Interaction of AI-Enabled Quantitative Coronary Plaque Volumes on Coronary CT Angiography, FFRCT, and Clinical Outcomes: A Retrospective Analysis of the ADVANCE Registry.

BACKGROUND: Luminal stenosis, computed tomography-derived fractional-flow reserve (FFRCT), and high-risk plaque features on coronary computed tomography angiography are all known to be associated with adverse clinical outcomes. The interactions between these variables, patient outcomes, and quantitative plaque volumes have not been previously described. METHODS: Patients with coronary computed tomography angiography (n=4430) and one-year outcome data from the international ADVANCE (Assessing Diagnostic Value of Noninvasive FFRCT in Coronary Care) registry underwent artificial intelligence-enabled quantitative coronary plaque analysis. Optimal cutoffs for coronary total plaque volume and each plaque subtype were derived using receiver-operator characteristic curve analysis. The resulting plaque volumes were adjusted for age, sex, hypertension, smoking status, type 2 diabetes, hyperlipidemia, luminal stenosis, distal FFRCT, and translesional delta-FFRCT. Median plaque volumes and optimal cutoffs for these adjusted variables were compared with major adverse cardiac events, late revascularization, a composite of the two, and cardiovascular death and myocardial infarction. RESULTS: At one year, 55 patients (1.2%) had experienced major adverse cardiac events, and 123 (2.8%) had undergone late revascularization (>90 days). Following adjustment for age, sex, risk factors, stenosis, and FFRCT, total plaque volume above the receiver-operator characteristic curve-derived optimal cutoff (total plaque volume >564 mm3) was associated with the major adverse cardiac event/late revascularization composite (adjusted hazard ratio, 1.515 [95% CI, 1.093-2.099]; P=0.0126), and both components. Total percent atheroma volume greater than the optimal cutoff was associated with both major adverse cardiac event/late revascularization (total percent atheroma volume >24.4%; hazard ratio, 2.046 [95% CI, 1.474-2.839]; P<0.0001) and cardiovascular death/myocardial infarction (total percent atheroma volume >37.17%, hazard ratio, 4.53 [95% CI, 1.943-10.576]; P=0.0005). Calcified, noncalcified, and low-attenuation percentage atheroma volumes above the optimal cutoff were associated with all adverse outcomes, although this relationship was not maintained for cardiovascular death/myocardial infarction in analyses stratified by median plaque volumes. CONCLUSIONS: Analysis of the ADVANCE registry using artificial intelligence-enabled quantitative plaque analysis shows that total plaque volume is associated with one-year adverse clinical events, with incremental predictive value over luminal stenosis or abnormal physiology by FFRCT. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02499679.

Impact of Smoking on Coronary Volume-to-Myocardial Mass Ratio: An ADVANCE Registry Substudy.

Purpose To examine the relationship between smoking status and coronary volume-to-myocardial mass ratio (V/M) among individuals with coronary artery disease (CAD) undergoing CT fractional flow reserve (CT-FFR) analysis. Materials and Methods In this secondary analysis, participants from the ADVANCE registry evaluated for suspected CAD from July 15, 2015, to October 20, 2017, who were found to have coronary stenosis of 30% or greater at coronary CT angiography (CCTA) were included if they had known smoking status and underwent CT-FFR and V/M analysis. CCTA images were segmented to calculate coronary volume and myocardial mass. V/M was compared between smoking groups, and predictors of low V/M were determined. Results The sample for analysis included 503 current smokers, 1060 former smokers, and 1311 never-smokers (2874 participants; 1906 male participants). After adjustment for demographic and clinical factors, former smokers had greater coronary volume than never-smokers (former smokers, 3021.7 mm3 ± 934.0 [SD]; never-smokers, 2967.6 mm3 ± 978.0; P = .002), while current smokers had increased myocardial mass compared with never-smokers (current smokers, 127.8 g ± 32.9; never-smokers, 118.0 g ± 32.5; P = .02). However, both current and former smokers had lower V/M than never-smokers (current smokers, 24.1 mm3/g ± 7.9; former smokers, 24.9 mm3/g ± 7.1; never-smokers, 25.8 mm3/g ± 7.4; P < .001 [unadjusted] and P = .002 [unadjusted], respectively). Current smoking status (odds ratio [OR], 0.74 [95% CI: 0.59, 0.93]; P = .009), former smoking status (OR, 0.81 [95% CI: 0.68, 0.97]; P = .02), stenosis of 50% or greater (OR, 0.62 [95% CI: 0.52, 0.74]; P < .001), and diabetes (OR, 0.67 [95% CI: 0.56, 0.82]; P < .001) were independent predictors of low V/M. Conclusion Both current and former smoking status were independently associated with low V/M. Keywords: CT Angiography, Cardiac, Heart, Ischemia/Infarction Clinical trial registration no. NCT02499679 Supplemental material is available for this article. © RSNA, 2024.

Postpartum spontaneous coronary artery dissection recovered by coronary artery bypass grafting supported with Impella device.

A 34-year-old female who had delivered a baby 9 days ago was transferred to our hospital due to sudden dyspnea and cardiogenic shock. Her electrocardiogram showed ST-segment elevation in precordial leads, and left ventricular ejection fraction was 20%.

Simultaneous hybrid off-pump coronary artery bypass grafting and transcatheter aortic valve implantation in elderly patients.

Purpose: Optimal strategy for transcatheter aortic valve implantation (TAVI) in patients with coronary artery disease (CAD) is unresolved. We evaluated the surgical outcomes of hybrid coronary artery bypass grafting (CABG) and TAVI in elderly patients. Methods: We retrospectively evaluated patients who underwent simultaneous TAVI and CABG at Wakayama Medical University, Japan. All patients underwent off-pump CABG (OPCAB) including minimally invasive cardiac surgery (MICS-CABG). In an earlier period, OPCAB + transfemoral TAVI (TF-TAVI) was the only method used, while in a later period, we introduced MICS-CABG and alternative approaches for TAVI. Results: Twenty-seven patients were enrolled, the average age was 83.6 ± 5.1 years. In the MICS-CABG and TAVI group, average patient age was higher (87.0 ± 3.1 years) than in the earlier group. Thirty-day and in-hospital mortalities were zero. Incomplete revascularization rate was 33.3% and one patient required percutaneous coronary intervention after the operation. Graft patency rate was 100%. In MICS-CABG group, the number of distal anastomoses was smaller (1.29, range 1-2), but the number of days required to re-starting walking and postoperative hospital stay were shorter, and the rate of discharge to home was higher (100%) than in the other groups. Conclusions: Although 33.3% of patients did not achieve complete revascularization, there was no 30-day or in-hospital mortality. TAVI and hybrid OPCAB, including MICS-CABG, were suggested to be feasible treatment in elderly patients.

Diagnostic significance of paradoxical left ventricular hypertrophy in detecting cardiac amyloidosis.

Background: Cardiac amyloidosis (CA) progresses rapidly with a poor prognosis. Therefore, methods for early diagnosis that are easily accessible in any hospital, are required. We hypothesized that based on the pathology of CA, morphological left ventricular hypertrophy (LVH) without electrical augmentation, namely paradoxical LVH, could be used to diagnose CA. This study aimed to investigate whether paradoxical LVH has diagnostic significance in identifying CA in patients with LVH. Methods: Patients who presented with left ventricular (LV) wall thickness ≥ 12 mm on cardiac magnetic resonance (CMR) were enrolled from a multicentre CMR registry. Paradoxical LVH was defined as a LV wall thickness ≥ 12 mm on CMR, SV1 + RV5 < 3.5 mV, and a lack of secondary ST-T abnormalities. The diagnostic significance of paradoxical LVH in identifying CA was assessed. Results: Of the 110 patients enrolled, 30 (27 %) were diagnosed with CA and 80 (73 %) with a non-CA aetiology. The CA group demonstrated paradoxical LVH more frequently than the non-CA group (80 % vs. 16 %, P < 0.001). It was an independent predictor for detecting CA in patients with LVH (odds ratio: 33.44, 95 % confidence interval: 8.325-134.3, P < 0.001). The sensitivity, specificity, positive predict value, negative predict value and accuracy of paradoxical LVH for CA detection were 80 %, 84 %, 65 %, 92 % and 83 %, respectively. Conclusions: Paradoxical LVH can be used for identifying CA in patients with LVH. Our findings could contribute to the early diagnosis of CA, even in non-specialized hospitals.

Impact of pulmonary vein anatomy and left atrial size on postoperative atrial fibrillation after esophagectomy for esophageal cancer.

BACKGROUND: This study aimed to investigate the relationship between postoperative atrial fibrillation (POAF) after esophagectomy and pre-existing cardiac substrate. METHODS: We retrospectively analyzed 212 consecutive patients from between July 2010 and December 2022 who were scheduled to undergo esophagectomy for esophageal cancer without previous history of atrial fibrillation. All the patients underwent both echocardiography and contrast-enhanced multi-detector computed tomography (MDCT). RESULTS: POAF occurred in 49 patients (23.1%). Multivariable logistic analysis demonstrated that independent predictors for POAF were age [OR; 1.06 (1.01-1.10), P < 0.01), three-field lymph node dissection [OR; 2.55 (1.25-5.23), P < 0.01), left atrial dilatation (> 35 mm) assessment by echocardiography [OR; 3.05 (1.49-6.25), P < 0.01) and common left pulmonary vein [OR; 3.03 (1.44-6.39), P < 0.01). The correlation coefficient was high for left atrial dimensions assessed by echocardiography and MDCT (r = 0.91, P < 0.01). Combination of left atrial dilatation by echocardiography and common left pulmonary vein had high odds ratio [OR; 8.10 (2.62-25.96), P < 0.01). Instead of echocardiographic assessment, combination of left atrial enlargement (> 35 mm) assessed by MDCT and common left pulmonary vein also showed high odds ratio for POAF [OR; 11.23 [2.19-57.63], P < 0.01). CONCLUSION: Incidence of POAF after esophagectomy was related to both left atrial enlargement and common left pulmonary vein assessed by preoperative MDCT. Additional analysis of atrial size and pulmonary vein variation would facilitate preoperative assessment of the risk of POAF, but future studies must ascertain therapeutic strategy.

Impact of left ventricular ejection fraction and preoperative hemoglobin level on perioperative adverse cardiovascular events in noncardiac surgery.

The prediction of a perioperative adverse cardiovascular event (PACE) is an important clinical issue in the medical management of patients undergoing noncardiac surgery. Although several predictors have been reported, simpler and more practical predictors of PACE have been needed. The aim of this study was to investigate the predictors of PACE in noncardiac surgery. We retrospectively analyzed 723 patients who were scheduled for elective noncardiac surgery and underwent preoperative examinations including 12-lead electrocardiography, transthoracic echocardiography, and blood test. PACE was defined as cardiac death, non-fatal myocardial infarction, unstable angina, congestive heart failure, arrhythmia attack that needs emergency treatment (rapid atrial fibrillation, ventricular tachycardia, and bradycardia), acute pulmonary embolism, asystole, pulseless electrical activity, or stroke during 30 days after surgery. PACE occurred in 54 (7.5%) of 723 patients. High-risk operation (11% vs. 3%, p = 0.003) was more often seen, left ventricular ejection fraction (LVEF) (55 ± 8% vs. 60 ± 7%, p = 0.001) and preoperative hemoglobin level (11.8 ± 2.2 g/dl vs. 12.7 ± 2.0 g/dl, p = 0.001) were lower in patients with PACE compared to those without PACE. By multivariate logistic regression analysis, high-risk operation (odds ratio (OR): 7.05, 95% confidence interval (CI) 2.16-23.00, p = 0.001), LVEF (OR 1.06, every 1% decrement, 95% CI 1.03-1.09, p = 0.001), and preoperative hemoglobin level (OR 1.22, every 1 g/dl decrement, 95% CI 1.07-1.39, p = 0.003) were identified as independent predictors of PACE. Receiver operating characteristic analysis demonstrated that LVEF of 58% (sensitivity = 80%, specificity = 61%, area under the curve (AUC) = 0.723) and preoperative hemoglobin level of 12.2 g/dl (sensitivity = 63%, specificity = 64%, AUC = 0.644) were optimal cut-off values for predicting PACE. High-risk operation, reduced LVEF, and reduced preoperative hemoglobin level were independently associated with PACE in patients undergoing noncardiac surgery.

Noninvasive assessment of left ventricular end-diastolic pressure by deceleration time of early diastolic mitral annular velocity in patients with heart failure.

OBJECTIVE: To examine the diagnostic ability of the deceleration time of early mitral annular velocity (e'DT) as determined by tissue Doppler velocity image, a method for assessing LV filling pressure. BACKGROUNDS: Estimation of LV filling pressure by Doppler echocardiography requires a combination of various parameters. Therefore, there remains a need for a simple index in LV filling pressure estimation. The e' is known to be reduced and delayed with increased LV filling pressure during development of heart failure. Thus, we hypothesized that e'DT would be shortened as LV filling pressure is increased. METHODS: Simultaneous LV end-diastolic pressure (LVEDP) measurement and Doppler echocardiography were performed in 94 patients who were admitted to our hospital for heart failure. Exclusion criteria were atrial fibrillation, mitral valve surgery, and acute coronary syndrome. RESULTS: The e'DT in 31 patients with LVEDP >16 mm Hg (68±13 ms) was significantly shorter than that in 63 patients with LVEDP ≤16 mm Hg (103±27 ms). Both e'DT and early transmitral flow velocity (E)/e' were significantly correlated with LVEDP. In 30 patients with 10-14 E/e', significance of correlation in e'DT was remained, while E/e' was not. The area under the ROC curve for prediction of LVEDP >16 mm Hg for e'DT was greater than that for E/e' (0.91 vs 0.74, P=.046). CONCLUSION: The e'DT is useful to assess LV filling pressure, especially in 10-14 E/e'. This simple tissue Doppler index may be a potential parameter for easily distinguishing between mild and severe heart failures.

Safety and efficacy of limus-eluting stents and balloon angioplasty for sirolimus-eluting in-stent restenosis.

OBJECTIVES: The aim of this study was to compare the safety and efficacy of everolimus-eluting stent (EES), sirolimus-eluting stent (SES), and plain old balloon angioplasty (POBA) for the treatment of SES in-stent restenosis (S-ISR). BACKGROUND: The optimal treatment for drug-eluting in-stent restenosis remains controversial. METHODS: The study cohort comprised 310 consecutive patients (444 lesions) who presented with S-ISR to our institution and underwent treatment with EES (43 patients), SES (102), or POBA (165). The analyzed clinical parameters were the 1-year rates of death, Q-wave myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), definite stent thrombosis (ST) and major adverse cardiac event (MACE) defined as the composite of death, MI, or TLR at 1-year. RESULTS: The three groups were well matched for the conventional risk factors for coronary artery disease except for smoking. The 1-year analyzed clinical parameters were similar in the three groups: MACE (EES=14%, SES=18%, POBA=20%; p=0.65), death (EES=2.3%, SES=6.2%, POBA=6.1%; p=0.61), MI (EES=4.8%, SES=2.1%, POBA=2.5%; p=0.69), TLR (EES=11.9%, SES=12.1%, POBA=24%; p=0.78), and TVR (EES=11.9%, SES=24.8%, POBA=22.2%; p=0.23). There were no cases of definite ST. MACE-free rate was significantly lower in patients with recurrent in-stent restenosis (log-rank p=0.006). Presentation with acute MI, number of treated lesions and a previous history of MI were found to be independent predictors of MACE. CONCLUSIONS: In patients presenting with S-ISR, treatment with implantation of an EES, SES, or POBA is associated with similar clinical outcomes. Patients presenting with recurrent ISR may have a poorer clinical outcome.

Long-term outcome after deferral of revascularization in patients with intermediate coronary stenosis and gray-zone fractional flow reserve.

BACKGROUND: A strategy of deferred percutaneous coronary intervention for coronary stenosis with fractional flow reserve (FFR) 0.75-0.80, termed the gray zone, remains a matter of debate. The aim of this study was to assess the safety of deferring revascularization for patients with FFR 0.75-0.80 compared with those with FFR >0.80. METHODS AND RESULTS: We assessed 3-year clinical outcome in 150 patients with angiographically intermediate stenosis who had revascularization deferred on the basis of FFR ≥ 0.75 (FFR 0.75-0.80, n=56; FFR >0.80, n=94). Target vessel failure (TVF), defined as a composite of cardiac death, target vessel-related myocardial infarction (MI), and ischemia-driven target vessel revascularization (TVR) was evaluated during follow-up. Cardiac death was observed in 1 patient with FFR 0.75-0.80. There was no target vessel-related MI in either group. The incidence of ischemia-driven TVR was higher in patients with FFR 0.75-0.80 than in those with FFR >0.80 (14% vs. 3%, P=0.020). TVF-free survival was significantly worse for the patients with FFR 0.75-0.80 than those with FFR >0.80 (hazard ratio, 5.2; 95% confidence intervals: 1.4-19.5; P=0.015). CONCLUSIONS: Patients with FFR 0.75-0.80 were at higher risk of TVF mainly due to TVR than those with FFR >0.80.

Effect of atorvastatin therapy on fibrous cap thickness in coronary atherosclerotic plaque as assessed by optical coherence tomography: the EASY-FIT study.

BACKGROUND: The detailed mechanism of plaque stabilization by statin therapy is not fully understood. OBJECTIVES: The aim of this study was to assess the effect of lipid-lowering therapy with 20 mg/day of atorvastatin versus 5 mg/day of atorvastatin on fibrous cap thickness in coronary atherosclerotic plaques by using optical coherence tomography (OCT). METHODS: Seventy patients with unstable angina pectoris and untreated dyslipidemia were randomized to either 20 mg/day or 5 mg/day of atorvastatin therapy. OCT was performed to assess intermediate nonculprit lesions at baseline and 12-month follow-up. RESULTS: Serum low-density lipoprotein cholesterol level was significantly lower during therapy with 20 mg/day compared with 5 mg/day of atorvastatin (69 mg/dl vs. 78 mg/dl; p = 0.039). The increase in fibrous cap thickness was significantly greater with 20 mg/day compared with 5 mg/day of atorvastatin (69% vs. 17%; p < 0.001). The increase in fibrous cap thickness correlated with the decrease in serum levels of low-density lipoprotein cholesterol (R = -0.450; p < 0.001), malondialdehyde-modified low-density lipoprotein (R = -0.283; p = 0.029), high-sensitivity C-reactive protein (R = -0.276; p = 0.033), and matrix metalloproteinase-9 (R = -0.502; p < 0.001), and the decrease in grade of OCT-derived macrophages (R = -0.415; p = 0.003). CONCLUSIONS: Atorvastatin therapy at 20 mg/day provided a greater increase in fibrous cap thickness in coronary plaques compared with 5 mg/day of atorvastatin. The increase of fibrous cap was associated with the decrease in serum atherogenic lipoproteins and inflammatory biomarkers during atorvastatin therapy. (Effect of Atorvastatin Therapy on Fibrous Cap Thickness in Coronary Atherosclerotic Plaque as Assessed by Optical Coherence Tomography: The EASY-FIT Study; NCT00700037).

The impact of diabetes mellitus on long-term clinical outcomes after percutaneous coronary saphenous vein graft interventions in the drug-eluting stent era.

OBJECTIVES: We aimed to compare early and late clinical outcomes in diabetic and nondiabetic patients who underwent saphenous vein graft (SVG) percutaneous coronary interventions (PCI) with the use of drug-eluting stents (DES). BACKGROUND: Patients with diabetes mellitus are shown to have less favorable outcomes after SVG intervention with the use of bare metal stents. In the DES era, the impact of diabetes mellitus on restenosis and clinical outcomes post-SVG intervention is not clearly defined. METHODS: From our institutional PCI registry database, we retrospectively analyzed 477 consecutive patients with prior coronary artery bypass graft surgery undergoing SVG PCI with the implantation of DES stratified by the presence or absence of diabetes mellitus. The primary end-point was 1-year major adverse cardiac event (MACE) rate, defined as death, Q wave myocardial infarction, and target lesion revascularization. RESULTS: Baseline clinical characteristics, including mean graft age (120 ± 77 vs. 131 ± 86 months, P = 0.14), were similar between groups, save for a higher prevalence of systemic hypertension and chronic renal insufficiency, and higher body mass index in the diabetic group. Among the 604 SVG lesions treated with DES, the angiographic and procedural characteristics were well matched between groups except for the higher rate of distal protection device use (32% vs. 29%, P = 0.007) in the diabetic group. The rates of 1-year MACE (21% vs. 15%, P = 0.12) and all-cause mortality (7.6% vs. 6.7%, P = 0.86) were similar between groups. After adjustment for the relevant clinical co-variables, diabetic status was not associated with the composite end-point. CONCLUSION: In conclusion, DES, when used for the treatment of vein graft lesions, equate the short- and long-term outcomes between diabetic and nondiabetic patients, suggesting that DES should be considered the default stent in diabetic populations undergoing PCI for the treatment of SVG lesions.

Comparison of outcomes after percutaneous coronary intervention among different coronary subsets (stable and unstable angina pectoris and ST-segment and non-ST-segment myocardial infarction).

Percutaneous coronary intervention in the setting of acute myocardial infarction is known to predict stent thrombosis (ST). This study aims to compare the ST rates across different coronary subsets. This was an observational cohort study from a large, single-center registry. Included were 12,198 consecutive patients who underwent percutaneous coronary intervention with stenting. Patients were categorized according to their clinical presentation: stable angina pectoris (SAP, n = 3,700), unstable angina pectoris (UAP, n = 2,845), non-ST-segment elevation myocardial infarction (NSTEMI, n = 4,083), and ST-segment elevation myocardial infarction (STEMI, n = 1,570). The study end points were ST rates at 1 year. Patients with STEMI were younger with a lower prevalence of cardiovascular risk factors, except for smoking. More type C lesions were treated in STEMI, whereas drug-eluting stents were used less frequently in patients with STEMI compared with the other groups. Definite ST at 1 year was highest in patients with STEMI (1.4%; vs SAP, 0.4%; UAP, 0.5%; NSTEMI, 0.5%; p <0.001). One-year definite/probable ST rates were SAP, 0.8%; UAP, 1.1%; NSTEMI, 1.4%; and STEMI, 3.2% (p <0.001). On multivariable analysis, STEMI independently predicts definite ST (hazards ratio [HR] 3.07, 95% confidence interval [CI] 1.32 to 7.10), whereas both STEMI (HR 3.36, 95% CI 1.84 to 6.12) and NSTEMI (HR 2.04, 95% CI 1.20 to 3.07) were independent predictors of definite/probable ST. Clopidogrel cessation was the strongest predictor of ST (definite ST, HR 17.00, 95% CI 7.54 to 38.31; definite/probable ST, HR 4.69, 95% CI 2.39 to 9.20). In conclusion, in patients who underwent percutaneous coronary intervention, the acuity of clinical presentation corresponds to an increase in ST incidence. Adherence to clopidogrel is critical to prevent ST in patients who underwent percutaneous coronary intervention, especially in STEMI.

Long-term safety and efficacy of second-generation everolimus-eluting stents compared to other limus-eluting stents and bare metal stents in patients with acute coronary syndrome.

OBJECTIVES: This study aimed to investigate the long-term safety and efficacy of everolimus-eluting stents (EES) compared with other limus-eluting stents and bare metal stents (BMS) in ACS patients. BACKGROUND: There have been concerns about the long-term safety of drug-eluting stents in the setting of acute coronary syndrome. METHODS: The study cohort included 1,612 patients presenting with acute coronary syndrome who underwent BMS, SES, E-ZES, or EES implantation. End points included probable or definite stent thrombosis and major adverse cardiovascular events (MACE), defined as a composite of all-cause death, Q-wave myocardial infarction, and target lesion revascularization up to 3 years. RESULTS: The overall MACE rates were significantly higher for both BMS and SES, but not E-ZES, when compared with EES (EES vs. BMS: HR 2.68, 95% CI 1.91-3.78, P <0.001; EES vs. SES: HR 1.75, 95% CI 1.24-2.47, P = 0.001 and EES vs. E-ZES: HR 1.08, 95% CI 0.65-1.77, P = 0.72). Stent thrombosis rates were similar for EES, E-ZES, and BMS but higher for SES throughout the 3-year follow-up (EES vs. BMS: HR 1.02, 95% CI: 0.31-3.35, P = 0.973; EES vs. SES: HR 4.90, 95% CI: 1.75-13.69, P = 0.002 and EES vs. E-ZES: HR 1.63, 95% CI 0.37-7.31, P = 0.449). CONCLUSIONS: There was an improvement in the long-term outcome for MACE with EES when compared to earlier-generation stents, but this was comparable with the 2nd-generation E-ZES. There was no additional risk of early or late stent thrombosis in EES when compared with BMS.

Acceleration time of systolic coronary flow velocity to diagnose coronary stenosis in patients with microvascular dysfunction.

BACKGROUND: The aim of this study was to test whether acceleration time of systolic coronary flow velocity could contribute to the diagnosis of coronary stenosis in patients with microvascular dysfunction, on the basis of the hypothesis that systolic coronary flow is less influenced by microvascular function because of compressed myocardium. METHODS: Coronary flow velocity was assessed in the left anterior descending coronary artery during hyperemia with intravenous adenosine by echocardiography in 502 patients who were scheduled for coronary angiography because of coronary artery disease and significant valvular disease. Coronary flow velocity reserve (CFVR) and the percentage acceleration time (%AT), as the percentage of the time from the beginning to the peak of systolic coronary flow over systolic time during hyperemia, were calculated. The diagnostic ability of CFVR and %AT for angiographic coronary artery stenosis was then analyzed. As invasive substudies, fractional flow reserve and %AT by a dual-sensor (pressure and Doppler velocity) guidewire were measured simultaneously with %AT on transthoracic echocardiography (n = 14). RESULTS: Patients with coronary stenosis had significantly lower CFVR (1.7 ± 0.4) and greater %AT (65 ± 9%) compared with those without stenosis (2.6 ± 0.6 and 50 ± 13%, respectively). Percentage acceleration time by Doppler echocardiography was in good agreement with %AT (r = 0.98) and fractional flow reserve (r = 0.74) invasively measured by dual-sensor guidewire. Cutoff values of CFVR and %AT were determined as 2.0 and 60% in receiver operating characteristic curve analysis. The sensitivity, specificity, and accuracy of CFVR to detect coronary stenosis were 71.1%, 77.3%, and 75.4%, while those of %AT were 83.4%, 71.8%, and 75.4%, respectively. In addition, %AT provided high accuracy to detect coronary stenosis, especially in patients with previous myocardial infarctions, valvular disease, and left ventricular hypertrophy (81.1%, 84.1%, and 73.4%, respectively). CONCLUSIONS: The %AT of systolic coronary flow velocity is a promising marker to diagnose coronary stenosis in patients with microvascular dysfunction.

High-density lipoprotein cholesterol level is associated with fibrous cap thickness in acute coronary syndrome.

BACKGROUND: Although low high-density lipoprotein cholesterol (HDL-C) level has been reported as an independent risk factor for coronary artery disease, few studies addressed the direct relationship between the presence of thin-cap fibroatheroma (TCFA) that is considered as vulnerable plaque in pathology and HDL-C level. The aim of this study was to investigate whether lesion vulnerability is related to HDL-C level in patients with acute coronary syndrome (ACS). METHODS AND RESULTS: A total of 261 patients with ACS who underwent optical coherence tomography prior to percutaneous coronary intervention, were enrolled. Patients were divided into a TCFA group (n=124) and a non-TCFA group (n=137). TCFA was defined as a lipid plaque (lipid content in ≥1 quadrant) covered with <70 µm-thickness fibrous caps. There were no differences in patient characteristics and clinical results between the 2 groups except for HDL-C level, low-density lipoprotein cholesterol (LDL-C) level, and high-sensitive C-reactive protein (hs-CRP) level. On multivariate regression analysis, low HDL-C level (ß coefficient: 0.302, P<0.001), high LDL-C level (ß coefficient: -0.172, P=0.008), hs-CRP level (ß coefficient: -0.145, P=0.017), and current smoking (ß coefficient: -0.124, P=0.028) were identified as independent contributors to fibrous cap thickness. CONCLUSIONS: HDL-C is correlated with fibrous cap thickness of the culprit lesion in patients with ACS. HDL-C may be considered as a therapeutic target for plaque stabilization.

Second-generation everolimus-eluting stents compared to first-generation drug-eluting stents in patients treated for multivessel disease.

OBJECTIVE: This study aimed to compare the safety and efficacy of everolimus-eluting stents (EES) to first-generation drug-eluting stents (DES) in multivessel disease (MVD). BACKGROUND: Second-generation EES have demonstrated superiority over first-generation DES for single-vessel disease, although the merits of EES in MVD are less established. METHODS: A cohort of 1,285 patients (3,124 lesions) with ≥ 2 diseased vessels were treated with either first-generation DES (n = 1,002) or EES (n = 283). The rates of death, myocardial infarction, target lesion revascularization, target vessel revascularization, definite stent thrombosis, and major adverse cardiac events (MACE), defined as the combined incidence of target vessel revascularization, death, and non-fatal myocardial infarction, were compared at 1 year. RESULTS: Baseline characteristics were similar except for a lower left ventricular ejection fraction and a lower incidence of stable angina pectoris in the first-generation DES group (P = 0.001 and 0.013, respectively). At 1 year, the MACE rate was lower in the EES group (9.5P% vs. 15.7%; P = 0.01). Multivariable analysis demonstrated that EES use predicted a higher chance of freedom from MACE at 1 year (hazard ratio 0.58 [0.38-0.87]; P = 0.009; 95% confidence interval). CONCLUSIONS: The use of EES in patients with MVD is safe with signals for improved effectiveness compared to first-generation DES. Randomized trials comparing new-generation DES to coronary artery bypass grafting surgery are warranted.

Safety and efficacy outcomes of overlapping second-generation everolimus-eluting stents versus first-generation drug-eluting stents.

The safety and efficacy outcomes of stent overlap with second-generation drug-eluting stents (DES) have not been well established. This study aimed to compare the 1-year clinical outcomes of overlapping everolimus-eluting stents (EES) with those of overlapping first-generation DES. This retrospective analysis included 350 patients treated with overlapping EES (169 patients with 237 lesions), sirolimus-eluting stents (SES, 102 patients with 252 lesions), or paclitaxel-eluting stents (PES, 79 patients with 182 lesions). End points were major adverse cardiovascular events (MACE: defined as the composite of death, myocardial infarction, or target lesion revascularization), target vessel revascularization, and definite stent thrombosis at 1 year. During a follow-up of 1 year, overall MACE occurred in 6.5% of EES-, 16.8% of SES-, and 10.1% of PES-treated patients (p = 0.026). Myocardial infarction was lowest in the EES group versus SES and PES groups (0 vs 1.0% vs 2.5%, respectively; p = 0.080), and mortality was similar (3.6% vs 9.0% vs 5.1%, p = 0.162). The EES patients showed a trend toward lower rates of 1-year target lesion revascularization (3.1% vs 8.2% vs 6.5%, p = 0.181) and target vessel revascularization (3.7% vs 9.1% vs 11.7%, p = 0.051) compared with the SES- and PES-treated patients. The cumulative incidence of definite stent thrombosis was lowest in the EES group (0 for EES vs 3.9% for SES vs 2.5% for PES, p = 0.014). In conclusion, stent overlap with EES versus first-generation DES was associated with lower rates of MACE and stent thrombosis. Our results suggest that the use of EES when deploying overlapping stents is effective and safe.

Optimal revascularization strategies for percutaneous coronary intervention of distal anastomotic lesions after coronary artery bypass surgery.

OBJECTIVE: To determine the best revascularization strategy when treating distal anastomotic lesions. BACKGROUND: Distal anastomotic lesions are the most common reason for venous graft failure especially early after bypass surgery. However, the best percutaneous method for treating these lesions is still controversial. METHODS: All patients from 2/2000 to 1/2011 who underwent percutaneous coronary intervention of bypass graft distal anastomotic lesions were retrospectively enrolled. Among the 139 patients included, 26 (18.7%) were treated with plain old balloon angioplasty (POBA), 68 (48.9%) with bare metal stents (BMS), and 45 (32.4%) with drug-eluting stents (DES). RESULTS: Baseline characteristics were generally comparable among the 3 groups. At 6 months' follow-up, the highest rate of target lesion revascularization-major adverse cardiac events (TLR-MACE) was seen in the BMS group compared to the DES and POBA groups (16.2 vs. 2.2 vs. 3.8%, respectively, P=0.03), which was driven mainly by the highest rates of death and TLR in the BMS group (11.8 and 4.7%, respectively). At 1-year follow-up, a higher rate of TLR-MACE was seen in the BMS group compared to the DES and POBA groups (20.6 vs. 11.1 vs. 7.7%, respectively, P=0.19). After adjustment, on Cox regression analysis for hazard ratios, no significant differences were found among the 3 groups at 1-year follow-up of TLR-MACE. CONCLUSIONS: When selecting the treatment modality for saphenous vein graft distal anastomotic lesions, BMS implantation should be discouraged while POBA and DES implantation can be performed with favorable long-term outcomes. The optimal treatment approach should be evaluated in large, randomized clinical trials.