 min, p = 0.002, respectively). The major adverse cardiovascular event-free survival curves were similar between the OCT- and IVUS-guided groups after adjusting for clinical background using propensity score (log-rank p = 0.328). Conclusions: After adjusting for clinical background, OCT-guided PCI could provide comparable clinical outcomes to IVUS-guided PCI in patients with ACS. Shorter fluoroscopy time and total procedure time with OCT may reduce patient radiation exposure and also improve hospital workflow.

Efficacy of a new generation intracoronary optical coherence tomography imaging system with fast pullback.

OBJECTIVES: We sought to investigate whether a novel, fast-pullback, high-frequency optical coherence tomography (HF-OCT) imaging system enables data acquisition with a reduced amount of contrast agents while retaining the same qualitative and quantitative lesion assessment to conventional OCT. BACKGROUND: The increased amount of administered contrast agents is a major concern when performing intracoronary OCT. METHODS: The present study is a single-center, prospective, observational study including 10 patients with stable coronary artery disease. A total of 28 individual coronary arteries were assessed by both fast-pullback HF-OCT and by conventional OCT. RESULTS: The contrast volume used in each OCT run for the HF-OCT system was significantly lower than for the conventional OCT system (5.0 ± 0.0 mL vs. 7.8 ± 0.7 mL, respectively, with a mean difference of -2.84 [95% confidence interval [CI]: -3.10 to -2.58]). No significant difference was found in the median value of the clear image length between the two OCT systems (74 mm [interquartile range [IQR]; 63, 81], 74 mm [IQR; 71, 75], p = 0.89). Fast-pullback HF-OCT showed comparable measurements to conventional OCT, including minimum lumen area (3.27 ± 1.53 mm2 vs. 3.21 ± 1.53 mm2 , p = 0.27), proximal reference area (7.03 ± 2.28 mm2 vs. 7.03 ± 2.34 mm2 , p = 0.96), and distal reference area (5.93 ± 1.96 mm2 vs. 6.03 ± 2.02 mm2 , p = 0.23). Qualitative OCT findings were comparable between the fast-pullback HF-OCT runs and conventional OCT with respect to identifying lipid-rich plaques, calcifications, layered plaques, macrophages, and cholesterol crystals. CONCLUSION: With the fast pullback function of a novel HF-OCT imaging system, we acquired OCT images using a significantly lower amount of contrast volume while retaining a comparable qualitative and quantitative lesion assessment to conventional OCT.

Automated diagnosis of optical coherence tomography imaging on plaque vulnerability and its relation to clinical outcomes in coronary artery disease.

This study sought to develop a deep learning-based diagnostic algorithm for plaque vulnerability by analyzing intravascular optical coherence tomography (OCT) images and to investigate the relation between AI-plaque vulnerability and clinical outcomes in patients with coronary artery disease (CAD). A total of 1791 study patients who underwent OCT examinations were recruited from a multicenter clinical database, and the OCT images were first labeled as either normal, a stable plaque, or a vulnerable plaque by expert cardiologists. A DenseNet-121-based deep learning algorithm for plaque characterization was developed by training with 44,947 prelabeled OCT images, and demonstrated excellent differentiation among normal, stable plaques, and vulnerable plaques. Patients who were diagnosed with vulnerable plaques by the algorithm had a significantly higher rate of both events from the OCT-observed segments and clinical events than the patients with normal and stable plaque (log-rank p < 0.001). On the multivariate logistic regression analyses, the OCT diagnosis of a vulnerable plaque by the algorithm was independently associated with both types of events (p = 0.047 and p < 0.001, respectively). The AI analysis of intracoronary OCT imaging can assist cardiologists in diagnosing plaque vulnerability and identifying CAD patients with a high probability of occurrence of future clinical events.

Layered Plaque in Organic Lesions in Patients With Coronary Artery Spasm.

Background Coronary artery spasm plays a vital role in the pathogenesis of coronary plaques. We sought to investigate the plaque characteristics of co-existing organic lesions in patients with coronary artery spasm in comparison to those without coronary artery spasm by intracoronary optical coherence tomography (OCT). Methods and Results We included 39 patients who presented with a symptom suspected of coronary spastic angina and had an organic lesion, defined as ≥plaque burden of 50% assessed by OCT. Coronary artery spasm was diagnosed by positive acetylcholine provocation test, or by spontaneous spasm detected during coronary angiography. A total of 51 vessels with an organic lesion were identified. Of these, coronary artery spasm was observed in 30 vessels (spasm), while not in 21 vessels (non-spasm). Organic lesions in the spasm vessels, compared with those in the non-spasm vessels, had a higher prevalence of layered plaque (93% versus 38%, P<0.001), macrophages (80% versus 43%, P=0.016), and intraplaque microchannels (73% versus 24%, P<0.001), and lower prevalence of macrocalcification (23% versus 62%, P=0.009) as assessed by OCT. Conclusions Layered plaque, macrophages, and intraplaque microchannels, were frequently observed in organic lesions in patients with coronary artery spasm. These findings suggest that coronary artery spasm induces local thrombus formation as well as active inflammatory response, therefore increasing the risk of rapid plaque progression and ischemic events in patients with coronary artery spasm.

Early Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Increases the Success of Aortic Remodeling.

BACKGROUND: Type B aortic dissection (TBAD) is treated with thoracic endovascular aortic repair (TEVAR). However, the optimal timing of the surgical intervention remains unclear. We aimed to investigate whether the timing of TEVAR impacts aortic remodeling. METHODS: Forty-three patients with TBAD (31 men and 12 women) who had undergone surgical intervention with TEVAR between January 2014 and June 2021 were retrospectively evaluated. The relationship between the timing of TEVAR and success of aortic remodeling was assessed using linear regression analysis. Successful aortic remodeling was defined by a reduction of diametric ratio (false lumen/aorta) at 3 points (thoracic region, thoracoabdominal region, and abdominal region) and measured using computed tomography both pre- and post-operatively. The level of statistical significance was set at P < 0.05. RESULTS: The timing of TEVAR after symptom onset was defined as early (≤14 days, n = 27, group E) or late (≥15 days, n = 16, group L). The median duration from symptom onset to TEVAR in groups E and L were 3 days (interquartile range [IQR], 1.5-6 days) and 196 days (IQR, 89.8-252.3 days), respectively (P < 0.001). Patent type, rupture, malperfusion, and continuous pain were present preoperatively in 82%, 3.7%, 14.8%, and 33.3% of patients in group E, respectively, and in 37.5%, 0%, 6.3%, and 0% of patients in group L, respectively. In group E, thoracic aortic diameter and false luminal thickness were decreased significantly from pre- to post-operation (36.9 ± 12.4 vs. 35 ± 12.7 mm, P = 0.03; 13.6 ± 6.2 vs. 3.4 ± 4.5 mm, P < 0.001, respectively). Whereas, thoracic aortic diameter significantly increased, and false luminal thickness did not significantly change pre- and post-operation in group L (32.7 ± 9.5 vs. 37 ± 12.8 mm, P = 0.041; 9.1 ± 4.5 vs. 7.5 ± 9.5 mm, P = 0.4, respectively). CONCLUSIONS: Our results suggest that early intervention for TBAD with TEVAR increases the success of aortic remodeling.

Bifurcation percutaneous coronary intervention of left main trunk treated using a proximal optimizing technique and proximal balloon edge dilation technique.

We present a case of bifurcation percutaneous coronary intervention (PCI) of the left main trunk (LMT) using a proximal balloon edge dilation (PBED) technique following a proximal optimizing technique (POT). The procedure of the PBED technique entailed precise positioning of the balloon for SB dilation, with the proximal radiopaque marker lying in the cross-sectional plane of the stent struts at the left circumflex artery (LCx) ostium. The PBED technique might prevent stent deformation induced by side branch (SB) dilation and eliminates the need for the second POT procedure in the re-POT sequence. In fact, three-dimensional reconstruction of optical coherence tomography (3D-OCT) revealed good opening of stent cells overlying the LCx ostium without deformation of stent struts causing incomplete stent apposition at the site opposite the LCx, so the second POT procedure was unnecessary in this case. .

Relationship of acute type A aortic dissection and disseminated intravascular coagulation.

OBJECTIVE: Acute type A aortic dissection (ATAAD) is a critical disease presenting with disseminated intravascular coagulation (DIC). However, the relationship between the degree of DIC and false lumen conditions remains unclear. In the present study, we evaluated the degree of preoperative DIC and the outcomes of ATAAD treatment. METHODS: A total of 124 patients with ATAAD (70 men and 54 women) treated from January 2012 to January 2020 were included in the present study. The correlation between the preoperative Japanese Association for Acute Medicine (JAAM) DIC score and the false lumen diameter and length, measured using preoperative computed tomography, was examined retrospectively. The correlations were calculated using liner regression analysis. The level of statistical significance was set at P < .05. RESULTS: The patients were divided into two groups: a low JAAM DIC score group and a high JAAM DIC score group. The preoperative JAAM DIC scores in the high- and low-score groups were 4.8 ± 1.2 and 1.7 ± 2.3, respectively (P < .001). The 5-year survival rates and aortic event-free rates in the low-score group were favorable compared with the high-score group; however, the differences were not statistically significant (80.8% vs 54.5%, P = .065; 63.9% vs 59.8%, P = .15, respectively). The false lumen diameter in the ascending aorta was greater in the high-score group than that in the low-score group (P < .05). The JAAM DIC score correlated significantly with the ascending false lumen diameter and the dissection length (r = 0.32 and P < .001; r = 0.29 and P = .001, respectively). A high JAAM DIC score was associated with communicating-type ATAAD (P < .05). CONCLUSIONS: Our results suggest that high preoperative JAAM DIC scores are associated with a large false lumen and communicating-type ATAAD.

Influence of dual antiplatelet therapy duration on neointimal condition after second-generation drug-eluting stent implantation.

Guidelines recommend shorter duration (1-12 months) for dual antiplatelet therapy (DAPT) in the second-generation drug-eluting stent (DES) era. However, whether shorter DAPT duration affects stent strut conditions and neointimal characteristics at mid-term follow-up remains uncertain. Therefore, we studied the relation between DAPT duration and vascular healing response as assessed by optical coherence tomography (OCT). This study was retrospective observational study. Participants comprised 64 patients who underwent serial OCT at both 9 and 18 months after DES implantation. All patients received DAPT until the 9-month follow-up then were divided into two groups: 49 patients who continued DAPT (longer DAPT group); and 15 patients who stopped taking the P2Y12 inhibitor and were treated with aspirin alone (shorter DAPT group) at the 18-month follow-up. Using OCT, we evaluated and compared stent strut conditions and neointimal characteristics between groups at both 9 and 18 months after stent implantation. Baseline clinical and procedural parameters were mostly similar between groups. At the 18-month follow-up, no in-stent thrombus assessed by OCT was observed in either group. No significant differences in OCT characteristics or measurements of neointima were seen between groups at 9- or 18-month follow-ups. Neointimal volume increased from 9 to 18 months in both groups, with a similar degree of neointimal proliferation in both groups (shorter DAPT group, 0.23 ± 0.29 mm3/mm; longer DAPT group, 0.19 ± 0.27 mm3/mm; P = 0.56). In conclusion, interrupting DAPT 9 months after second-generation DES implantation did not affect the development of in-stent thrombus, neointimal proliferation or stent strut coverage at 18-month follow-up compared with continuing DAPT.

Urgent percutaneous transluminal septal myocardial ablation for left ventricular outflow tract obstruction exacerbated after surgical aortic valve replacement.

Percutaneous transluminal septal myocardial ablation (PTSMA) is an established procedure for treating symptomatic hypertrophic obstructive cardiomyopathy. We report a case of urgent PTSMA for treating refractory heart failure due to exacerbated obstruction of the left ventricular outflow tract after surgical aortic valvular replacement to treat severe aortic stenosis.

Impact of Coronary Stent Design in Proximal Balloon Edge Dilation Technique for Bifurcation Percutaneous Coronary Intervention.

The proximal optimizing technique (POT) -proximal balloon edge dilation (PBED) sequence for side branch (SB) dilatation with cross-over single-stent implantation decreases both strut obstruction at the SB ostium and stent deformation at the main branch (MB).The purpose of this experimental bench test was to assess the impact of stent design on stent deformation, obstruction by stent struts at a jailed SB ostium, and stent strut malapposition in the POT-PBED sequence.Fractal coronary bifurcation bench models (60- and 80-degree angles) were used, and crossover single-stent implantation (3-link stent: XIENCE Sierra, Abbott Vascular, Santa Clara, CA, n = 10; 2-link stent: Synergy, Boston Scientific, Marlborough, MA, n = 10) was performed from the MB using the POT-PBED sequence. Jailing rates at the SB ostium, stent deformation, and stent strut malapposition of the bifurcation segment were assessed using videoscopy and optical coherence tomography.After SB dilatation using the PBED technique, jailing rates at the SB ostium and stent deformation did not differ significantly between the two types of stents. Conversely, the rate of malapposed struts of the bifurcation segment after the PBED procedure was significantly lower with 3-link stents than with 2-link stents for both 60- and 80-degree angles (60-degree angle: 4.3% ± 4.4% versus 22.0% ± 11.1%, P = 0.044; 80-degree angle: 20.8% ± 15.1% versus 57.2% ± 17.0%, P < 0.001, respectively).In the POT-PBED sequence, 3-link stents might be a preferable coronary bifurcation stent, maintaining a jailed SB ostium while significantly reducing stent strut malapposition of the bifurcation segment when compared with 2-link stents.

Abnormal shear stress and residence time are associated with proximal coronary atheroma in the presence of myocardial bridging.

BACKGROUND: Atheromatous plaques tend to form in the coronary segments proximal to a myocardial bridge (MB), but the mechanism of this occurrence remains unclear. This study evaluates the relationship between blood flow perturbations and plaque formation in patients with an MB. METHODS AND RESULTS: A total of 92 patients with an MB in the mid left anterior descending artery (LAD) and 20 patients without an MB were included. Coronary angiography, intravascular ultrasound, and coronary physiology measurements were performed. A moving-boundary computational fluid dynamics algorithm was used to derive wall shear stress (WSS) and peak residence time (PRT). Patients with an MB had lower WSS (0.46 ± 0.21 vs. 0.96 ± 0.33 Pa, p < 0.001) and higher maximal plaque burden (33.6 ± 15.0 vs. 14.2 ± 5.8%, p < 0.001) within the proximal LAD compared to those without. Plaque burden in the proximal LAD correlated significantly with proximal WSS (r = -0.51, p < 0.001) and PRT (r = 0.60, p < 0.001). In patients with an MB, the site of maximal plaque burden occurred 23.4 ± 13.3 mm proximal to the entrance of the MB, corresponding to the site of PRT. CONCLUSIONS: Regions of low WSS and high PRT occur in arterial segments proximal to an MB, and this is associated with the degree and location of coronary atheroma formation.

Highly Sensitive Determination of Amino Acids by LC-MS under Neutral Conditions.

Peptide drug leads possess unusual structural features that allow them to exert their unique biological activities and ideal physicochemical properties. In particular, these peptides often have D-amino acids, and therefore the absolute configurations of the component amino acids have to be elucidated during the structural determination of newly isolated peptide drug leads. Recently, we developed the highly sensitive labeling reagents D/L-FDVDA and D/L-FDLDA for the structural determination of the component amino acids in peptides. In an LC-MS-based structural study of peptides, these reagents enabled us to detect infinitesimal amounts of amino acids derived from mild degradative analysis of the samples. Herein, we firstly report the improved LC-MS protocols for the highly sensitive analyses of amino acids. Second, two new labeling reagents were synthesized and their detection sensitivities evaluated. These studies increase our understanding of the structural basis of these highly sensitive labeling reagents, and should provide opportunities for future on-demand structural modifications of the reagents to enhance their hydrophobicity, stability, and affinity for applications to specialized HPLC columns.

Acute coronary syndrome demonstrating plaque rupture in calcified plaque visualized by optical coherence tomography and near-infrared spectroscopy combined with intravascular ultrasound.

Optical coherence tomography (OCT) can visualize calcification of the coronary plaque as a low-intensity lesion with sharp borders. However, residual lipid tissue inside the calcification could pose a problem in plaque evaluation by OCT. We present a case of acute coronary syndrome (ACS) demonstrating plaque rupture in the calcified plaque. In this case, OCT demonstrated a cavity suspected to represent rupture in the calcified plaque and near-infrared spectroscopy revealed a lipid component behind the calcified plaque. Although calcified plaque is not considered a reason for ACS except for calcified nodules, residual lipid tissue inside the calcification might cause ACS if the thin fibrous cap over the lipid tissue is disrupted, even if surrounded by calcification. .