Perioperative Antiplatelet Strategy in Patients Undergoing Noncardiac Surgery Within One Year After Percutaneous Coronary Intervention.

BACKGROUND: The optimal antiplatelet therapy (APT) for patients undergoing non-cardiac surgery within 1 year after percutaneous coronary intervention (PCI) is not yet established. METHODS: Patients who underwent non-cardiac surgery within 1 year after second-generation drug-eluting stent implantation were included from a multicenter prospective registry in Korea. The primary endpoint was 30-day net adverse clinical event (NACE), including all-cause death, major adverse cardiovascular event (MACE), and major bleeding events. Covariate adjustment using propensity score was performed. RESULTS: Among 1130 eligible patients, 708 (62.7%) continued APT during non-cardiac surgery. After propensity score adjustment, APT continuation was associated with a lower incidence of NACE (3.7% vs 5.5%; adjusted odds ratio [OR], 0.48; 95% confidence interval [CI], 0.26-0.89; P = .019) and MACE (1.1% vs 1.9%; adjusted OR, 0.35; 95% CI, 0.12-0.99; P = .046), whereas the incidence of major bleeding events was not different between the 2 APT strategies (1.7% vs 2.6%; adjusted OR, 0.61; 95% CI, 0.25-1.50; P = .273). CONCLUSIONS: The APT continuation strategy was chosen in a substantial proportion of patients and was associated with the benefit of potentially reducing 30-day NACE and MACE with similar incidence of major bleeding events, compared with APT discontinuation. This study suggests a possible benefit of APT continuation in non-cardiac surgery within 1 year of second-generation drug-eluting stent implantation.

Consensus Decision-Making for the Management of Antiplatelet Therapy before Non-Cardiac Surgery in Patients Who Underwent Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents: A Cohort Study.

Background Although antiplatelet therapy (APT) has been recommended to balance ischemic-bleeding risks, it has been left to an individualized decision-making based on physicians' perspectives before non-cardiac surgery. The study aimed to assess the advantages of a consensus among physicians, surgeons, and anesthesiologists on continuation and regimen of preoperative APT in patients with coronary drug-eluting stents. Methods and Results A total of 3582 adult patients undergoing non-cardiac surgery after percutaneous coronary intervention with second-generation stents was retrospectively included from a multicenter cohort. Physicians determined whether APT should be continued or discontinued for a recommended period before non-cardiac surgery. There were 3103 patients who complied with a consensus decision. Arbitrary APT, not based on a consensus decision, was associated with urgent surgery, high bleeding risk of surgery, female sex, and dual APT at the time of preoperative evaluation. Arbitrary APT independently increased the net clinical adverse event (adjusted odds ratio [ORadj], 1.98; 95% CI, 1.98-3.11), major adverse cardiac event (ORadj, 3.11; 95% CI, 1.31-7.34), and major bleeding (ORadj, 2.34; 95% CI, 1.45-3.76) risks. The association was consistently noted, irrespective of the surgical risks, recommendations, and practice on discontinuation of APT. Conclusions Most patients were treated in agreement with a consensus decision about preoperative APT based on a referral system among physicians, surgeons, and anesthesiologists. The risk of perioperative adverse events increased if complying with a consensus decision was failed. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03908463.

Patterns of Antiplatelet Therapy During Noncardiac Surgery in Patients With Second-Generation Drug-Eluting Stents.

Background Continuing antiplatelet therapy (APT) has been generally recommended during noncardiac surgery, but it is uncertain if preoperative discontinuation of APT has been avoided or harmful in patients with second-generation drug-eluting coronary stents. Methods and Results Patients undergoing noncardiac surgery after second-generation drug-eluting coronary stent implantation were assessed in a multicenter cohort in Korea. Net adverse clinical events within 30 days postoperatively, defined as all-cause death, major adverse cardiac events, and major bleeding, were evaluated. Of 3582 eligible patients, 49% patients discontinued APT during noncardiac surgery. The incidence of net adverse clinical events was comparable between patients with continuation versus discontinuation (4.1% versus 3.4%; P=0.257) of APT during noncardiac surgery. Perioperative discontinuation of APT did not impact on net adverse clinical events (adjusted hazard ratio [HR], 1.00; 95% CI, 0.69-1.44; P=0.995). In subgroup analysis, patients undergoing intra-abdominal surgery were exposed to less risk of major bleeding by discontinuing APT (adjusted HR, 0.26; 95% CI, 0.08-0.91; P=0.035). Prolonged discontinuation of APT for ≥9 days was associated with higher risk of a major adverse cardiac event compared with continuing APT (adjusted HR, 3.38; 95% CI, 1.36-8.38; P=0.009). Conclusions APT was discontinued preoperatively in almost half of patients with second-generation drug-eluting coronary stents. Our explorative analysis showed that there was no significant impact of discontinuing APT on the risk of perioperative adverse events except that discontinuing APT may be associated with decreased hemorrhagic risk in patients undergoing intra-abdominal surgery. Registration URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT03908463.

Predictors of Severe or Moderate Coronary Artery Disease in Asymptomatic Individuals with Extremely Low Coronary Calcium Scores.

PURPOSE: To evaluate predictors of severe or moderate coronary artery disease (CAD) in individuals with zero or very low (<10) coronary artery calcium (CAC) scores. MATERIALS AND METHODS: The 1175 asymptomatic persons with zero or very low (<10) CAC scores were analyzed for CAD stenosis using coronary computed tomography angiography. Moderate and severe CADs were defined as having more than 50% and more than 70% stenosis in any of the major coronary arteries, respectively. Age, gender, body mass index, hypertension, type II diabetes, dyslipidemia, lipid profile, creatinine, and smoking status were evaluated as predictors for moderate and severe CAD. RESULTS: In the study population, moderate and severe CADs were found in 7.5% and 3.3%, respectively. Among evaluated risk factors, age [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.02-1.07, p<0.001], current smoking status (OR 3.12, 95% CI 1.82-5.34, p<0.001), and CAC 1-9 (OR 1.80, 95% CI 1.08-3.00, p=0.024) were significantly associated with moderate CAD. Meanwhile, age (OR 1.05, 95% CI 1.02-1.08, p=0.003), low high density lipoprotein (HDL) (OR 0.96, 95% CI 0.93-0.99, p=0.003), and current smoking status (OR 2.34, 95% CI 1.14-5.30, p=0.022) were found to be significantly associated with severe CAD. Improvement of discrimination power for predicting severe CAD was observed when smoking and HDL cholesterol were serially added into the age model. CONCLUSION: Smoking showed significant correlations with moderate or severe CAD, and low HDL cholesterol also proved to be a predictor of severe CAD in asymptomatic individuals with extremely low CAC scores.

Comparison of Spot versus Long Stenting for Femoropopliteal Artery Disease.

BACKGROUND: Optimal stenting strategy for long femoropopliteal artery lesions still remains undefined. Longer stent length has been shown to be associated with increased risk of restenosis. We sought to compare the efficacy of spot versus long stenting in the treatment of femoropopliteal artery disease. METHODS: This study was designed as a multicenter randomized controlled trial to compare immediate and mid-term outcomes of spot versus long primary stenting for femoropopliteal arterial lesions. A total of 125 patients were randomized 1:1 to spot stenting group (n = 59) or long stenting group (n = 66). RESULTS: All lesions were treated with self-expanding bare nitinol stents. Baseline clinical and lesion characteristics were similar between the 2 groups except for male gender and current smoker. The mean lesion length was 24.1 ± 8.8 cm. Technical success was achieved in all patients. The 1-year primary patency and TLR-free (target lesion revascularization) survival did not differ significantly between the 2 groups. However, the spot stenting group showed a trend toward higher primary patency (86.1% vs. 72.7%, P = 0.158) and TLR-free survival (94.2% vs. 82.5%, P = 0.120). The total stented length (hazard ratio [HR] 1.01, 95% confidence interval [CI] 1.00-1.01, P = 0.011) and age (HR 0.94, 95% CI 0.90-1.00, P = 0.035) were independent predictors of restenosis. CONCLUSIONS: The spot stenting appears to be more favorable than the long stenting in terms of primary patency and TLR-free survival, although the difference was not statistically significant. The stented length was an independent predictor of restenosis.

Impact of National Health Checkup Service on Hard Atherosclerotic Cardiovascular Disease Events and All-Cause Mortality in the General Population.

Whether health checkups favorably impact the occurrence of atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality in the general population remains in debate. We investigated further the impact of health checkups on hard ASCVD events and all-cause mortality. We compared the occurrence of hard ASCVD events and all-cause deaths for 4 years starting in 2010 between participants who used the National Health Checkup Service (NHCS) more than twice and nonparticipants who never used the NHCS from 2006 to 2009. From the 342,594 survivors aged 40 to 69 years old in 2006 listed in the National Health Insurance Service-National Sample Cohort, a total of 55,275 pairs were selected by propensity matching. Hard ASCVD events were defined as the composite of myocardial infarction and stroke. In the 55,275 matched pairs, we found a significant association between the use of the NHCS and the reduction in hard ASCVD events (adjusted hazard ratio = 0.84, 95% confidence interval 0.76 to 0.92, p <0.001) and all-cause deaths (adjusted hazard ratio = 0.50, 95% confidence interval 0.45 to 0.55, p <0.001). The participants had more medical care, including outpatient care and hospitalizations, and took more hypertension and dyslipidemia medications, whereas hospitalizations for more than 60 days were significantly more frequent in the nonparticipants. In the subgroup analysis, the reduction in hard ASCVD events for NHCS participants was significantly greater in patients without a previous history of dyslipidemia or who did not have outpatient care. In conclusion, the use of the NHCS was significantly associated with reduced hard ASCVD events and all-cause mortality in the general population.

Impact of Cigarette Smoking: a 3-Year Clinical Outcome of Vasospastic Angina Patients.

BACKGROUND AND OBJECTIVES: Cigarette smoking is a risk significant factor in coronary artery disease (CAD) and vasospastic angina (VSA). However, it is largely unknown whether smoking adds to any long-term clinical risk in VSA patients. SUBJECTS AND METHODS: A total of 2797 patients without significant CAD underwent acetylcholine (Ach) provocation test between November 2004 and October 2010. Patients were divided into three groups, based on the presence of coronary artery spasm (CAS) and smoking habits (non-CAS group: n=1188, non-smoking CAS group: n=1214, smoking CAS group: n=395). All CAS patients were prescribed with anti-anginal medications for at least 6 months. The incidence of major clinical outcomes and recurrent angina of these groups were compared up to 3 years. RESULTS: There were considerable differences in the baseline clinical and angiographic characteristics among the three groups, but there was no difference in the endpoints among the three groups (including individual and composite hard endpoints) such as death, myocardial infarction, de novo percutaneous coronary intervention, cerebrovascular accident, and major adverse cardiac events. However, there was a higher incidence of recurrent angina in both the non-smoking CAS group and smoking CAS group, as compared to the non-CAS group. In multivariable adjusted Cox-proportional hazards regression analysis, smoking CAS group exhibited a higher incidence of recurrent angina compared with the non-CAS group (hazard ratio [HR]; 2.46, 95% confidence interval [CI]; 1.46-4.14, p=0.001) and non-smoking CAS group (HR; 1.76, 95% CI; 1.08-2.87, p=0.021). CONCLUSION: Cigarette smoking CAS group exhibited higher incidence of recurrent angina during the 3-year clinical follow-up compared with both the non-CAS group and non-smoking CAS group. Quitting of smoking, paired with intensive medical therapy and close clinical follow-up, can help to prevent recurrent angina.

Preventive effect of pretreatment with intravenous nicorandil on contrast-induced nephropathy in patients with renal dysfunction undergoing coronary angiography (PRINCIPLE Study).

PURPOSE: To investigate the effect of pretreatment with intravenous nicorandil on the incidence of contrast-induced nephropathy (CIN) in patients with renal dysfunction undergoing coronary angiography. MATERIALS AND METHODS: This randomized controlled multicenter study enrolled a total of 166 patients (nicorandil n=81; control n=85) with an estimated glomerular filtration rate <60 mL/min. Nicorandil 12 mg dissolved in 100 mL of 0.9% saline was administered intravenously for 30 minutes just prior to coronary angiography in the nicorandil group. The same volume of only saline was given to the control group. The primary endpoint was the incidence of CIN, defined as >0.5 mg/dL increase or >25% rise in serum creatinine (SCr) concentration within 48 hours of contrast exposure compared to baseline. RESULTS: The final analysis included 149 patients (nicorandil n=73; control n=76). The baseline characteristics and the total volume of the used contrast (Iodixanol, 125.6±69.1 mL vs. 126.9±74.6 mL, p=0.916) were similar between the two groups. The incidence of CIN also did not differ between the nicorandil and control groups (6.8% vs. 6.6%, p=0.794). There was no difference between the two groups in the relative change in SCr from baseline to peak level within 48 hours after coronary angiography (-1.58±24.07% vs. 0.96±17.49%, p=0.464), although the nicorandil group showed less absolute change in SCr than the control group (-0.01±0.43 mg/mL vs. 0.02±0.31 mg/mL, p=0.005). CONCLUSION: Prophylactic intravenous infusion of nicorandil did not decrease the incidence of CIN in patients with renal dysfunction undergoing coronary angiography.

Recurrence of coronary-subclavian steal syndrome after successful angioplasty of malfunctioning arteriovenous fistula.

We report a case of coronary-subclavian steal syndrome, which had been masked by a malfunctioning hemodialysis access vessel and then reappeared after a successful angioplasty of multiple stenoses in the arteriovenous fistula of the left arm in a 61-year-old man. This case suggests that coronary-subclavian steal syndrome should be considered before a coronary artery bypass grafting surgery using internal mammary artery conduit is done, especially when hemodialysis using the left arm vessels is expected.

Sudden cardiac arrest with acute myocardial infarction induced by left subclavian artery occlusion in a patient with prior coronary artery bypass surgery.

Multivascular preventive and therapeutic approaches are necessary in patients with coronary artery disease because atherosclerosis has a common systemic pathogenesis. We present a rare case of sudden cardiac arrest with acute myocardial infarction induced by the total occlusion of left subclavian artery (LSCA) in a patient with a history of previous coronary artery bypass surgery using the left internal mammary artery. We initially performed blind-puncture of left brachial artery, attempting percutaneous coronary intervention because pulses were absent in both upper and lower extremities. However, the cause of sudden cardiac arrest was atherosclerotic total occlusion of LSCA. The patient was stabilized after successful revascularization of LSCA by percutaneous transluminal angioplasty with stent insertion.

Enhancement of MSC adhesion and therapeutic efficiency in ischemic heart using lentivirus delivery with periostin.

Many approaches have shown beneficial effects of modified mesenchymal stem cells (MSCs) for treatment of infarcted myocardium, but have primarily focused on enhancing the survival of transplanted MSCs. Here, we show the dual benefits of periostin-overexpressing MSCs (p-MSCs) for infarcted myocardium. P-MSCs led to the marked histological and functional recovery of infarcted myocardium by enhancing survival of MSCs and directly preventing apoptosis of cardiomyocytes. Survival of p-MSCs themselves and cardiomyocytes co-cultured with p-MSCs or treated with the conditioned media from p-MSCs was significantly increased under hypoxic conditions. Decreases in adhesion-related integrins were reversed in cardiomyocytes co-cultured with p-MSCs, followed by increases in p-PI3K and Akt, indicating that periostin activates the PI3K pathway through adhesion-related integrins. When p-MSCs were injected into myocardial infarcted rats, histological pathology and cardiac function were significantly improved compared to MSC-injected controls. Thus, periostin might be a new target of therapeutic treatments using MSCs as carriers for infarcted myocardium.

Unusual Presentation Chronic Pulmonary Embolism due to Calcified Right Ventricular Mass.

Cardiac calcified amorphous tumors (CATs) can arise in all four chambers of the heart. Cardiac CATs can cause diverse symptoms according to their locations, and mass or embolic effects. Pulmonary emboli arising from cardiac CATs have been reported, but the true incidence is unknown due to their rarity. Herein we report a rare case with diffuse CATs in the right ventricle which caused a calcific pulmonary embolism and right-sided heart failure. Echocardiography, chest non-contrast computed tomography, and cardiac magnetic resonance imaging helped us diagnose the CATs. We recommend the usefulness of a multimodality imaging approach to characterize intracardiac masses and their complications accurately.

Aortic dissection and rupture in a child.

After developing sudden severe chest pain, an 11-year-old boy presented to the emergency room with chest pain and palpitations and was unable to stand up. The sudden onset of chest pain was first reported while swimming at school about 30 minutes prior to presentation. Arterial blood pressure (BP) was 150/90 mmHg, heart rate was 120/minute, and the chest pain was combined with shortness of breath and diaphoresis. During the evaluation in the emergency room, the chest pain worsened and abdominal pain developed. An aortic dissection was suspected and a chest and abdomen CT was obtained. The diagnosis of aortic dissection type B was established by CT imaging. The patient went to surgery immediately with BP control. He died prior to surgery due to aortic rupture. Here we present this rare case of aortic dissection type B with rupture, reported in an 11-year-old Korean child.

Aortic dissection and rupture in an 11-year-old child: A case report.

We present the case of an 11-year-old boy who developed sudden severe chest pain. When he was referred to the emergency department with this chest pain and palpitation, he could not even stand up. The sudden onset of chest pain was first complained about while he was swimming at school about 30 min previously. His arterial blood pressure was 150/90 mm Hg, heart rate was 120/min, and the chest pain was combined with shortness of breath and diaphoresis. During the evaluation in the emergency room, he complained of much severer chest pain and newly developed abdominal pain. We suspected aortic dissection and took computed tomography (CT) images of his chest and abdomen. The diagnosis of aortic dissection type B was established with the help of CT imaging. The patient went to surgery immediately with blood pressure control. He was lost before the operation because of aortic rupture. We report one rare case of aortic dissection type B with rupture in an eleven-year-old child in Korea.

Effects of pericardiectomy on early diastolic mitral annular velocity in patients with constrictive pericarditis.

BACKGROUND: In patients with constrictive pericarditis (CP), early diastolic mitral annular velocity (E') is usually normal or exaggerated due to limitation of lateral expansion by the constricting pericardium. Although pericardiectomy is the treatment of choice for CP, it is difficult to evaluate its effectiveness. Theoretically, E' may decrease after successful pericardiectomy. However, little data are available regarding the effect of pericardiectomy on E'. The purpose of this study was to assess the change in E' after pericardiectomy in patients with CP. METHODS: We studied 16 patients (12 males, mean age 62.3+/-7.0 years) with surgically confirmed CP for changes in pre-discharge Doppler parameters following pericardiectomy. CP was secondary to previous cardiac surgery in 4 patients, tuberculosis in 4 patients, radiation-induced in 1 patient, and idiopathic in 7 patients. Ten patients underwent complete pericardiectomy (62.5%). E' was measured at the septal annulus before pericardiectomy and a mean duration of 10 (+/-6) days after. RESULTS: E' significantly decreased from 9.2+/-2.7 cm/s to 7.4+/-2.6 after pericardiectomy (p=0.013). The mean percent change of E' after pericardiectomy was 17.9+/-25.9%. The decrement of E' was significantly higher in patients with complete pericardiectomy than in patients who underwent a partial pericardiectomy (2.7+/-2.3 vs. 0.4+/-2.1, p=0.042). Also, more than 15% decrease of E' was significantly higher in patients with improvement of symptom after pericardiectomy (9 (100.0%) vs. 3 (42.9%), p=0.019). CONCLUSION: E' decreased following pericardiectomy in most of the patients with CP. The change of E' after pericardiectomy may be useful in evaluating the effectiveness of pericardiectomy.

Rescuing an entrapped guidewire using a Tornus catheter.

Entrapment of a guidewire is a rare event, but it could happen especially in severe calcified stenotic lesion. This complication is life-threatening because it can lead to myocardial ischemia, infarction, or lethal arrhythmia due to intracoronary thrombosis. In the event of failed retrieval and persistent signs of ischemia, patients should be urgently referred to surgery. During percutaneous coronary intervention, the Tornus catheter has been applied to patients with severe coronary artery disease when balloon catheter or microcatheter cannot be crossed across the lesion after successful wire crossing. This is a case of a patient that a Tornus catheter rescued an entrapped guidewire in severe calcified coronary disease.

Age-related contribution of Lp(a) with coronary artery calcification in patients with acute coronary syndrome: a potential role of metabolic disorder in calcified plaque.

Lp(a) and coronary artery calcification (CAC) have recently been reported as predictors of plaque instability, but this is surrounded by much controversy. We investigated the influence of Lp(a) and CAC compared other acute coronary syndrome (ACS) risk factors. 698 patients diagnosed with at least minimal coronary artery obstructive disease from a coronary angiography were randomly selected using SPSS. Lp(a), other lipid profiles and past histories were checked, and CAC semi quantitatively graded on stored fluoroscopic images. The prevalence of CAC was significantly higher in the ACS than the non-ACS group (38.0% vs. 29.9%, p=0.026). The serum level of Lp(a) (26.89 +/- 30.64 vs. 20.85 +/- 21.63, p < 0.01) and prevalence of positive Lp(a) (> 35 mg/dl) was higher in the ACS group (24% vs. 15.7%, p < 0.01). The risk of ACS was higher in the patients with both CAC and elevated an Lp(a) than in those with only one (OR: 2.16, p=0.009, 95% CI; 1.213 - 3.843 vs. OR: 1.79, p < 0.001, 95% CI; 1.300 - 2.456). The risk of ACS was increased 1.451 times (p=0.040, 95% CI; 1.071- 2.071) in patients with CAC and 1.648 times (p=0.014, 95% CI; 1.107- 2.455) in patients with a Lp(a) > 35 mg/dl. In the younger patients (< 60 years), the Lp(a), but not the CAC, was an independent risk factor for ACS (OR=2.248, p=0.005, 95% CI; 1.281-3.943). In the older patients (> 60 years), CAC, but not the Lp(a), was an independent risk factor (OR=1.775, p=0.021, 95% CI; 1.090 - 2.890). Both the Lp(a) and CAC were risk factors for ACS, and they had a synergistic effect on its development. In the younger Lp(a), and the older CAC, was the more potent risk factor for ACS, respectively.