Optimal duration of dual antiplatelet therapy following treatment with the endeavor zotarolimus-eluting stent in real-world Japanese patients with coronary artery disease (OPERA): study design and rationale.

BACKGROUND: In patients with coronary artery disease (CAD), there is an increasing therapeutic need among interventional cardiologists to conduct dual antiplatelet therapy (DAPT) whose duration is shorter than current guideline-recommended 6-12 months after the implantation of drug-eluting stents. However, no clinical grounds sufficient to rationalize the need are available. OBJECTIVES: To define the optimal duration of DAPT and to examine the safety and efficacy of the Endeavor zotarolimus-eluting stent (E-ZES) in real-world Japanese patients with CAD. STUDY DESIGN: The present prospective, nonrandomized, multicenter, controlled study is uniquely designed to examine the analysis set to be formulated after integrating two different databases consisting of the following two study arms: the 3-month DAPT arm, in which 1,210 patients were consecutively enrolled at 106 medical institutions; and the 12-month DAPT arm, in which 1,210 patients will be consecutively extracted from the Endeavor Japan post-marketing surveillance at 60 medical institutions. The primary endpoint is "net adverse cardiac and cerebrovascular events-death, myocardial infarction, cerebrovascular accident, and major bleeding)" at 12 months after implantation. The secondary endpoints are as follows: major adverse cardiac events at 1, 3, 6, 9, and 12 months after implantation; target vessel revascularization and target lesion revascularization at 9 and 12 months after implantation; and stent thrombosis, DAPT compliance, and bleeding events at 12 months after implantation. Noninferiority in the E-ZES's profiles between the study arms will be investigated. CONCLUSIONS: The present study will provide insight into the optimal duration of DAPT after the E-ZES implantation in individual, real-world patients with CAD.

A multicenter randomized comparison of paclitaxel-coated balloon catheter with conventional balloon angioplasty in patients with bare-metal stent restenosis and drug-eluting stent restenosis.

BACKGROUND: The aim of this study was to investigate the efficacy and safety of paclitaxel-coated balloon (PCB) for the treatment of the bare-metal stent restenosis (BMS-ISR) and drug-eluting stent restenosis (DES-ISR). METHODS: This study was a prospective, multicenter, randomized (2:1) trial conducted in 208 patients with 213 in-stent restenosis lesions (BMS-ISR: 123 lesions, DES-ISR: 90 lesions) at 13 centers in Japan. Patients were randomly assigned to a PCB group (137 patients with 142 lesions) or a conventional balloon angioplasty (BA) group (71 patients with 71 lesions). The primary end point was target vessel failure at 6-month follow-up. RESULTS: Clinical and angiographic follow-up 6 months after intervention was performed in 207 patients (99.5%) with 208 lesions (97.7%). Target vessel failure was noted in 6.6% of the PCB group and 31.0% of the BA group (P < .001). Recurrent restenosis occurred in 4.3% of the PCB group and 31.9% of the BA group (P < .001). Late lumen loss was lower in the PCB group than in the BA group (0.11 ± 0.33 mm vs 0.49 ± 0.50 mm, P < .001). In PCB-treated lesions, recurrent restenosis occurred in 1.1% of patients with BMS-ISR and in 9.1% of patients with DES-ISR (P = .04). Late lumen loss was lower in patients with BMS-ISR than in patients with DES-ISR (0.05 ± 0.28 mm vs 0.18 ± 0.38 mm, P = .03). CONCLUSIONS: This randomized clinical study suggested that PCB provided much better clinical and angiographic outcomes than did conventional BA in patients with BMS-ISR and DES-ISR. Drug-eluting stent restenosis was associated with poorer outcomes compared with BMS-ISR after treatment with PCB.

Lipid-lowering and anti-inflammatory effect of ezetimibe in hyperlipidemic patients with coronary artery disease.

We evaluated the effects of adding ezetimibe to statin therapy in hypercholesterolemic patients with coronary artery disease (CAD) who could not achieve the target cholesterol levels recommended in the 2007 Japan Atherosclerosis Society Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases on statin monotherapy. Ezetimibe (10 mg) was added to basal statin therapy for 12 weeks in 35 patients with hypercholesterolemia and a history of CAD who had not achieved their target cholesterol level with statin monotherapy. Changes in serum lipids, obesity markers, an oxidative stress marker, inflammatory markers, and laboratory values were investigated. Total cholesterol (from 200.6 ± 30.4 mg/dL in week 0 to 173.4 ± 33.3 mg/dL in week 12, P < 0.001), low-density lipoprotein cholesterol (LDL-C) (121.3 ± 29.4 vs. 94.6 ± 30.4 mg/dL, P < 0.001), and remnant lipoprotein cholesterol (6.4 ± 3.5 vs. 5.3 ± 3.0 mg/dL, P < 0.05) all decreased significantly after addition of ezetimibe. The LDL-C/high-density lipoprotein cholesterol ratio also decreased significantly (2.5 ± 0.8 in week 0 vs. 1.9 ± 0.7 in week 12, P < 0.001). The percentage of patients achieving the target LDL-C level (<100 mg/dL) increased significantly (70.8 % in week 4 and 65.4 % in week 12, P < 0.001). There were no significant changes in the obesity or oxidative stress markers and high-sensitivity C-reactive protein (an inflammatory marker). However, another inflammatory marker (tumor necrosis factor-α) was decreased significantly by ezetimibe (1.36 ± 1.06 in week 0 vs. 0.96 ± 0.24 in week 12, P = 0.042). In conclusion, when ezetimibe was added to basal statin therapy, serum lipids improved significantly and the rate of achieving the target cholesterol level increased. Thus, ezetimibe efficiently decreases LDL-C and might prevent arteriosclerosis in hypercholesterolemic patients with CAD when added to basal statin therapy.

Late stent malapposition with marked positive vascular remodeling observed only at the site of drug-eluting stents after multivessel coronary stenting.

A 74-year-old woman presented with effort-induced chest pain. Diagnostic coronary angiography revealed three-vessel disease. A successful angioplasty was performed with two sirolimus-eluting stents placed in the left anterior descending artery (LAD) and left circumflex artery (LCX). The right coronary artery (RCA) was treated with a bare-metal stent. Follow-up angiography and intravascular ultrasound (IVUS) assessment were performed 8 months later, which showed late stent malapposition (LSM) with marked positive vascular remodeling around the drug-eluting stents (DES) in both LAD and LCX lesions, but there was no evidence of ectatic area around the BMS in the RCA lesion. Compared with the baseline IVUS, a significant increase in external elastic membrane (EEM) cross-sectional area was found. Twenty-seven months later, we performed repeat follow-up angiography. Intravascular ultrasound still showed vessel malapposition. A previous report showed that aneurysmal dilatation of the stented segment with severe localized hypersensitivity reaction could be a potential cause of late thrombosis after DES implantation. If LSM is related to hypersensitivity of the DES, it may have a potential risk of adverse events. Although there is a paucity of data regarding malapposition as the cause of adverse events, careful long-term follow-up of patients with vessel enlargement after DES placement is recommended.

Preventive effect of N-acetylcysteine on contrast-induced nephropathy following coronary angiography and angioplasty.

Contrast-induced nephropathy (CIN) is one of the serious side effects of contrast media. A few studies have suggested that N-acetylcysteine (NAC) is effective to prevent CIN, but the efficacy remains unclear in Japanese. Therefore, we retrospectively studied the preventive effect of NAC on CIN in Sakakibara Heart Institute. Patients who had been administered NAC for the purpose of preventing CIN before coronary intervention between February 2005 and November 2006 were included in the NAC group. In addition, age- and rate of diabetes mellitus-matched controls were randomly extracted. We retrieved and analyzed patient data including demographics, NAC dosage, and serum creatinine concentrations (Scr). NAC group (n=16) showed significantly higher baseline Scr (p<0.01) and a tendency toward a lower dose of contrast media (p=0.068) compared with controls (n=48). Since the occurrence of CIN was low, there was no significant difference in the proportion of CIN between the groups (NAC: 6%, controls: 4%). NAC group trended toward a decrease in Scr after the use of contrast media, while controls increased (-0.04+/-0.25 versus +0.03+/-0.36 mg/dl, p=0.096). The multivariate analysis showed that the dosage of NAC is inversely correlated with Scr independent of baseline Scr and dosage of contrast media. Despite higher baseline Scr (i.e., high-risk with CIN) in the NAC group, the real Scr value reflected a lower trend on average. In addition, this finding suggests that a larger dose of NAC results in a lower Scr value, we consider that the NAC dosage more likely prevented CIN.

A multicenter randomized comparison of paclitaxel-coated balloon with plain balloon angioplasty in patients with small vessel disease.

AIM: We investigated the efficacy and safety of using paclitaxel-coated balloon (PCB) to treat small vessel disease. METHODS AND RESULTS: In this multicenter, prospective, randomized controlled trial, one-hundred and thirty-five patients with native coronary lesions in small vessels were randomized into a PCB group and plain balloon angioplasty (POBA) group at a ratio of 2:1. There were no differences in target vessel failure (TVF) that was defined as cardiac death or target vessel-related myocardial infarction or target lesion revascularization (TLR), between the two groups (3.4 vs. 10.3%; P = 0.20), and TLR was slightly lower in the PCB group (2.3%) than that in the POBA group (10.3%) during 24 weeks follow-up. The late lumen loss (LLL) was significantly lower in the PCB group (0.01 ± 0.31 vs. 0.32 ± 0.34 mm; P < 0.01) and late lumen enlargement (LLE) was more frequently observed in the PCB group (48 vs. 15%; P < 0.01) by angiographic follow-up after 24 weeks. There were no cases of death, myocardial infarction, thrombosis and reocclusion in either group. CONCLUSIONS: This study was not able to demonstrate superiority of PCB compared with POBA.

The echocardiographic determinants of functional mitral regurgitation differ in ischemic and non-ischemic cardiomyopathy.

BACKGROUND: Functional mitral regurgitation (MR) is one of the common and severe complications in patients with dilated cardiomyopathy. The detailed mechanisms that cause functional MR remain to be elucidated. Using two-dimensional transthoracic echocardiography, we investigated the differences in major determinants of MR severity between ischemic cardiomyopathy (ICM) and non-ICM patients. METHODS: We enrolled 103 patients (91 males; age 64+/-12 years) with significant left ventricular (LV) dilatation. They were divided into ICM group (n=69) with significant coronary disease, and non-ICM (n=34) group without coronary disease. We devised a novel and simple parameter; the short-axis sphericity index (SI), to evaluate global LV remodeling, and used coaptation depth (CD) and tenting area (TA) to evaluate mitral deformity. RESULTS: In all cases, CD, TA and left atrium diameter (LAD) correlated positively with maximum regurgitation area (MRA) (r=0.54, 0.57, 0.57; P<0.0001). A negative correlation was observed between MRA and SI (r=-0.33, P=0.0008). There was no significant relationship between MRA and LV ejection fraction (EF). In non-ICM cases, SI tended to be lower with reduced EF. Multivariate stepwise linear regression analysis showed the following equations; ICM: MRA=-9.4+0.81CD+0.21LAD (r2=0.47, P<0.0001), non-ICM: MRA=-7.2+0.17LVDs (LV end systolic diameter) -8.7SI+0.27LAD (r2=0.63, P<0.0001). CONCLUSIONS: The strongest determinants of functional MR severity differ in ICM and non-ICM. While LV diameter and SI (global LV remodeling index) mainly determine the severity in non-ICM, CD that reflects mitral deformity is the major determinant in ICM.

Three-year follow-up outcomes of SES and PES in a randomized controlled study stratified by the presence of diabetes mellitus: J-DEsSERT trial.

BACKGROUND: Three-year clinical follow-up of patients with diabetes mellitus (DM) in the Japan-Drug Eluting Stents Evaluation; a Randomized Trial (J-DESsERT) using 2 different drug eluting stents (DES). A recent study demonstrated that efficacy of sirolimus eluting stents (SES) attenuated over time in diabetic patients. METHODS: In the largest trial of its kind, 1724 DM patients out of 3533 enrolled patients were randomized to either SES or paclitaxel eluting stents (PES). RESULTS: There were no significant differences in baseline clinical characteristics aside from hypertension. Incidence of major adverse cardiac cerebrovascular events (MACCE) mainly due to higher target vessel failure (TVF) initially indicated a benefit in SES (MACCE rate at 1 year: SES 9.4%, PES 12.2%, p=0.08); however this had attenuated by the time of the 3-year follow-up (MACCE rate from 1 to 3 years: SES 8.4%, PES 6.1%, p=0.10). A similar pattern was observed in insulin-treated patients: MACCE rate from 1 to 3 years was 10.5% in SES and 6.4% in PES (p=0.25). Angiographic follow-up also resulted in higher major adverse cardiac event (MACE) rates at 1 year (presence 11.5%, absence 8.3%, p=0.04); however by 3 years rates were similar regardless of the presence of angiographic follow-up (MACE rate at 3 years: presence 16.0%, absence 14.5%, p=0.35). CONCLUSIONS: The superiority of SES over PES in MACCE at 1 year had attenuated by 3-year follow-up. Eventually, the 3-year safety and efficacy profiles were similar regardless of insulin treatment.

Echocardiographic prediction of left ventricular dysfunction after mitral valve repair for mitral regurgitation as an indicator to decide the optimal timing of repair.

OBJECTIVES: This study sought to determine whether echocardiography before mitral valve repair (MVR) for mitral regurgitation (MR) was predictive of postoperative left ventricular (LV) dysfunction and useful for deciding the optimal timing of repair. BACKGROUND: Some reports have shown that the preoperative echocardiographic data of left ventricular ejection fraction (LVEF) and left ventricular end-systolic diameter (LVDs) were good predictors of postoperative LV dysfunction. However, few reports were based on long-term follow-up data of large numbers of patients who underwent MVR in the last decade. METHODS: A total of 274 patients with moderate or severe MR underwent MVR between October 1, 1991, and September 30, 2000. Among them, 171 patients who had both an operation for isolated MR due to degenerative pathology and a postoperative echocardiogram were studied. Postoperative echocardiograms were performed 3.9 +/- 2.4 years after the operation. The LVEF decreased from 66 +/- 10% before surgery to 63 +/- 11% after surgery (p < 0.0001). On univariate analysis, preoperative LVEF and LVDs correlated with postoperative LVEF (r = 0.41 and r = -0.39, respectively). Overall, postoperative LV dysfunction (defined as LVEF <50%) was not frequent (12%). However, the incidence of postoperative LV dysfunction was high in patients with preoperative LVEF <55% (38%) or LVDs > or =40 mm (23%). CONCLUSIONS: In patients with MR, the echocardiographic data of LVEF and LVDs were good predictors of postoperative LV dysfunction. When a decrease in LVEF or an increase in LVDs is detected, MVR should be considered to preserve postoperative LV function.

Outcomes of the largest multi-center trial stratified by the presence of diabetes mellitus comparing sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) in patients with coronary artery disease. The Japan drug-eluting stents evaluation: a randomized trial (J-DESsERT).

The Japan drug-eluting stents evaluation: a randomized trial (J-DESsERT) was conducted to compare the effectiveness of 2 different drug-eluting stents (DES). It remains uncertain which is more efficacious in diabetic patients, sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES). In this trial, the largest of its kind, 3,533 patients including 1,724 diabetes mellitus (DM) patients were randomized to either SES or PES. Stratification was based on the presence or absence of DM. PES target vessel failure (TVF) non-inferiority at 8 months (primary endpoint) was not demonstrated when compared to SES (SES 4.5 % vs. PES 6.4 %, p = 0.23). In addition, PES TVF superiority at 8 months in the DM subset (secondary endpoint) was not shown (SES 5.6 % vs. PES 7.6 %, p = 0.10). Insulin treatment was associated with increased TVF rates, however, this was less pronounced in the PES group. At 8 months, the similar TVF rates for SES and PES up to that point diverged significantly, favoring SES out to 12 months. Patients undergoing routine angiographic follow-up demonstrated lower TVF prior to the 8-month point, and higher TVF after 8 months, as compared to those followed clinically. In conclusion, the current study failed to demonstrate the proposed superiority of PES for DM patients. In addition, the diversion of TVF at 8 months may reflect an "oculo-stenotic reflex" bias (the tendency to treat lesions found during routine, rather than clinically driven, angiographic follow-up), which could constitute an obstacle for evaluating the true clinical effect of new devices.

Impact of a preoperative mitral regurgitation scoring system on outcome of surgical repair for mitral valve prolapse.

The optimal timing of surgical correction of severe mitral regurgitation (MR) is important for improved morbidity and mortality. We utilized a scoring system to decide the timing of procedures. Based on clinical features and echocardiographic data, we hypothesized that preoperative semi-quantitation of MR using this scoring system may be useful for predicting prognosis after repair. The MR score was composed of 6 parameters associated with disease severity (i.e., history of heart failure, atrial fibrillation, pulmonary hypertension, left ventricular end-systolic dimension, fractional shortening, and left atrial dimension). The maximum score was 6. Of 267 patients who underwent mitral valve repair in the last 10 years, 191 patients with mitral valve prolapse were studied. Patients were categorized into 2 groups according to MR score (group low [L] : 0 to 2.5 and group high [H]: >/=3.0) irrespective of New York Heart Association functional class. A significant difference in postoperative event-free survival was observed between both groups (p = 0.0014); the adjusted risk ratio was 3.4 (95% confidence interval 1.6 to 7.2). Postoperative echocardiography showed larger left ventricular systolic dimensions (p <0.0001), lower fractional shortening (p = 0.0016), and larger left atrial dimensions (p <0.0001) in group H than group L. Thus, an MR score is a simple way to predict the prognosis of severe MR independently of subjective symptoms in patients undergoing mitral valve repair.

Etiology of aortic valve disease and recent changes in Japan:a study of 600 valve replacement cases.

BACKGROUND: Recent studies on the etiology of aortic valve disease in the US showed a decrease in rheumatic valve disease and an increase in age-related degenerative disease. The purpose of this study was to describe the etiology of aortic valve disease and its temporal changes in Japan, based on a large number of cases. METHODS: The medical charts of all patients who underwent aortic valve replacement at our institute between 1977 and 1999 were reviewed. Among the 600 patients analyzed, 213 (36%) had pure aortic stenosis, 265 (44%) had pure aortic regurgitation, and 122 (20%) had combined stenosis and regurgitation. RESULTS: The causes were rheumatic change (49%), degenerative change (19%), bicuspid valves (18%), infective endocarditis (5%) and others (9%). Rheumatic disease continued to be the most common cause of aortic stenosis, but its frequency decreased from 100% in 1977-1979 to 37% in 1995-1999. In contrast, the frequency of degenerative change among stenotic valves increased recently from 11% in 1990-1994 to 30% in 1995-1999. Similarly, rheumatic disease remained to be the leading cause of aortic regurgitation, with a decline in frequency from 46% in 1985-1989 to 27% in 1995-1999. The percentage of degenerative change among regurgitant valves did not change appreciably. CONCLUSIONS: There was a shift in the causes of aortic valve disease, with a decrease in rheumatic disease and an increase in degenerative disease. This trend was similar to that observed in the US. These findings suggest the increasing importance of aortic valve disease due to degenerative change.

Normalization of left ventricular parameters following combined pimobendan and carvedilol treatment in a case of unclassified cardiomyopathy with longstanding refractory status.

A 58-year-old man with a 64-month history of unclassified cardiomyopathy developed congestive heart failure (CHF) and had been dependent on long-term intravenous positive inotropes. Combined pimobendan and carvedilol administration resulted in marked symptomatic improvement from New York Heart Association functional class IV to I. Echocardiograms showed improvement of left ventricular (LV) ejection fraction from 15 to 48%, and LV end-diastolic diameter from 6.7 to 4.9 cm. This mode of therapy not only improved LV contractile function but also normalized LV volume, which was an unusual clinical course compared with the general course of advanced CHF.

Early and long-term outcomes of coronary artery bypass grafting and percutaneous coronary intervention in patients with left main disease: single-center results of multidisciplinary decision making.

OBJECTIVE: Coronary artery bypass grafting (CABG) is considered the standard treatment for patients with left main disease (LMD). However, percutaneous coronary intervention (PCI) has recently emerged as a treatment option for selected patients. We assessed early and long-term outcomes of patients with LMD who underwent either CABG or PCI in our institution. METHODS: We reviewed the records of 438 patients with LMD who underwent revascularization between January 2005 and December 2010. Treatment modality, chosen by our heart team, was CABG in 409 patients and PCI in 29. Age, prevalence of women, and mean ejection fraction of patients were not significantly different between groups. Mean logistic European system for cardiac operative risk evaluation score was 7.7. Mean follow-up was 37.1 months. RESULTS: In CABG group, mean number of anastomoses was 4.0 and complete revascularization was achieved in 97.1 %. Bilateral internal thoracic arteries were used in 87.0 %. In PCI group, mean number of stents was 1.3 and complete revascularization was achieved in 44.8 %. Drug-eluting stent was used in 72.4 %. In-hospital mortality was 1.1 % (1.0 %, CABG group vs. 3.4 %, PCI group; p = 0.29). At 3 years, overall survival was 94.3 % (95.3 vs. 81.1 %; p < 0.01) and rate of freedom from major adverse cardiac events and cerebrovascular accidents was 88.9 % (89.8 vs. 77.3 %; p = 0.05). CONCLUSIONS: Our heart team's approach resulted in favorable overall results in patients with LMD. Multidisciplinary decision making in these high-risk patients can make good long-term outcomes in CABG.

Non-invasive diagnosis of coronary artery disease by 123I-BMIPP/201TlCl dual myocardial SPECT in patients with heart failure.

BACKGROUND/OBJECTIVES: Detecting the presence of coronary artery disease (CAD) is critically important in managing patients with heart failure of uncertain cause. The recently introduced 123I-BMIPP/201TlCl dual myocardial single-photon emission computed tomography (dual SPECT) is potentially a non-invasive diagnostic tool in detecting ischemic heart disease. The aim of our study is to evaluate the efficacy of detecting CAD by dual SPECT in patients with heart failure. METHODS: We studied 501 consecutive patients (366 males, mean age 68±12 years) who were admitted because of heart failure between January 2005 and April 2009. In all patients, the dual SPECT was performed in clinically stabilized states, followed by coronary angiography within 1 week. The polar map of the SPECT image was divided into 17 segments, each scored on a scale of 0-4 based on segmental percent uptake. The mismatch score was defined as the difference between 123I-BMIPP defect score and 201TlCI defect score. The uptake of 201TlCl and 123I-BMIPP was analyzed quantitatively using the Heart Score View software. RESULTS: The 201TlCI defect score and mismatch score were significantly higher in CAD patients than in non-CAD patients. The receiver operating characteristic (ROC) curve revealed that the mismatch score was a significantly more effective marker in detecting the presence of CAD than 201TlCl defect score (area under the curve: 0.84 versus 0.73, p<0.05). Using the mismatch score, the sensitivity and specificity of dual SPECT in detecting CAD were 84% and 83%, respectively. CONCLUSION: Dual SPECT is a useful non-invasive procedure for the detection of CAD in patients with heart failure.

Post-exercise diastolic stunning detected by velocity vector imaging is a useful marker for induced ischemia in ischemic heart disease.

BACKGROUND: Recently, post-exercise diastolic stunning (PES) has been reported as a new clinical marker of induced ischemia. Velocity vector imaging (VVI) has been developed to visualize regional wall motion abnormalities based on vectors detected by the tissue tracking technique, which has the potential to visualize PES. Thus, the aim of this study was to evaluate the usefulness of PES detection by VVI as an objective marker of ischemia compared to stress thallium-201 (Tl-201) single photon emission computed tomography (SPECT). METHODS: We studied consecutive patients who were scheduled to undergo exercise stress Tl-201 SPECT for the diagnosis of ischemic heart disease. Transthoracic echocardiography was recorded digitally before and 20 min after exercise for Tl-201 SPECT, and the data were used subsequently for VVI analysis. We defined PES regions as those with new abnormal vectors observed during isovolumic relaxation. RESULTS: After excluding 14 patients with old myocardial infarction and/or atrial fibrillation, echocardiograms suitable for VVI analysis were obtained from 62 of 65 patients (feasibility, 95 %; 44 men; mean age, 64 ± 11 years). SPECT revealed induced ischemia in 20 patients, whereas VVI identified PES in 18 patients. VVI detected inducible ischemia with 85 % sensitivity and 98 % specificity compared to SPECT. CONCLUSIONS: VVI detection of PES is a new clinical tool for induced ischemia. Regional diastolic wall motion abnormalities following induced ischemia can be noninvasively detected by VVI.

A case of osteopetrosis with severe aortic stenosis treated by transcatheter aortic valve implantation.

Osteopetrosis is a rare hereditary disease characterized by osteoclast dysfunction and consequently diminished bone resorption and disturbed bone building and remodeling, resulting in abnormally dense and brittle bones. Pathologic fractures are common in patients with osteopetrosis. We report a case of benign adult form of osteopetrosis with severe aortic stenosis (AS) and coronary artery disease (CAD). A 67-year-old female patient presented with long-standing dyspnea and palpitation. She was diagnosed with benign adult form of osteopetrosis in her childhood, upon detailed investigations for a pathologic fracture. Physical examination and imaging studies revealed severe AS and two-vessel CAD. Aortic valve replacement and coronary artery bypass grafting were indicated, but open heart surgery by median sternotomy was high risk because of osteopetrosis. We performed staged percutaneous coronary intervention (PCI) and transcatheter aortic valve implantation (TAVI) as minimally invasive treatment. The postoperative course was uneventful and transthoracic echocardiography showed a properly functioning prosthetic valve and no sign of AS. This is the first case report of successful treatment of severe AS and CAD by combined TAVI and PCI in a patient with osteopetrosis. .

Angiographic findings of everolimus-eluting as compared to sirolimus-eluting stents: angiographic sub-study from the Randomized Evaluation of Sirolimus-eluting versus Everolimus-eluting stent Trial (RESET).

Several recent randomized trials comparing everolimus-eluting stent (EES) and sirolimus-eluting stent (SES) reported similar clinical outcomes. This study was aimed to clarify the differences in the angiographic findings of EES as compared to SES. Randomized Evaluation of Sirolimus-eluting versus Everolimus-eluting stent Trial is a prospective multicenter randomized open-label trial comparing EES with SES in Japan. From February to July 2010, 3197 patients were randomly assigned to receive either EES or SES. Of these, angiographic sub-study enrolled 571 patients (EES 285 patients, SES 286 patients). Angiograms were assessed qualitatively and quantitatively at procedure and at 8-12 months in the independent core angiographic laboratory. Late loss of the proximal edges tended to be greater in the EES group than that in the SES group (0.12 ± 0.49 vs. 0.04 ± 0.43 mm, P = 0.05), although late loss in the other segments was similar between the 2 groups. Edge restenosis was mainly observed in EES group, whereas body restenosis was demonstrated in half of SES group. Stent fracture was observed only in the SES group (1.5 %), and peri-stent contrast staining (PSS) tended to be more frequently observed in the SES group than in the EES group (3.6 and 1.5 %, P = 0.18). Restenotic response in the proximal edge was more prominent in the EES group as compared to the SES group. Abnormal angiographic findings such as stent fracture and PSS tended to be more frequent in the SES group.

Excessive axial plaque redistribution during coronary stent implantation confirmed by intravascular ultrasound.

We report a case of excessive axial plaque redistribution leading to luminal narrowing at the reference segment confirmed by serial intravascular ultrasound during coronary stent implantation.

Rotational atherectomy followed by cutting-balloon plaque modification for drug-eluting stent implantation in calcified coronary lesions.

BACKGROUND: Drug-eluting stent (DES) underexpansion has been reported as an independent factor for restenosis and thrombosis; therefore, adequate plaque modification prior to DES implantation is the key of calcified lesion treatment. METHODS: Consecutive patients with severely calcified lesions undergoing rotational atherectomy (RA) followed by balloon dilatation before DES implantation were analyzed. Patients were divided into two groups based on the balloon type before stent implantation: the cutting balloon (ROTACUT group) and the plain balloon (control group). RESULTS: Twenty-five patients with 26 calcified lesions were identified: 10 patients (10 lesions) were included in the ROTACUT group and 15 patients (16 lesions) in the control group. There were statistically no differences in the final burr size (1.65 ± 0.21 mm vs 1.67 ± 0.22 mm; P=.803), the maximum (max) balloon diameter before stent implantation (2.85 ± 0.34 mm vs 2.72 ± 0.42 mm; P=.411), the max final balloon diameter (3.30 ± 0.33 mm vs 3.28 ± 0.44 mm; P=.908), and the max final balloon inflation pressure (15.3 ± 3.0 atm vs 16.4 ± 5.5 atm; P=.501). Final minimum stent cross-sectional area (CSA) was significantly larger in the ROTACUT group compared to the control group (6.80 ± 1.27 mm² vs 5.38 ± 1.89 mm²; P=.048). CONCLUSION: RA followed by cutting balloon plaque modification for DES implantation in severely calcified lesions appears to be more efficacious including significantly larger final stent CSA.