Repeated Syncope Following COVID-19 Infection.

A 74-year-old woman presented to our hospital with syncope after a coronavirus disease 2019 (COVID-19) infection. Upon admission, she passed out, and an 8 second sinus arrest was detected during telemetry monitoring. During the next syncope episode, telemetry monitoring showed that her heart rate decreased from 80 to 36 bpm, accompanied by a 2.4 second pause. A permanent pacemaker was implanted; however, the patient still experienced syncope. The head-up tilt test revealed a vasodepressor reflex syncope. The need for permanent pacemakers in patients with syncope following COVID-19 therefore remains controversial.

Intravascular ultrasound system-guided bail-out stent implantation for iatrogenic aortocoronary dissection: a case report.

Background: Iatrogenic aortocoronary dissection (ACD) is a rare but potentially devastating complication of cardiac catheterization. We describe a case of an iatrogenic ACD following catheter engagement and balloon inflation of the proximal right coronary artery (RCA) during an elective percutaneous coronary intervention (PCI). Case summary: An 81-year-old woman presented with an acute inferior wall ST-elevation myocardial infarction. Emergent coronary angiography revealed the three-vessel diseases. Primary PCI for the culprit lesion of the occluded mid-circumflex artery was successfully performed. After 10 days, an elective PCI for the residual RCA lesions was performed. After the balloon inflation of the proximal RCA, iatrogenic ACD was detected. Intravascular ultrasound-guided stent implantation sealing an entry tear prevented further dissection. The post-operative course was uneventful, and the patient was discharged 1 week later. Follow-up cardiac computed tomography revealed a disappearance of the aortocoronary intramural haematoma. Discussion: This case emphasizes the importance of prompt detection and intervention for iatrogenic ACD. Heart team discussion is essential to determine whether cardiovascular surgery or percutaneous management should be performed. Bail-out stent implantation sealing an entry tear is frequently used and effective, and an intravascular ultrasound system would help to recognize the morphology of ACD, contributing to the safe procedure.

Clinical Characteristics of the Patient With Unmeasurable Ankle-Brachial Index in Endovascular Treatment.

Introduction Ankle-brachial index (ABI) is an important indicator to diagnose lower extremity arterial disease (LEAD). However, patients with unmeasurable ABI are sometimes excluded from the analysis and their clinical characteristics are poorly understood. Methods One hundred twenty-two consecutive Japanese subjects (mean age, 72 years), who underwent successful endovascular treatment (EVT) for lower extremity arteries at our hospital were retrospectively studied. Results Of the 122 patients, 23 (19%) patients presented an unmeasurable ABI before EVT. Five of 23 (22%) had still an unmeasurable ABI one day after EVT. Comorbidities including hypertension, diabetes, dyslipidemia, hemodialysis, smoking, ischemic heart disease, atrial fibrillation, and past-EVT history were not different between ABI measurable and unmeasurable patients. However, patients with unmeasurable ABI presented a significantly higher degree of Rutherford category and a smaller number of tibial vessel runoff than patients with measurable ABI before EVT (p<0.05 and p<0.01, respectively). There was no difference in the lesion site between the two groups. The event rate including all-cause mortality, re-EVT, lower limb amputation, and bypass surgery did not differ between two groups four years after EVT. ABI after four years of initial EVT did not differ between pre-EVT measurable and unmeasurable patients (0.96 vs. 0.84, p=0.48). Conclusions Patients with unmeasurable ABI before EVT were characterized by higher degree of Rutherford categorization and a small number of tibial vessel runoff, but there was no significant difference in outcomes during the follow-up period.

Multiple Cardiac Calcified Amorphous Tumors.

A 61-year-old woman who underwent hemodialysis presented with heart failure. Echocardiography revealed multiple mobile masses in the left atrium. The masses were excised, and histopathologic examination revealed calcified amorphous tumors. Here, we present several echocardiography images, including 3-dimensional transesophageal echocardiography, demonstrating the revolving masses in the left atrium. (Level of Difficulty: Intermediate.).

Dynamic kinking of right coronary artery after the button Bentall procedure.

Postoperative coronary artery complications after Bentall procedures are well recognised but are rare and potentially fatal. There have been only five cases documenting percutaneous coronary intervention (PCI) for right coronary artery (RCA) involvements after button Bentall procedures. We describe a case of postoperative silent myocardial ischaemia in a 72-year-old man who underwent the button Bentall procedure for a right sinus of Valsalva aneurysm. On postoperative day 15, an RCA complication was incidentally detected by follow-up multidetector CT. Coronary angiography showed proximal RCA kinking, which was not an anastomosis but a native coronary artery. The patient underwent a successful PCI with drug-eluting stent implantation. We reviewed six cases consisting of this case and five previous cases treated with PCI. These cases enhance the recognition of potential RCA complications after the button Bentall procedure.

Rare pulmonary embolism caused by the combination of bilateral popliteal venous aneurysms and antiphospholipid syndrome.

Popliteal venous aneurysm (PVA) and antiphospholipid syndrome (APS) are under-recognised as potential causes of pulmonary embolism (PE). A 66-year-old woman presented with progressive shortness of breath. A contrast-enhanced CT revealed bilateral PE, a small renal infarction and bilateral PVAs. Direct oral anticoagulant (DOAC) therapy was initiated immediately for venous thrombosis. Given the positivity for serum antiphospholipid antibody (aPL) in an initial blood test, low-dose aspirin was included to prevent further arterial thrombosis. Her symptoms resolved and she was discharged 1 week later. Twelve weeks later, she was diagnosed with APS because of persistent aPL. Surgical resection of the right PVA was performed 1 year later from her hospitalisation. To the best of our knowledge, this is the first case of PE caused by the combination of bilateral PVAs and APS. This report emphasises the importance of careful screening to identify PE causes, and its optimal management.

Patients With Obesity Exhibit a Plateau Pattern of the Right Ventricular Waveform.

BACKGROUND: Ventricular waveforms are characterized by a dip-and-plateau pattern during diastole owing to an abrupt termination of ventricular filling because of pericardial constraint under conditions such as constrictive pericarditis (CP). However, constrictive hemodynamics is not specifically caused by CP. Therefore, this study aimed to evaluate whether patients with obesity exhibited constrictive hemodynamics. METHODS: Overall, 60 consecutive Japanese patients (mean age, 69.5 years; 45% women) who underwent right heart catheterization at the Japan Community Healthcare Organization Osaka Hospital from July 2016 to September 2018 were examined. Two-dimensional echocardiography was used to measure the epicardial adipose tissue (EAT) in the standard parasternal long-axis view during end-diastole. Because patients who underwent open-heart surgery were highly likely to have CP, they were excluded. RESULTS: Among the 60 patients, 11 (18%) exhibited a plateau pattern of the right ventricular waveform and had a mean EAT value of 4.2 mm, which was significantly higher than that of patients without such a pattern (2.1 mm, P < 0.001). Similarly, the mean body mass index (BMI) values were significantly higher in patients with a plateau pattern than in those without it (27.2 vs. 21.8 kg/m2, P < 0.001). EAT was significantly correlated with the BMI (r = 0.72, P < 0.001). In patients with a plateau pattern, the triglyceride (TG) and low-density lipoprotein cholesterol (LDL-C) levels were significantly higher (TG: 150 vs. 100 mg/dL, LDL-C: 121 vs. 95 mg/dL, P < 0.05) and the left atrial diameter (52.8 vs. 44.7 mm, P < 0.01) and left atrial volume index (58.7 vs. 47.6 mL/m2, P < 0.05) were significantly greater than those in the patients without it. The EAT was also significantly correlated with the TG level (r = 0.37, P < 0.01). CONCLUSIONS: Obese patients may present with constrictive hemodynamics, suggesting left ventricular diastolic dysfunction. EAT was significantly correlated with metabolic syndrome components, namely obesity and TG levels.

Hypertensive heart disease associated with methamphetamine abuse.

In Japan, methamphetamine accounts for the majority of illicit drug use and dependence is becoming a critical issue. Methamphetamine abuse induces cardiovascular complications, such as cardiomyopathy and heart failure. However, methamphetamine-associated cardiovascular complications are not common in Japan. We report the case of a young patient with hypertensive heart disease associated with habitual methamphetamine abuse. A 37-year-old man was admitted with congestive heart failure. He was a habitual methamphetamine abuser and developed chronic hypertension after he started methamphetamine abuse. His echocardiogram demonstrated left ventricular concentric hypertrophy with diffuse hypokinesis. An endomyocardial biopsy revealed histological evidence of a hypertensive heart. This case shows that habitual methamphetamine use may cause hypertensive heart disease because of chronic hypertension. .

Impact of intravascular ultrasound-guided minimum-contrast coronary intervention on 1-year clinical outcomes in patients with stage 4 or 5 advanced chronic kidney disease.

This study aims to elucidate 1-year clinical outcomes using this technique for patients with stage 4 or 5 advanced chronic kidney disease (CKD). Research has proven that imaging-guided percutaneous coronary intervention (PCI) reduces contrast volume significantly; however, only short-term clinical benefits have been reported. Minimum-contrast (MINICON) studies are based on the registry design pattern to enroll PCI results in patients with advanced CKD stage 4 or 5 comorbid with coronary artery disease. We excluded cases of emergency PCI or maintenance dialysis from this study. In this study, we compared the intravascular ultrasound (IVUS)-guided MINICON PCI group (n = 98) with the angiography-guided standard PCI group (n = 86). Enrollment of the MINICON studies started in 2006. Before 2012, IVUS-guided MINICON PCI was performed only in 14% (stage 1), but it was 100% after 2012 (stage 2). The enrollment finished in 2016. The IVUS-guided MINICON PCI group exhibited a significantly reduced contrast volume (22 ± 20 vs. 130 ± 105 mL; P < 0.0001) and contrast-induced acute kidney injury (CI-AKI; 2% vs. 15%; P = 0.001). The PCI success rate was similarly high (100% vs. 99%; P = 0.35). At 1 year (follow-up rate, 100%), we observed less induction of renal replacement therapy (RRT; 2.7% vs. 13.6%; P = 0.01), but all-cause mortality or myocardial infarction was similar in both groups. The IVUS-guided MINICON PCI reduces CI-AKI significantly and induction of RRT at 1 year in patients with stage 4 or 5 advanced CKD.

Acute coronary syndrome: insight from angioscopy.

Although the concept of vulnerable plaque has become common, it is still impossible to predict effectively the onset of acute coronary syndrome (ACS). Thin-cap fibroatheroma (TCFA) is regarded as vulnerable from pathological studies and various diagnostic tools have tried to detect TCFA clinically but failed to predict ACS. Because there are so many silent plaque ruptures detected, it is supposed that many vulnerable plaques might have ruptured but not caused ACS. Some factor(s) other than the rupture of vulnerable plaque is required for the onset of ACS. "Vulnerable blood" may be one of them. The thrombogenic potential of blood (ie, vulnerable blood) may play an important and determinant role in the onset of ACS, the process of which will be discussed from the angioscopic point of view.

Atherosclerotic and thrombogenic neointima formed over sirolimus drug-eluting stent: an angioscopic study.

OBJECTIVES: We sought to examine by angioscopy the neointima formation and thrombogenic potential of the neointima after deployment of a drug-eluting stent (DES). BACKGROUND: Late stent thrombosis after DES implantation, a major safety concern, has been associated with poor strut coverage by neointima. Intracoronary angioscopy provides a method for visual evaluation of stent coverage by neointima and detection of thrombus in the stented coronary segment. METHODS: Patients undergoing implantation of a sirolimus DES (n = 57) were serially examined by angioscopy immediately after (baseline) and again at 10 months (follow-up) after implantation. The angioscopic color grade of the neointima from white to yellow was assessed in a semiquantitative manner. Stent coverage was classified into not covered (Grade 0), covered by a thin layer (Grade 1), or buried under neointima (Grade 2). The thrombogenic potential of the neointima was evaluated by the prevalence of thrombus on the neointima. RESULTS: The maximum yellow color grade of the neointima within DES-implanted lesions increased significantly from baseline to follow-up (1.4 +/- 1.1 vs. 1.9 +/- 0.6, p = 0.0008). Even among lesions without yellow color at baseline, yellow color was detected in 94% (17 of 18) of lesions at follow-up. The prevalence of thrombus was significantly higher on the yellow than on the white neointimal areas. Thrombus was detected on yellow and/or Grade-0/1 neointima, but never on the white Grade-2 neointima. CONCLUSIONS: Sirolimus DES promoted formation of atherosclerotic yellow neointima in the stent-implanted lesion at 10-month follow-up. Thrombus was detected more often on the yellow area than on the white area and was never detected where a stent was buried under white neointima. These data suggest that the increased potential risk of late stent thrombosis in DES lesions may be due to the newly formed yellow neotima and cholesterol-laden plaque.

A large dissecting sub-epicardial hematoma and cardiac tamponade following elective percutaneous coronary intervention.

A 70-year-old woman was performed percutaneous coronary intervention at the stenotic lesion of the 1st diagonal branch. Soon after stenting, cardiac tamponade occurred and emergent cardiac surgery was performed. A large epicardial hematoma was observed in the antero-lateral wall that was compressing the distal diagonal branch. The patient died of multi-organ failure 3 days after surgery. An autopsy of her heart revealed an extensive intramural hematoma in the left ventricular wall. There was no evidence of perforation of the stented lesion. The suspected cause was neither coronary perforation nor coronary rupture of target lesion.

Plaque color analysis by the conventional yellow-color grading system and quantitative measurement using LCH color space.

BACKGROUND: Yellow plaques of higher color grades are regarded as more vulnerable. We tried to elucidate the characteristics of yellow color that are regarded as the sign of vulnerable plaques by an objective and quantitative plaque color analysis. METHODS: The color of yellow plaques was quantitatively analyzed using LCH color space and was presented by the maximum values of lightness (Lmax), chroma (Cmax), and hue (Hmax). Effect of light intensity on these parameters was experimentally examined (five plaque models, six light intensities). Relation between conventional yellow-color grade and LCH parameters was examined (31 plaques). Color analysis with LCH color space was applied (1) to compare the culprit lesions of unstable angina (eight patients) and of stable effort angina (nine patients) and (2) to evaluate the regression of yellow plaque by 80-week statin treatment (four patients, 19 plaques). RESULTS: Cmax and Hmax were not influenced by light intensity so far as it was within appropriate range. Cmax (13 +/- 3, 25 +/- 5, and 28 +/- 4) became higher and Hmax (178 +/- 26, 134 +/- 10, and 91 +/- 16) became lower as the grade became higher (P < 0.0001). Culprit lesions of unstable angina had higher Cmax (22.8 +/- 7.9 vs 14.8 +/- 7.5, P = 0.04) and lower Hmax (73.3 +/- 19.7 vs 168.0 +/- 71.5, P = 0.002) than stable effort angina. Statin treatment reduced Cmax (21.3 +/- 9.6 vs 14.6 +/- 3.1, P = 0.004) and increased Hmax (82.6 +/- 25.8 vs 142.3 +/- 54.1, P = 0.0005). CONCLUSIONS: Plaque color was consistently and quantitatively measurable using LCH color space uninfluenced by light intensity of appropriate range. Vulnerable yellow color had high chroma and low hue, indicating vivid and reddish-yellow color.

Acute myocardial infarction without disrupted yellow plaque in young patients below 50 years old.

OBJECTIVE: Thrombosis caused by disrupted yellow plaque is regarded as a cause of acute myocardial infarction (MI). However, it has not been clarified if young patients have the same pathophysiology as older ones. Therefore, we elucidated clinical and angioscopic characteristics of young patients. METHODS: Among a series of patients (n = 893) who received catheterization for acute MI, clinical characteristics were compared between patients <50 years (n = 66) and the rest of patients. Angioscopic appearance of culprit lesions was evaluated in 20 young patients in whom angioscopic examination was successfully performed. It was determined if culprit lesions had disrupted yellow plaque with thrombus (DYP&T). RESULTS: Patients <50 years had higher prevalence of smoking (68% vs. 48%, P = 0.001), obesity (42% vs. 15%, P < 0.0001), and hypercholesterolemia (56% vs. 35%, P = 0.0005) than those >or=50 years. DYP&T was detected at culprit lesions in 14 (70%) patients. Prevalence of DYP&T was lower in patients <40 years (44% vs. 91%, P = 0.02) than those between 40 and 50 years. Patients <40 years had a trend for higher prevalence of smoking (88% vs. 62%, P = 0.05) than those between 40 and 50 years. CONCLUSIONS: Patients with acute MI < 50 years, especially <40 years, had lower prevalence of DYP&T but higher prevalence of smoking, obesity, and hypercholesterolemia. Smoking may play an important role for thrombotic occlusion at lesions with relatively low thrombogenic potential.

Angioscopic evaluation of neointima coverage: sirolimus drug-eluting stent versus bare metal stent.

BACKGROUND: The process of neointima formation after bare metal stent (BMS) implantation has been previously elucidated by angioscopic observations; however, that after drug-eluting stent (DES) implantation has not been clarified. Therefore, we compared the angioscopic appearance of neointima over DESs with that over BMSs 6 months after implantation. METHODS AND RESULTS: Patients who received an implantation of a BMS (n = 13) or a sirolimus DES (n = 24) were included in this study. Angiographic and angioscopic examinations were performed at 6 months. The color of the stented lesion (white or yellow), coverage of stent by neointima (not covered, covered by a thin layer, or buried under neointima), and thrombus at the stented lesion (presence or absence) were angioscopically evaluated. Of the 24 lesions in which a DES was implanted, 11 (46%) had a part where the stent strut had no coverage, 21 (88%) had a part where it was covered by a thin layer, and 11 (46%) had a part where it was buried under neointima. Of the 13 lesions in which a BMS was implanted, 1 (8%) lesion had a part where the stent strut had no coverage, 4 (31%) lesions had a part where it was covered by a thin layer, and 13 (100%) lesions had a part where it was buried under neointima. The prevalence of a stent buried under neointima (46% vs 100%, P = .001) was lower and that of thrombus (42% vs 8%, P = .03) was higher in DES-implanted lesions as compared with BMS-implanted lesions. The prevalence of thrombus (64% vs 17%, P = .005) was higher in the yellow area than in the white area when a DES was implanted. CONCLUSION: Sirolimus DESs, as compared with BMSs, were poorly covered by neointima and were accompanied by thrombus especially when there was a yellow plaque under the stents. Thus, the thrombogenic potential in DES-implanted lesions may be sustained by the inhibition of neointima formation over thrombogenic plaques.