The estimation of coronary artery calcium thickness by computed tomography angiography based on optical coherence tomography measurements.

Optical coherence tomography (OCT) is recommended to be the most appropriate modality in assessing calcium thickness, however, it has limitations associated with infrared attenuation. Although coronary computed tomography angiography (CCTA) detects calcification, it has low resolution and hence not recommended to measure the calcium size. The aim of this study was to devise a simple algorithm to estimate calcium thickness based on the CCTA image. A total of 68 patients who had CCTA for suspected coronary artery disease and subsequently went on to have OCT were included in the study. 238 lesions of them divided into derivation and validation dataset at 2:1 ratio (47 patients with 159 lesions and 21 with 79, respectively) were analyzed. A new method was developed to estimate calcium thickness from the maximum CT density within the calcification and compared with calcium thickness measured by OCT. Maximum Calcium density and measured calcium-border CT density had a good correlation with a linear equation of y = 0.58x + 201 (r = 0.892, 95% CI 0.855-0.919, p < 0.001). The estimated calcium thickness derived from this equation showed strong agreement with measured calcium thickness in validation and derivation dataset (r2 = 0.481 and 0.527, 95% CI 0.609-0.842 and 0.497-0.782, p < 0.001 in both, respectively), more accurate than the estimation by full width at half maximum and inflection point method. In conclusion, this novel method provided the estimation of calcium thickness more accurately than conventional methods.

Biomarkers associated with coronary high-risk plaques.

Vascular inflammation, lipid metabolism, and thrombogenicity play a key role not only in atherogenesis but also in the development of acute coronary syndromes. Biomarkers associated with coronary high-risk plaques defined according to intravascular imaging have not been systematically studied. A total of 69 patients with coronary artery disease who underwent both optical coherence tomography and intravascular ultrasound imaging, and who provided blood specimens were included. Comprehensive biomarkers for inflammation, lipid, and coagulation were analyzed. Composite models sought biomarker patterns associated with thin-cap fibroatheroma (TCFA) and "high-risk plaques" (TCFA and large plaque burden). Two different composite models were developed for TCFA, based on the finding that high sensitivity C-reactive protein (hsCRP), plasminogen activator inhibitor-1, fibrinogen, IL-6, homocysteine and amyloid A levels were elevated, and high-density lipoprotein cholesterol (HDL) and bile acid levels were decreased in these patients. Both composite models were highly accurate for detecting patients with TCFA (area under curve [AUC]: 0.883 in model-A and 0.875 in model-B, both p < 0.001). In addition, creatinine, hsCRP, fibrinogen, tumor necrosis factor-α, IL-6, homocysteine, amyloid A, HDL, prothrombin, and bile acid were useful for detecting patients with "high-risk plaques". Two composite models were highly accurate for detection of patients with "high-risk plaques" (AUC: 0.925 in model-A and 0.947 in model-B, both p < 0.001). Biomarkers useful for detection of patients with high-risk coronary plaques defined according to intravascular imaging have been identified. These biomarkers may be useful to risk stratify patients and to develop targeted therapy.Clinical Trial Registration https://www.umin.ac.jp/ctr/ , UMIN000041692. Biomarkers and high-risk plaques hsCRP, PAI-1, fibrinogen, IL-6, homocysteine, amyloid A, HDL, and bile acid were useful for detecting patients with TCFA. hsCRP, fibrinogen, IL-6, homocysteine, amyloid A, creatinine, TNFα, HDL, prothrombin, and bile acid were useful for detecting patients with "high-risk plaques" (plaque which has both TCFA and large plaque burden). White arrowhead denotes TCFA. Red and green dashed lines denote lumen area and external elastic membrane area, respectively.

Gut Microbiota and Coronary Plaque Characteristics.

Background The relationship between gut microbiota and in vivo coronary plaque characteristics has not been reported. This study was conducted to investigate the relationship between gut microbiota and coronary plaque characteristics in patients with coronary artery disease. Methods and Results Patients who underwent both optical coherence tomography and intravascular ultrasound imaging and provided stool and blood specimens were included. The composition of gut microbiota was evaluated using 16S rRNA sequencing. A total of 55 patients were included. At the genus level, 2 bacteria were associated with the presence of thin-cap fibroatheroma, and 9 bacteria were associated with smaller fibrous cap thickness. Among them, some bacteria had significant associations with inflammatory/prothrombotic biomarkers. Dysgonomonas had a positive correlation with interleukin-6, Paraprevotella had a positive correlation with fibrinogen and negative correlation with high-density lipoprotein cholesterol, Succinatimonas had positive correlations with fibrinogen and homocysteine, and Bacillus had positive correlations with fibrinogen and high-sensitivity C-reactive protein. In addition, Paraprevotella, Succinatimonas, and Bacillus were also associated with greater plaque volume. Ten bacteria were associated with larger fibrous cap thickness. Some were associated with protective biomarker changes; Anaerostipes had negative correlations with trimethylamine N-oxide, tumor necrosis factor α, and interleukin-6, and Dielma had negative correlations with trimethylamine N-oxide, white blood cells, plasminogen activator inhibitor-1, and homocysteine, and a positive correlation with high-density lipoprotein cholesterol. Conclusions Bacteria that were associated with vulnerable coronary plaque phenotype and greater plaque burden were identified. These bacteria were also associated with elevated inflammatory or prothrombotic biomarkers. Registration URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000041692.

Prognostic relevance of B-type natriuretic peptide in patients with moderate mixed aortic valve disease.

AIMS: Data on B-type natriuretic peptide (BNP) levels and adverse outcomes in patients with moderate mixed aortic valve disease (MAVD), defined as moderate aortic stenosis (AS) and regurgitation (AR), are scarce. Therefore, this study investigated the impact of BNP on the clinical outcomes in such patients. METHODS AND RESULTS: Clinical data from 81 patients (mean age, 74.1 ± 6.8 years; 50.6%, men) treated for moderate MAVD and left ventricular ejection fraction (LVEF) ≥ 50% during 2010-2018 were retrospectively analysed. Specific echocardiographic data of the study patients were LVEF of 57.8 ± 5.0%, aortic valve index of 0.64 ± 0.04 cm2 /m2 , peak aortic valve velocity of 3.38 ± 0.29 m/s, and AR vena contracta width of 4.2 ± 0.7 mm. The median BNP level was 61.4 pg/mL (interquartile range, 29.7-109.9). The primary endpoint was a composite of all-cause death, heart failure hospitalization, and aortic valve replacement, and its cumulative incidence at 5 years was 57.7%. Multivariable analysis revealed that age (hazard ratio, 1.079; 95% confidence interval, 1.028-1.133; P = 0.002) and BNP levels (hazard ratio, 1.028; 95% confidence interval, 1.003-1.053; P = 0.027) were significantly related to the endpoint; specifically, BNP > 61.4 pg/mL had significantly higher incidence rates of the endpoint than those with a BNP ≤ 61.4 pg/mL (70.3% vs. 45.5% at 5 years; P = 0.018). Compared with patients with BNP ≤ 61.4 pg/mL, those with BNP > 61.4 pg/mL had significantly worse left ventricular global longitudinal strain (-17.1 ± 3.6% vs. -18.7 ± 2.6%; P = 0.029), along with higher left ventricular mass index (116.9 ± 27.8 g/m2 vs. 103.5 ± 19.7 g/m2 ; P = 0.014), relative wall thickness (0.45 ± 0.07 vs. 0.42 ± 0.05; P = 0.022), left atrial volume index (46.0 ± 28.4 mL/m2 vs. 31.4 ± 10.3 mL/m2 ; P = 0.003), pulmonary artery systolic pressure (32.6 ± 9.7 mmHg vs. 28.2 ± 4.7 mmHg; P = 0.011), and prevalence of moderate or greater tricuspid regurgitation (15.0% vs. 0.0%; P = 0.012). CONCLUSIONS: Patients with moderate MAVD are at higher risk of unfavourable clinical outcomes, and age and BNP are independently related to the occurrence of adverse events. High BNP levels may reflect extravalvular cardiac damage in patients with moderate MAVD.

Impact of Chronic Kidney Disease in Patients With Diabetes Mellitus after Percutaneous Coronary Intervention for Left Main Distal Bifurcation (From the Milan and New-Tokyo (MITO) Registry).

The impact of chronic kidney disease (CKD) on clinical outcomes after percutaneous coronary intervention for unprotected left main distal bifurcation lesions in patients with diabetes mellitus (DM) is not fully understood in drug eluting stent era. We identified 512 consecutive DM patients who underwent percutaneous coronary intervention for unprotected left main distal bifurcation lesions at New Tokyo Hospital, San Raffaele Scientific Institute and EMO-GVM Centro Cuore Columbus between January 2005 and December 2015. We analyzed according to estimated glomerular filtration rate (eGFR). Each group was defined as follows; no CKD (60 ≤ eGFR), mild CKD (45 ≤ eGFR < 60), moderate CKD (30 ≤ eGFR < 45), and severe CKD (15 ≤ eGFR < 30). The primary end point was target lesion failure (TLF) at 3 years. TLF was defined as a composite of cardiac death, target lesion revascularization, and myocardial infarction. The rate of TLF was significantly higher in the severe CKD group than that in the other groups (Adjusted HR of severe CKD relative to the others 3.64, [1.86 to 7.11], p < 0.001). Cardiac mortality was significantly higher in the severe CKD group than that in the other groups (Adjusted HR of severe CKD relative to the others 6.43, [2.19 to 18.9], p = 0.001). Target lesion revascularization rate was comparable in 4 groups (Adjusted HR of severe CKD relative to the others 1.71, [0.60 to 4.82], p = 0.31). In conclusions, in DM patients, those with severe CKD was extremely associated with worse clinical outcomes.

Peri-Procedural Acute Coronary Syndrome During Transcatheter Aortic Valve Replacement.

A 76-year-old male with severe chronic kidney disease, porcelain aorta and an oral squamous cell carcinoma (scheduled for chemotherapy and surgical excision) underwent transfemoral aortic valve replacement (TAVR) with a CoreValve Evolut R 34 due to severe aortic stenosis. The percutaneous treatment of a severely calcified stable lesion on ostial left circumflex (LCx) artery was not considered a priority due to the patient's comorbidities and the concerns about dual antiplatelet therapy. However, shortly afterwards valve deployment the patient developed an acute myocardial ischemia on the lateral wall due to LCx artery lesion becoming unstable; it was successfully treated with urgent coronary angioplasty and drug eluting stent implantation. A combination of multiple precipitating factors could be involved in the development of acute coronary syndrome during TAVR procedures.

Ultra-Low Contrast Percutaneous Coronary Intervention to Minimize the Risk for Contrast-Induced Acute Kidney Injury in Patients With Severe Chronic Kidney Disease.

BACKGROUND: The incidence of contrast-induced acute kidney injury (CI-AKI) is particularly high in patients with severe chronic kidney disease (CKD). Novel contrast-sparing strategies are warranted to guarantee the benefit of revascularization in this challenging and growing patient population. We aimed to evaluate the feasibility of an ultra-low contrast volume percutaneous coronary intervention (ULC-PCI) protocol in patients with severe CKD. METHODS: The ULC-PCI protocol is based on the prespecification of the maximum contrast volume to be administered, extensive intravascular ultrasound (IVUS) and/or dextran-based optical coherence tomography (OCT) guidance, and use of diluted contrast media. We created a retrospective registry to compare the outcomes of the ULC-PCI protocol vs conventional angiography-based PCI in patients with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m², applying no angiographic or procedural restriction criteria. RESULTS: We included 111 patients (ULC-PCI group, n = 8; conventional group, n = 103). Baseline clinical and angiographic characteristics were similar between groups. Contrast volume (8.8 mL [interquartile range, 1.3-18.5] vs 90 mL [interquartile range, 58-140 mL]; P<.001) was markedly lower in the ULC-PCI group. Technical success was achieved in all ULC-PCI procedures; in 7 of the 8 cases (88%), the ULC-PCI protocol was also successful (contrast-volume-to-eGFR ratio <1). The incidence of CI-AKI was 0% vs 15.5% in the ULC-PCI and conventional groups, respectively (P=.28). Procedures in the ULC-PCI group included the use of rotational atherectomy, two-stent bifurcation PCI, and mechanically supported chronic total occlusion PCI. CONCLUSIONS: An ULC-PCI protocol in patients with advanced CKD is feasible, appears to be safe, and has the potential to decrease the incidence of CI-AKI, compared with angiographic guidance alone.

Bioresorbable vascular scaffold implantation for severely calcified lesions after excimer laser lesion preparation.

Bioresorbable vascular scaffolds (Absorb BVS, Abbott Vascular, Santa Clara, CA) temporarily elute antiproliferative drugs and provide vessel support, which then subsequently resorb to allow restoration of normal vessel function and architecture. To attain the best possible results with BVS, a dedicated implantation technique (PSP: adequate lesion preparation, proper sizing, postdilatation) is considered mandatory, and calcified lesions are one of the most challenging lesion subsets for BVS implantation. In five cases with severe calcifications refractory to balloon predilatation, we performed excimer laser catheter ablation (ELCA: Turbo Elite catheter; Spectranetics Corporation, Colorado Springs, CO, USA), which facilitated adequate lesion expansion with high-pressure noncompliant balloon inflation and BVS implantation. During the follow-up period (481 days [interquartile range: 445-579]), all patients continued dual antiplatelet therapy (DAPT) and there were no cases of cardiac death, myocardial infarction, or scaffold thrombosis. For treatment of severely calcified lesions with bioresorbable scaffolds, ELCA could be considered an effective potential strategy. After the procedure, prolonged DAPT was prescribed.

What the surgeon needs to know about percutaneous coronary intervention treatment of chronic total occlusions.

Chronic total occlusion (CTO) accounts for 10-20% of lesions identified in coronary artery disease (CAD) patients. CTO percutaneous coronary intervention (PCI) is one of the most challenging of lesion subsets due to its technical difficulty, requiring specific operator expertise and equipment. There has been increased interest on CTO PCI evolving with the development of novel techniques and dedicated devices. Furthermore, in order to effectively and systematically utilize these techniques and devices, CTO PCI algorithms have been established. All of these developments have resulted in procedural success rates increasing to approximately 90%. In this review, we outline the evidence base for CTO PCI, conventional and contemporary CTO PCI techniques, CTO algorithms and outline integrated management strategies between cardiac surgeons and interventional cardiologists.

Percutaneous Direct Annuloplasty With Edge-to-Edge Technique for Mitral Regurgitation: Replicating a Complete Surgical Mitral Repair in a One-Step Procedure.

Surgical treatment of functional mitral regurgitation (MR) is usually based on the correction of both annular dilation and leaflet disease to minimize the risk of recurrence of MR at follow-up. This combined approach may also represent an interesting strategy during transcatheter mitral valve repair systems. We report a successful case of combined Cardioband (Edwards Lifesciences, Irvine, California) and MitraClip (Abbott, Santa Clara, California) implantation for the treatment of functional MR, with good acute and medium-term clinical and echocardiographic outcomes.

Zero-Contrast Percutaneous Coronary Intervention Guided by Dextran-Based Optical Coherence Tomography.

Individuals with advanced chronic kidney disease (CKD) and coronary artery disease are often denied percutaneous coronary intervention (PCI) because of an aversion to the risk of contrast-induced nephropathy. We present the case of a 76-year-old man with stage 4 CKD requiring coronary revascularization. Zero-contrast PCI was successfully performed using dextran-based optical coherence tomography (OCT) guidance. Our report suggests the feasibility of dextran-based, OCT-guided, zero-contrast PCI in patients with advanced CKD. Further studies should evaluate the safety and efficacy of this novel approach.

Subadventitial Advancement of a Mother-and-Child Catheter to Allow Successful Recanalization of a Complex In-Stent Chronic Total Occlusion: Testing the Resistance of the Adventitia.

In-stent chronic total occlusion (CTO) represents a challenging lesion subset for percutaneous coronary intervention (PCI), and although a true-to-true lumen crossing is the first-line strategy, a subadventitial approach may become necessary. Here we describe a case of successful in-stent right coronary artery CTO-PCI performed with subadventitial crossing, crushing of the occluded stents, and advancement of a mother-and-child catheter to the distal right coronary artery through the subadventitial space to allow stent delivery. The use of intracoronary imaging in this setting proved crucial to confirm adequate apposition of the newly implanted stents and optimal crushing of the occluded stents.

The STENTYS® paclitaxel-eluting stent in the treatment of unprotected distal left main.

BACKGROUND: Vessel tapering represents an important limitation of the balloon-expandable drug-eluting stent (DES) in the treatment of distal unprotected left main coronary artery (ULMCA) lesions. In this study, we assessed the suitability of the STENTYS DES((P)) , a self-apposing nitinol paclitaxel-eluting stent, for use in the treatment of distal ULMCA lesions. METHODS AND RESULTS: From February 2012 to September 2013, 75 consecutive patients with tapered (that is a >1 mm difference in the diameter from the proximal to the distal main vessel) distal ULMCA lesions were treated with the STENTYS DES((P)) (STENTYS-DES group) at the Clinica Mediterranea (Naples, Italy). A matched-group of 75 patients treated with second-generation DES in the same period (Control group) was selected from the database of New Tokyo Hospital (Chiba, Japan). The result was assessed by both quantitative coronary angiography and intravascular ultrasound (IVUS). Although the final balloon diameter was larger in the Control group (4.51 ± 0.51 vs. 3.62 ± 0.49 mm; P < 0.001), the IVUS analysis showed a larger final minimal lumen area in the STENTYS-DES group than in the Control group (left main: 17.45 ± 3.45 vs. 14.84 ± 3.45 mm(2) ; P < 0.001; polygon of confluence: 15.74 ± 3.28 vs. 12.55 ± 5.45 mm(2) ; P < 0.002; ostial left anterior descending artery: 11.73 ± 1.97 vs. 8.56 ± 1.80 mm(2) ; P < 0.001). At 12 ± 5 months, major adverse cardiac events (including death, myocardial infarction, and repeat revascularization) occurred in seven patients in both groups. CONCLUSIONS: This pilot study suggests that the self-apposing properties of the STENTYS DES((P)) offer a valid alternative for the treatment of the distal ULMCA lesions.