Dual Antiplatelet Therapy Duration After Multivessel Optimal Intravascular Ultrasound-Guided Percutaneous Coronary Intervention.

BACKGROUND: There is a scarcity of data evaluating contemporary real-world dual antiplatelet therapy (DAPT) strategies after percutaneous coronary intervention (PCI).Methods and Results: In the OPTIVUS-Complex PCI study multivessel cohort enrolling 982 patients undergoing multivessel PCI, including left anterior descending coronary artery using intravascular ultrasound (IVUS), we conducted 90-day landmark analyses to compare shorter and longer DAPT. DAPT discontinuation was defined as withdrawal of P2Y12inhibitors or aspirin for at least 2 months. The prevalence of acute coronary syndrome and high bleeding risk by the Bleeding Academic Research Consortium were 14.2% and 52.5%, respectively. The cumulative incidence of DAPT discontinuation was 22.6% at 90 days, and 68.8% at 1 year. In the 90-day landmark analyses, there were no differences in the incidences of a composite of death, myocardial infarction, stroke, or any coronary revascularization (5.9% vs. 9.2%, log-rank P=0.12; adjusted hazard ratio, 0.59; 95% confidence interval, 0.32-1.08; P=0.09) and BARC type 3 or 5 bleeding (1.4% vs. 1.9%, log-rank P=0.62) between the off- and on-DAPT groups at 90 days. CONCLUSIONS: The adoption of short DAPT duration was still low in this trial conducted after the release of the STOPDAPT-2 trial results. The 1-year incidence of cardiovascular events was not different between the shorter and longer DAPT groups, suggesting no apparent benefit of prolonged DAPT in reducing cardiovascular events even in patients who undergo multivessel PCI.

Pseudo Atrium?: A Rare Presentation of Interventricular Septal Dissection Extending Into the Left Atrium.

Interventricular septal dissection is a rare complication of myocardial infarction. In cases with few left-to-right shunts in the ventricular septal perforation, interventricular septal dissection expands in the chronic phase. It is rare for the interventricular septal dissection to extend from the ventricular septum to the left atrial free wall. (Level of Difficulty: Intermediate.).

Single-Session Versus Staged Multivessel Optimal IVUS-Guided PCI in Patients With CCS or NSTE-ACS.

Background: There are no studies comparing single-session vs staged multivessel intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in patients with chronic coronary syndrome (CCS) or non-ST-segment-elevation acute coronary syndrome (NSTE-ACS). Objectives: The authors aimed to compare single-session vs staged multivessel IVUS-guided PCI in patients with CCS or NSTE-ACS. Methods: The OPTIVUS-Complex PCI study multivessel cohort was a prospective multicenter single-arm trial enrolling 1,021 patients with CCS or NSTE-ACS undergoing multivessel PCI including left anterior descending coronary artery using IVUS aiming to meet the prespecified OPTIVUS criteria for optimal stent expansion. We compared single-session vs staged multivessel PCI. The primary endpoint was a composite of death, myocardial infarction, stroke, or any coronary revascularization. Results: There were 246 patients (24.1%) undergoing single-session multivessel PCI, and 775 patients (75.9%) undergoing staged multivessel PCI. There was a wide variation in the prevalence of single-session multivessel PCI across the participating centers. The staged multivessel PCI group more often had complex coronary anatomy such as 3-vessel disease, chronic total occlusion, and calcified lesions requiring an atherectomy device compared with the single-session multivessel PCI group. The rates of PCI success, procedural complications, and meeting OPTIVUS criteria were not different between groups. The cumulative 1-year incidence of the primary endpoint was not different between single-session and staged multivessel PCI groups (9.0% vs 10.8%, log-rank P = 0.42). After adjusting confounders, the effect of single-session multivessel PCI relative to staged multivessel PCI was not significant for the primary endpoint (HR: 0.95; 95% CI: 0.58-1.55; P = 0.84). Conclusions: Single-session and staged multivessel IVUS-guided PCI had similar 1-year outcomes.

Optimal Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients With Multivessel Disease.

Background: Intravascular ultrasound (IVUS) was only rarely used in landmark trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel disease. Objectives: The authors aimed to evaluate clinical outcomes after optimal IVUS-guided PCI in patients undergoing multivessel PCI. Methods: The OPTIVUS (OPTimal IntraVascular UltraSound)-Complex PCI study multivessel cohort was a prospective multicenter single-arm study enrolling 1,021 patients undergoing multivessel PCI, including left anterior descending coronary artery using IVUS, aiming to meet the prespecified criteria (OPTIVUS criteria: minimum stent area > distal reference lumen area [stent length ≥28mm], and minimum stent area >0.8 × average reference lumen area [stent length <28mm]) for optimal stent expansion. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) (death/myocardial infarction/stroke/any coronary revascularization). The predefined performance goals were derived from the CREDO-Kyoto (Coronary REvascularization Demonstrating Outcome study in Kyoto) PCI/CABG registry cohort-2 fulfilling the inclusion criteria in this study. Results: In this study, 40.1% of the patients met OPTIVUS criteria in all stented lesions. The cumulative 1-year incidence of the primary endpoint was 10.3% (95% CI: 8.4%-12.2%), which was significantly lower than the predefined PCI performance goal of 27.5% (P < 0.001), and which was numerically lower than the predefined CABG performance goal of 13.8%. The cumulative 1-year incidence of the primary endpoint was not significantly different regardless of meeting or not meeting OPTIVUS criteria. Conclusions: Contemporary PCI practice conducted in the OPTIVUS-Complex PCI study multivessel cohort was associated with a significantly lower MACCE rate than the predefined PCI performance goal, and with a numerically lower MACCE rate than the predefined CABG performance goal at 1 year.

Target Lesion Revascularization After Intravascular Ultrasound-Guided Percutaneous Coronary Intervention.

BACKGROUND: Several stent expansion criteria derived from the intravascular ultrasound (IVUS) evaluation have been proposed to predict future clinical outcomes, but optimal stent expansion criteria as a guide during percutaneous coronary intervention (PCI) are still controversial. There are no studies evaluating the utility of stent expansion criteria along with the clinical and procedural factors in predicting target lesion revascularization (TLR) after contemporary IVUS-guided PCI. METHODS: OPTIVUS-Complex PCI study (Optimal Intravascular Ultrasound Guided Complex Percutaneous Coronary Intervention) multivessel cohort was a prospective multicenter study enrolling 961 patients undergoing multivessel PCI including left anterior descending coronary artery using IVUS with an intention to meet the prespecified criteria for optimal stent expansion. We compared several stent expansion criteria (minimum stent area [MSA], MSA/distal or average reference lumen area, MSA/distal or average reference vessel area, OPTIVUS criteria, IVUS-XPL [Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions] criteria, ULTIMATE [Intravascular Ultrasound Guided Drug Eluting Stents Implantation in "All-Comers" Coronary Lesions] criteria, and modified MUSIC [Multicenter Ultrasound Stenting in Coronaries Study] criteria) as well as clinical, angiographic, and procedural characteristics between lesions with and without TLR. RESULTS: Among 1957 lesions, the cumulative 1-year incidence of lesion-based TLR was 1.6% (30 lesions). Hemodialysis, treatment of proximal left anterior descending coronary artery lesions, calcified lesions, small proximal reference lumen area, and small MSA had univariate associations with TLR, while all of the stent expansion criteria except for MSA were not associated with TLR. The independent risk factors of TLR were calcified lesions (hazard ratio, 2.34 [95% CI, 1.03-5.32]; P=0.04) and small proximal reference lumen area (Tertile 1: hazard ratio, 7.01 [95% CI, 1.45-33.93]; P=0.02; and Tertile 2: hazard ratio, 5.40 [95% CI, 1.17-24.90]; P=0.03). CONCLUSIONS: In contemporary IVUS-guided PCI practice, the 1-year incidence of TLR was very low. MSA, but not other stent expansion criteria, had univariate association with TLR. Independent risk factors of TLR were calcified lesions and small proximal reference lumen area, although the findings should be interpreted with caution due to small number of TLR events, limited lesion complexity, and short duration of follow-up.

Late onset of coronary ostial stenosis following surgical aortic valve replacement in a patient with anomalous origin of the right coronary artery.

Surgical aortic valve replacement (SAVR) in patients with anomalous origination of a coronary artery from the opposite sinus is associated with risk for myocardial ischemia during the perioperative period. [1] However, iatrogenic coronary ostial stenosis (ICOS) generally occurs within the first 6 months after SAVR. We present an unusual case of a 74-year-old man with anomalous origination of the right coronary artery from the left coronary sinus, who developed effort angina due to ICOS 19 months following SAVR and ascending aorta replacement. Angiography and computed tomography were utilized to perform a comparison before and after the procedure. From the results, it was evident that the flattened mild stenosis preoperatively was caused by anomalous origination of a coronary artery from the opposite sinus and progressed to severe stenosis by ICOS after the procedure. The patient was successfully treated with percutaneous coronary intervention. .

Erythropoietin prevention trial of coronary restenosis and cardiac remodeling after ST-elevated acute myocardial infarction (EPOC-AMI): a pilot, randomized, placebo-controlled study.

BACKGROUND: Erythropoietin (EPO) enhances re-endothelialization and anti-apoptotic action. Larger clinical studies to examine the effects of high-dose EPO are in progress in patients with acute myocardial infarction (AMI). METHODS AND RESULTS: The aim of this multi-center pilot study was to investigate the effect of `low-dose EPO' (6,000 IU during percutaneous coronary intervention (PCI), 24 h and 48 h) in 35 patients with a first ST-elevated AMI undergoing PCI who was randomly assigned to EPO or placebo (saline) treatment. Neointimal volume, cardiac function and infarct size were examined in the acute phase and 6 months later (ClinicalTrials.gov identifier: NCT00423020). No significant regression in in-stent neointimal volume was observed, whereas left ventricular (LV) ejection fraction was significantly improved (49.2% to 55.7%, P=0.003) and LV end-systolic volume was decreased in the EPO group (47.7 ml to 39.0 ml, P=0.036). LV end-diastolic volume tended to be reduced from 90.2% to 84.5% (P=0.159), whereas in the control group it was inversely increased (91.7% to 93.7%, P=0.385). Infarction sizes were significantly reduced by 38.5% (P=0.003) but not in the control group (23.7%, P=0.051). Hemoglobin, peak creatine kinase values, and CD34(+)/CD133(+)/CD45(dim) endothelial progenitors showed no significant changes. No adverse events were observed during study periods. CONCLUSIONS: This is a first study demonstrating that short-term `low-dose' EPO to PCI-treated AMI patients did not prevent neointimal hyperplasia but rather improved cardiac function and infarct size without any clinical adverse effects.

Swallowing syncope: complex mechanisms of the reflex.

A 69-year-old woman was admitted to our hospital for the examination of syncope. When she ate solid food, she had dizziness or loss of consciousness. The ambulatory ECG suggested sino-atrial block during swallowing with a maximum sinus pause of 6 seconds. An electrophysiologic study revealed pre-existing sinus node dysfunction, which was exaggerated by the balloon inflation in the esophagus. Atropine counteracted the slowing of the basal sinus rate induced by esophageal pressure, but it did not block the effect on the maximum sinus node recovery time. This observation suggested that the syncope was mediated partly by a non-vagal mechanism.

Reverse redistribution of Tc-99m tetrofosmin in a patient with "takotsubo" cardiomyopathy.

An 82-year-old woman was referred to the authors' institution because of an electrocardiographic abnormality mimicking acute myocardial infarction. Left ventriculography showed apical wall hypokinesis and basal wall hyperkinesis. Coronary angiography revealed no organic stenosis. Three days earlier, she was told she had renal cancer. She was diagnosed as having "takotsubo" cardiomyopathy. She underwent early and delayed Tc-99m tetrofosmin single photon emission computed tomography (SPECT). The early SPECT images revealed homogeneous tracer uptake in the left ventricle, but the delayed images revealed decreased uptake in the apical wall. Reverse redistribution of Tc-99m tetrofosmin was observed in this patient with "takotsubo" cardiomyopathy.

Intermediate fixed coronary artery stenosis at the site of ergonovine-provoked spasm as a predictor of long-term major adverse cardiac events of patients with coronary spastic angina.

BACKGROUND: Organic coronary artery stenosis is a significant prognostic factor in patients with coronary spastic angina (CSA), so the present study was focused on assessing the impact of intermediate fixed stenosis at sites of provoked spasm on the long-term outcomes of CSA patients. METHODS AND RESULTS: CSA patients diagnosed on the basis of ergonovine-provoked spasm were enrolled and the clinical background and long-term prognosis of CSA patients with intermediate fixed stenosis at the site of provoked spasm (with-fixed-stenosis group, n=37) and those without fixed stenosis (without-fixed-stenosis group, n=126) were retrospectively compared. During the follow-up period (average 4.01 years for with-fixed-stenosis, 4.47 years for without-fixed-stenosis), the with-fixed-stenosis group had a significantly lower event-free survival rate, as well as a higher frequency of admission for unstable angina and percutaneous coronary intervention than the without-fixed-stenosis group, whereas the survival rate did not differ significantly between the 2 groups. In the multivariate analysis, intermediate fixed stenosis at the site of provoked spasm was a predictor of long-term major adverse cardiac events (MACE). CONCLUSIONS: Intermediate fixed stenosis at the site of ergonovine-provoked spasm is an independent risk factor for MACE during the long-term period in CSA patients.

Pathogenesis of acute myocardial infarction in young male adults with or without obesity.

OBJECTIVES: Obesity may be linked with coronary atherosclerosis in young males. This study investigated the etiology of acute myocardial infarction (AMI) in young Japanese male patients with or without obesity. METHODS AND RESULTS: This retrospective study included 2,230 AMI patients enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2005. Clinical background, risk factors, angiographic findings, acute results of primary percutaneous coronary intervention (PCI), and in-hospital outcome were evaluated in 33 young male patients < 40 years old. The study group was divided into the obese group [body mass index (BMI) > or =25, n=21] and non-obese group (BMI < 25, n=12). Four of the 12 non-obese patients had underlying disease (Kawasaki disease 2, Buerger's disease 1, drug abuse 1). The non-obese group had a higher prevalence of underlying disease than the obese group. The non-obese group had a higher incidence of left anterior descending coronary artery as culprit lesion and higher Thrombolysis in Myocardial Infarction (TIMI) grade flow in the infarct-related artery before primary PCI. The acquisition rates of TIMI 3 flow after primary PCI and in-hospital outcome did not differ between the two groups. CONCLUSIONS: Non-obese young AMI male patients have a higher frequency of underlying disease. Most young male AMI patients were obese, suggesting that obesity may be important in the pathogenesis of AMI in young male adults.

In-hospital outcomes of primary percutaneous coronary interventions performed at hospitals with and without on-site coronary artery bypass graft surgery.

BACKGROUND: Primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) is performed in hospitals without on-site coronary artery bypass graft surgery in the ;real world'. However, data on the in-hospital outcomes of primary PCI performed at hospitals with and without on-site cardiac surgery are still lacking in Japan. METHODS AND RESULTS: In the present study, 2,230 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2005. Of these, 1,817 patients underwent primary PCI. Excluding patients without adequate data, we retrospectively compared clinical background, coronary risk factors, angiographic findings, acute results of primary PCI and in-hospital prognosis between patients undergoing primary PCI in hospitals without on-site cardiac surgery (without surgery group, n=792) and those in hospitals with (with surgery group, n=993). The without surgery group had higher prevalence of previous myocardial infarction, Killip class>or=3 at admission and multivessels as a culprit lesion than the with surgery group. The without surgery group was more likely to have lower frequency of stent usage and lower thrombolysis in myocardial infarction flow grade just after PCI, whereas it was more likely to have intra-aortic balloon pumping and temporary pacing during procedures. The overall in-hospital mortality did not differ between the 2 groups. On multivariate analysis, in AMI patients undergoing primary PCI, Killip class>or=3 at admission, multivessels or left main trunk (LMT) as culprit lesions, number of diseased vessels>or=2 or diseased LMT, and age were the independent predictors of the in-hospital mortality, but the presence of on-site cardiac surgery was not. CONCLUSIONS: These results suggest that in-hospital outcomes in AMI patients undergoing primary PCI at hospitals without on-site cardiac surgery are comparable to those at hospitals with on-site cardiac surgery in Japan.

Intracoronary transplantation of non-expanded peripheral blood-derived mononuclear cells promotes improvement of cardiac function in patients with acute myocardial infarction.

BACKGROUND: Transplantation of non-expanded peripheral blood mononuclear cells (PBMNCs) enhances neovessel formation in ischemic myocardium and limbs by releasing angiogenic factors. This study was designed to examine whether intracoronary transplantation of PBMNCs improves cardiac function after acute myocardial infarction (AMI). METHODS AND RESULTS: After successful percutaneous coronary intervention (PCI) for a ST-elevation AMI with occlusion of proximal left anterior descending coronary artery within 24 h, patients received an intracoronary infusion of PBMNCs within 5 days after PCI (PBMNC group). PBMNCs were obtained from patients by COBE spectra-apheresis and concentrated to 10 ml, 3.3 ml of which was infused via over-the-wire catheter. The global left ventricular ejection fraction (LVEF) change from baseline to 6 months followup in th ePBMNC group that underwent standard PCI for similar AMI [corrected]. The primary endpoint was the global left ventricular ejection fraction (LVEF) change from baseline to 6 months' follow-up. The data showed that the absolute increase in LVEF was 7.4% in the control group and 13.4% (p=0.037 vs control) in the PBMNC group. Cell therapy resulted in a greater tendency of DeltaRegional ejection fraction (EF) or significant improvement in the wall motion score index and Tc-99m-tetrofosmin perfusion defect score associated with the infarct area, compared with controls. Moreover, intracoronary administration of PBMNCs did not exacerbate either left ventricular (LV) end-diastolic and end-systolic volume expansion or high-risk arrhythmia, without any adverse clinical events. CONCLUSION: Intracoronary infusion of non-expanded PBMNCs promotes improvement of LV systolic function. This less invasive and more feasible approach to collecting endothelial progenitor cells may provide a novel therapeutic option for improving cardiac function after AMI.

Medium-term prognosis of young Japanese adults having acute myocardial infarction.

BACKGROUND: Data on the medium- and long-term prognosis of young Japanese patients with acute myocardial infarction (AMI) are still lacking. METHODS AND RESULTS: In the present study, 1,458 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2003. Of these, clinical characteristics and medium-term prognosis were retrospectively compared in 21 young patients < 40 years (young group), and 190 non-young patients 60-70 years old (non-young group) who could be followed after hospital discharge. The young group was all male and had higher prevalence of current smoking and greater body mass index, but previous myocardial infarction (MI) and hypertension were more prevalent in the non-young group. The young group had a higher prevalence of single-vessel disease and a lesser incidence of left circumflex coronary artery as the culprit lesion. The acquisition rates of Thrombolysis In Myocardial Infarction 3 flow after primary percutaneous coronary intervention did not differ between the 2 groups, but the data of maximal creatine kinase was significantly higher in the young group. During the follow-up period (average 2.42 years for young, 2.37 years for non-young), survival and event-free survival rates and incidence of major adverse cardiac events (MACE) did not differ between the 2 groups. The predictor of MACE during follow-up period was the presence of multivessel disease in the young group, whereas the presence of multivessel disease, history of previous MI and longer hospitalization were the predictors of MACE in the non-young group. CONCLUSIONS: These results suggest that the medium-term prognosis in young AMI patients is comparable to that of non-young AMI patients in Japan.

Relation of obesity to acute myocardial infarction in Japanese patients.

BACKGROUND: It remains uncertain whether obesity is an independent risk factor for coronary heart disease in young adults, as well as adults, in Japan. METHODS AND RESULTS: In the present study, 1,260 cases of acute myocardial infarction (AMI) and 3,775 community controls were recruited from the AMI-Kyoto Multi-Center Risk Study and Kyoto Citizen's Health and Nutrition Study, respectively. Obesity and other risk factors were retrospectively examined between cases and controls in each subgroup of young males (20-40 years), middle-aged males or females (40-60 years), older males or females (60-80 years), and very old males or females (80-100 years). In young, middle-aged, and older males, as well as in older females, cases had a higher body mass index (BMI) than controls. In young males, as well as in middle-aged and older females, cases had a higher prevalence of smoking than controls. Except for very old males, the prevalences of hypercholesterolemia, hypertension, and diabetes mellitus were higher in each subgroup of cases than in controls. Multivariate logistic regression analysis revealed that obesity (BMI >or=25) was an independent risk for AMI in young and middle-aged males, but not in females, whereas smoking was an independent risk for AMI in middle-aged and older females as well as in older males. CONCLUSIONS: Obesity is significantly associated with AMI, independent of the classic coronary risk factors, in young and middle-aged males. These findings support the current emphasis on controlling obesity to prevent coronary events in young Japanese male adults.

'Gadolinium' as an alternative to iodinated contrast media for X-ray angiography in patients with severe allergy.

Some patients cannot undergo coronary angiography (CAG) because of the adverse effects of contrast media. In the present study gadolinium, (gadodiamide hydrate: Gd DTPA-BMA) commonly used for magnetic resonance imaging (MRI), was used as the contrast agent for diagnostic CAG in 3 patients with severe allergy to iodine or iodinated contrast agents. The indications for CAG were recurrent chest pain, evaluation of peri-operative risk of gastric cancer and abdominal aortic aneurysm, and evaluation of graft patency after coronary artery bypass grafting. The procedure was well tolerated by each patient and the amount of the gadolinium-based contrast media did not exceed 40 ml, which is twice the volume used for MRI. The images were of fair quality. In patients with allergy to iodinated contrast media, CAG with gadolinium-based contrast media is an alternative technique for evaluating coronary artery disease.

Acute myocardial infarction in young Japanese adults.

BACKGROUND: The prevalence and clinical manifestations of acute myocardial infarction (AMI) in young patients in Japan have not been fully investigated. METHODS AND RESULTS: In the present study, 1651 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and June 2004. Of these, the clinical background, risk factors, angiographic findings, acute results of primary percutaneous coronary intervention (PCI) and in-hospital outcomes for 27 young patients <40 (young group), and 338 non-young patients 60