Prognostic Impact of Prehospital Simple Risk Index in Patients With ST-Elevation Myocardial Infarction.

BACKGROUND: The simple risk index recorded in the emergency room (ER-SRI), which is calculated using the formula (heart rate × [age / 10]2) / systolic blood pressure, was shown to be able to stratify the prognosis in ST-elevation myocardial infarction (STEMI) patients. However, the prognostic impact of the prehospital simple risk index (Pre-SRI) remains unknown.Methods and Results: This study enrolled 2,047 STEMI patients from the Mie Acute Coronary Syndrome (ACS) registry. Pre-SRI was calculated using prehospital data and ER-SRI was calculated using emergency room data. The primary endpoint was 30-day all-cause mortality. The cut-off values of Pre-SRI and ER-SRI for predicting 30-day mortality were 34.8 and 34.1, with accuracies of 0.816 and 0.826 based on receiver operating characteristic analyses (P<0.001 for both). There was no difference in the accuracy of the 2 indices. Multivariate Cox regression analysis demonstrated that a High Pre-SRI (≥34) was a significant independent predictor of 30-day mortality. With combined Pre-SRI and ER-SRI assessment, patients with High Pre-SRI/High ER-SRI showed significantly higher mortality than those with High Pre-SRI/Low ER-SRI, Low Pre-SRI/High ER-SRI, and Low Pre-SRI/Low ER-SRI (P<0.001). The addition of High Pre-SRI to High ER-SRI showed incremental prognostic value of the Pre-SRI. CONCLUSIONS: Pre-SRI can identify high-risk STEMI patients at an early stage and combined assessment with Pre-SRI and ER-SRI could be of incremental prognostic value for risk stratification in STEMI patients.

Prognostic Impact of Peak Aortic Jet Velocity on Patients With Acute Myocardial Infarction.

BACKGROUND: Aortic valve stenosis (AS) leads to increased cardiovascular mortality and morbidity, and recent studies reported that even mild-to-moderate AS was associated with poor prognosis in the general population. This study investigated the prognostic impact of mild or moderate AS, defined as 2.0 m/s ≤ peak aortic jet velocity (Vmax) ≤3.9 m/s using echocardiography in acute myocardial infarction (AMI) patients.Methods and Results: This study enrolled 3,049 AMI patients using data from the Mie ACS registry. Patients were divided into 2 groups according to Vmax: Group 1: Vmax <2.0 m/s and/or visually intact aortic valve in which all 3 leaflets are fully and evenly open; Group 2: 2.0 m/s ≤ Vmax ≤ 3.9 m/s. There were 2,976 patients in Group 1and 73 patients in Group 2. The Group 2 patients were older, had a higher percentage of males and had lower body mass index and Killip ≥2 than the Group 1 patients. Angiographic data, door-to-balloon time, and mechanical support were not different between the 2 groups. The Group 2 patients demonstrated a significantly higher all-cause mortality rate (P<0.01) and composite of cardiovascular death and heart failure hospitalization (P<0.01), and Kaplan-Meier analysis showed the same tendency in propensity score-matched patients. CONCLUSIONS: The present study revealed that mild or moderate AS based on Vmax is associated with poor prognosis following AMI.

Prevalence and Prognosis of Familial Hypercholesterolemia in Patients With Acute Coronary Syndrome in Mie Prefecture, Japan　- Report From Mie ACS Registry.

BACKGROUND: Familial hypercholesterolemia (FH) is an autosomal dominant disorder characterized by elevated low-density lipoprotein cholesterol concentration and premature acute coronary syndrome (ACS). However, hereditary diseases may have regional characteristics, and few data are available regarding the prevalence of FH throughout particular regions in Japan. This study investigated the prevalence and prognosis of FH in patients with ACS in Mie Prefecture, Japan.Methods and Results:This study investigated 738 ACS patients from the Mie ACS Registry in Mie Prefecture, and 706 (95.7%) with sufficient data to diagnose FH were enrolled for analysis. Eighteen patients (2.5%) were diagnosed with FH, which was similar to findings of another multidistrict registry conducted in Japan. Patients with FH were significantly younger and had a higher prevalence of premature onset of ACS than patients with non-FH (P<0.01). Incidence of major adverse cardiac and cerebrovascular events (MACCE) was not statistically different between patients with FH and non-FH in this study population, even in the propensity score-matched analysis. CONCLUSIONS: Prevalence of FH in ACS patients from the Mie Prefecture was similar to that found in another Japanese multidistrict registry. Among ACS patients, short-term incidence of MACCE was not statistically different between patients with FH and non-FH in this study population.

Rural-Urban Disparity in Emergency Care for Acute Myocardial Infarction in Japan.

BACKGROUND: There are few reports examining regional differences between rural prefectures and metropolitan areas in the management of acute myocardial infarction (AMI) in Japan.Methods and Results:In the Rural AMI registry, a prospective, multi-prefectural registry of AMI in 4 rural prefectures (Ishikawa, Aomori, Ehime and Mie), a total of 1,695 consecutive AMI patients were registered in 2013. Among them, 1,313 patients who underwent primary percutaneous coronary intervention (PPCI) within 24 h of onset were enrolled in this study (Rural group), and compared with the cohort data from the Tokyo CCU Network registry for AMI in the same period (Metropolitan group, 2,075 patients). The prevalence of direct ambulance transport to PCI-capable facilities in the Rural group was significantly lower than that in the Metropolitan group (43.8% vs. 60.3%, P<0.01), which resulted in a longer onset-to-balloon time (OTB: 225 vs. 210 min, P=0.02) and lower prevalence of PPCI in a timely fashion (OTB ≤2 h: 11.5% vs. 20.7%, P<0.01) in the Rural group. Multivariate analysis revealed that direct ambulance transport was the strongest predictor for PPCI in a timely fashion (odds ratio=4.13, P<0.001). CONCLUSIONS: AMI patients in rural areas were less likely to be transported directly to PCI-capable facilities, resulting in time delay to PPCI compared with those in metropolitan areas.

Echocardiographic Assessment of Cardiac Structural and Functional Abnormalities in Patients With End-Stage Renal Disease Receiving Chronic Hemodialysis.

BACKGROUND: The aim of this study was to assess the echocardiographic characteristics of chronic hemodialysis (HD) patients with end-stage renal disease (ESRD) in a multicenter prospective cohort study.Methods and Results:Three hundred and fifteen patients with ESRD (67.9±10.6 years, 47.6% male) on chronic HD for ≥1 year were examined on transthoracic echocardiography, including Doppler-derived aortic valve area (AVA) measurement. Only 11.5% and 3.4% of all patients had normal left ventricular (LV) geometry and normal LV filling pattern, respectively. The majority of patients had aortic and mitral valvular calcification, and approximately 50% of all 315 patients had aortic valve narrowing with AVA <2.0 cm2. Patients were divided into 3 groups according to AVA index tertile: group 1, highest tertile; group 2, middle tertile; and group 3, lowest tertile. Group 3 was older, had a greater cardiothoracic ratio on chest X-ray, higher plasma brain natriuretic peptide and total LV afterload, and lower stroke volume index than the other 2 groups. Age and intact parathyroid hormone (PTH) level were independently associated with low AVA index. CONCLUSIONS: Patients with ESRD on chronic HD have a high prevalence of cardiac structural and functional abnormalities including calcified aortic sclerosis. High age and PTH were associated with aortic valve narrowing in these patients.

Effect of perioperative complications after endovascular therapy in patients with peripheral artery disease due to femoropopliteal lesions.

OBJECTIVE: Despite wide use, high initial success, and acceptable durability of endovascular therapy (EVT) for femoropopliteal (FP) lesions, the frequency of 30-day perioperative complications (POCs) and their effect on clinical outcomes have not been systematically evaluated, which is the subject of this study. METHODS: We used a multicenter database of 2145 consecutive patients (70% male; overall mean age, 73 ± 9 years) who successfully underwent EVT for FP lesions to investigate independent predictors of POCs (logistic regression analysis) and effect of POCs on prognostic outcomes (Cox proportional regression). RESULTS: POCs were observed in 209 patients (10%). In multivariate logistic regression analysis, body mass index <18.5 kg/m(2), critical limb ischemia, and TransAtlanic Inter-Society Consensus for the Management of Peripheral Arterial Disease class D lesions were independently associated with POCs (adjusted odds ratios [95% confidence intervals], 2.0 [1.3-2.9], 2.5 [1.9-3.3], and 1.6 [1.2-2.1], respectively). After risk stratification of POCs according to the number of these risk factors, the incidence of POCs was higher in the groups with higher scores. Follow-up for >30 days (mean, 2.3 ± 1.8 years) was available for 2079 of 2145 patients. A Cox hazard regression model adjusted for baseline clinical characteristics showed POCs were negatively and independently associated with future occurrence of major adverse limb events (defined as major amputation and major reintervention) or death (hazard ratio [95% confidence interval], 1.6 [1.2-2.1]; P < .05). CONCLUSIONS: Body mass index <18.5 kg/m(2), critical limb ischemia, and TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease class D lesion were positively associated with POCs after EVT for FP lesions. The occurrence of POCs may adversely affect clinical outcomes in the chronic phase.

Renal resistive index as an indicator of the presence and severity of anemia and its future development in patients with hypertension.

BACKGROUND: We examined whether renal resistive index (RI), a simple index of renal vascular resistance, is associated with the presence and severity of anemia, and can predict the future development of anemia in patients with hypertension. METHODS: We retrospectively examined 175 patients with hypertension (mean age 67 ± 11 years, 32-85 years, 134 males) who underwent renal ultrasonography. Anemia was defined as a reduction in the concentration of hemoglobin <13.0 g/dL for men and <12.0 g/dL for women. Renal RI was measured in the interlobar arteries. RESULTS: Anemia was present in 37% of men and 34% of women. The mean estimated glomerular filtration rate (eGFR) was 58 ± 23 ml/min/1.73 m(2) (median: 56 ml/min/1.73 m(2), range: 16-168 ml/min/1.73 m(2)) and the mean renal RI was 0.70 ± 0.09 (median: 0.70, range: 0.45-0.92). Proteinuria was present in 29% of patients. Both eGFR and renal RI correlated significantly with hemoglobin levels. In the stepwise multivariate linear regression analysis, renal RI was associated with hemoglobin levels independently of potential confounders including eGFR. During the follow-up period (median: 959 days, range: 7-3595 days), Kaplan-Meier curves demonstrated that patients with renal RI above the median value had a higher incidence of the future development of anemia than other patients. Cox regression analysis showed that renal RI (hazard ratio 1.18, 95% CI 1.02-1.37 per 0.05 rises in renal RI, p =0.03) and the presence of proteinuria were (hazard ratio 1.80, 95% CI 1.08-3.01, p =0.03) were independently associated with the future development of anemia after correcting for confounding factors. CONCLUSIONS: Measurement of renal RI can be useful for elucidating the pathogenesis of anemia and for inferring its potential risk in patients with hypertension.

Effect of combination therapy of ezetimibe and rosuvastatin on regression of coronary atherosclerosis in patients with coronary artery disease.

Ezetimibe has been reported to provide significant incremental reduction in low-density-lipoprotein cholesterol (LDL-C) when added to a statin; however, its effect on coronary atherosclerosis has not yet been evaluated in detail. The aim of this study was to investigate the add-on effect of ezetimibe to a statin on coronary atherosclerosis evaluated by intravascular ultrasound (IVUS).In this prospective randomized open-label study, a total of 51 patients with stable coronary artery disease (CAD) requiring percutaneous coronary intervention (PCI) were enrolled, and assigned to a combination group (n = 26, rosuvastatin 5 mg/day + ezetimibe 10 mg/day) or a monotherapy group (n = 25, rosuvastatin 5 mg/day). Volumetric IVUS analyses were performed at baseline and 6 months after the treatment for a non-PCI site. LDL-C level was significantly reduced in the combination group (-55.8%) versus that in the monotherapy group (-36.8%; P = 0.004). The percent change in plaque volume (PV), the primary endpoint, appeared to decrease more effectively in the combination group compared with the monotherapy group (-13.2% versus -3.1%, respectively, P = 0.050). Moreover, there was a significant group × time interaction in the effects of the two treatments on PV (P = 0.021), indicating the regressive effect of the combination therapy on PV was greater than that of monotherapy for subtly different values of baseline PV in the two treatment groups. Moreover, percent change in PV showed positive correlations with percent change of LDL-C (r = 0.384, P = 0.015).Intensive lipid-lowering therapy with ezetimibe added to usual-dose statin may provide significant incremental reduction in coronary plaques compared with usual-dose statin monotherapy.

Relationship between CYP2C19 loss-of-function polymorphism and platelet reactivities with clopidogrel treatment in Japanese patients undergoing coronary stent implantation.

BACKGROUND: CYP2C19 loss-of-function genotype (*2 and/or *3 alleles) is related to low responsiveness to clopidogrel, which is a risk factor for ischemic cardiac events. The contribution of these genotypes to platelet reactivity in Japanese patients in a steady state receiving dual antiplatelet therapy after coronary stenting was evaluated. METHODS AND RESULTS: A total of 155 Japanese patients were classified according to their CYP2C19 loss-of-function genotype. Platelet reactivity was assayed by plasma levels of soluble P-selectin and platelet-derived microparticles, light transmittance aggregometry induced by ADP (ADP-LTA), shear stress-induced platelet aggregometry, vasodilator-stimulated phosphoprotein phosphorylation (VASP) index and the VerifyNow-P2Y12 assay. Linear and logistic regression models were used to assess the associations between CYP2C19 loss-of-function genotype and high on-treatment platelet reactivity. In total, 62 patients (40.0%) were extensive metabolizers (EMs), 70 (45.2%) were intermediate metabolizers (IMs) and 23 (14.8%) were poor metabolizers (PMs). ADP-specific assays (ADP-LTA, the VASP index and VerifyNow-P2Y12) differed according to CYP2C19 genotype, with a significant gene-dose effect (PMs>IMs>EMs). CYP2C19 loss-of-function carrier status was associated with more frequent high platelet reactivity. CYP2C19 loss-of-function genotype alone could explain 12.2%, 14.3%, and 14.7% of the variability in the ADP-LTA, VASP and VerifyNow-P2Y12 assays, respectively. CONCLUSIONS: CYP2C19 loss-of-function genotype is associated with more frequent high platelet reactivity, as assessed by ADP-specific platelet function tests, in Japanese patients.

Atrial fibrillation induced by inappropriate reactive antitachycardia pacing due to far field R wave oversensing: A case report.

An 89-year-old man with an intermittent 2:1 second-degree atrioventricular block received a permanent pacemaker (Medtronic Azure XT DR; Medtronic Inc., Minneapolis, MN, USA). Reactive antitachycardia pacing (ATP) was engaged in all transmissions 3 weeks later. Intracardiac recordings revealed a far-field R wave (FFRW) oversensing, occurring between atrial waves and premature atrial contractions. This event triggered the delivery of reactive ATP, which induced atrial fibrillation. A 79-year-old man underwent permanent pacemaker implantation for an intermittent complete atrioventricular block. One month after implantation, reactive ATP was initiated. The atrial electrogram of intracardiac recordings revealed one being a spontaneous P wave and the other an oversensed R wave. The criterion for an atrial tachycardia was fulfilled, and the device initiated reactive ATP. As a result, atrial fibrillation was induced by inappropriate reactive ATP. It was difficult to completely avoid inappropriate reactive ATP. Finally, we discontinued reactive ATP. The two cases presented in this study demonstrate the possibility of inappropriate reactive ATP due to FFRW oversensing, with the inappropriate reactive ATP inducing atrial fibrillation. All patients treated with reactive ATP should be carefully assessed for the presence of FFRW oversensing during pacemaker implantation and during the follow-up period. Learning objective: We present two cases of inappropriate reactive ATP caused by far-field R-wave oversensing. Inappropriate reactive ATP has not been previously reported. Therefore, we suggest that all patients provided with a DDD pacemaker should be carefully assessed for the presence of FFRW oversensing during pacemaker implantation and during the follow-up period. Remote monitoring enables very early detection of inappropriate reactive ATP delivery for rapid implementation of preventive measures.

Prevalence and signal characteristics of late gadolinium enhancement on contrast-enhanced magnetic resonance imaging in patients with takotsubo cardiomyopathy.

BACKGROUND: To determine the prevalence and signal intensity (SI) characteristics of late gadolinium enhancement (LGE) on magnetic resonance imaging (MRI) in takotsubo cardiomyopathy (TC). METHODS AND RESULTS: Cine, black-blood T2-weighted and LGE MR images were acquired in 23 patients with TC within 72 h of onset. Wall motion abnormality (WMA), edema and LGE were evaluated with a 16-segment model. The SI characteristics of LGE were analyzed using SI distribution in remote normal segments as reference. Follow-up MRI was performed 3 months later. Retrospective analysis of LGE MRI was also performed in 10 patients with acute myocardial infarction (AMI) to compare the SI characteristics between TC and AMI. In acute phase, WMA and edema were observed in 236 (64%) and 205 (56%) of 368 segments. LGE was observed in 10 (2.7%) of 368 segments and in 5 (22%) of 23 patients. All LGE lesions in TC exhibited transmural enhancement. The contrast-to-noise ratio (CNR) in TC was significantly lower than that of AMI (3.1±0.3 standard deviations (SD) vs. 6.1±1.2 SD, P<0.01), and CNR value of 4 was useful for distinguishing TC from AMI. Both LGE and WMA disappeared within 12 months. CONCLUSIONS: Grey myocardial signal on LGE MRI may be observed in patients with TC. However, the extent of LGE is substantially less than that of WMA and edema, and disappears within 12 months.

Moyamoya Disease Complicating Ebstein's Anomaly.

Ebstein's anomaly is an uncommon congenital disorder affecting the tricuspid valve. We herein report a 38-year-old woman who experienced consciousness and sensory disturbance during treatment for heart failure caused by Ebstein's anomaly. Urgent magnetic resonance imaging and cerebral angiography demonstrated acute cerebral infarction and internal carotid artery obstruction with the development of collateral arteries. We diagnosed her with multiple cerebral infarctions due to moyamoya disease. Ebstein's anomaly concomitant with moyamoya disease is extremely rare. However, we should consider the possibility of this rare but important concurrence when treating patients with heart failure due to Ebstein's anomaly to avoid excessive diuresis and vasodilation and irreversible brain injury.

Analyzing Effect of Waterclefts on Visual Functions Via Optical Simulations.

Purpose: To investigate the impact of the size and location of waterclefts (WC), which are one of several cataract subtypes, on visual function by optical simulation analysis. Methods: An optical simulation software (CODE V) was used to develop a schematic eye model and several sizes of WC central and peripheral types that were located below the anterior and posterior subcapsules of the crystalline lens, and analyses of refraction, higher-order aberrations (HOA), and the modulation transfer function (MTF) were performed. Results: An increase in the WC size increased the refraction and HOA and decreased the MTF. The impact of the WC below the posterior subcapsule on the visual function was more enhanced than that below the anterior subcapsule. Large WC demonstrated a remarkable hyperopic shift in refractive power as well as an increase in HOA. The MTF decreased slightly with increasing WC size at a spatial frequency of 20 cycles/mm, and it decreased remarkably at 60 cycles/mm. Conclusions: The impact on the visual function increased with increasing WC size. It was revealed that eyes with WC below the posterior subcapsule are more hyperopic than those with WC below the anterior subcapsule, and the former have a higher HOA and lower MTF than the latter.

Impact of hyperuricemia on coronary blood flow and in-hospital mortality in patients with acute myocardial infarction undergoing percutaneous coronary intervention.

BACKGROUND: Although serum uric acid (UA) is considered as a risk factor for cardiovascular disease, few data exist regarding the relationship between hyperuricemia, coronary blood flow, and subsequent outcome in patients with acute myocardial infarction (AMI). The purpose of our study is to assess whether hyperuricemia is associated with suboptimal coronary flow and increased risk of mortality in patients with AMI after percutaneous coronary intervention (PCI). METHODS: Using the Rural AMI registry data, 989 consecutive patients with AMI who underwent emergent PCI and had UA measurement at admission were analyzed. We defined hyperuricemia as serum UA ≥7.0 mg/dL in men and ≥ 6.0 mg/dL in women. The primary endpoint was suboptimal coronary flow, defined as post PCI Thrombosis In Myocardial Infarction flow grade ≤ 2. The secondary outcome was in-hospital mortality. RESULTS: Hyperuricemia was found in 249 (25.2%) patients. Patients with hyperuricemia were more often complicated with cardiogenic shock compared with those without (16.9% vs. 7.4%, p < 0.001). In addition, the median high-sensitivity C-reactive protein was significantly higher in patients with hyperuricemia (0.18 mg/dL; IQR, 0.09-0.71 mg/dL) than in those without (0.14 mg/dL; IQR, 0.07-0.41 mg/dL, p < 0.05). Under these conditions, the prevalence of suboptimal coronary flow after PCI (17.3% vs. 10.1%, p < 0.05) and in-hospital mortality (10.8% vs. 3.6%, p < 0.001) were significantly higher in patients with hyperuricemia compared with those without. Multivariable logistic regression analysis revealed that hyperuricemia was significantly associated with suboptimal coronary flow [odds ratio (OR), 1.60; 95% confidence interval (CI), 1.02-2.49; p < 0.05] and in-hospital mortality (OR, 2.08; 95% CI, 1.05-4.12; p < 0.05). CONCLUSIONS: Assessment of serum UA upon admission provides useful information for predicting suboptimal coronary flow and in-hospital mortality in patients with AMI undergoing PCI.

Comparison of Door-to-Balloon Time and 30-Day Mortality According to Symptom Presentation in Patients With Acute Myocardial Infarction.

Background: We hypothesized that symptom presentation in patients with acute myocardial infarction (AMI) may affect their management and subsequent outcome. Methods and Results: Using Rural AMI Registry data, 1,337 consecutive patients with AMI who underwent percutaneous coronary intervention were analyzed. Typical symptoms were defined as any symptoms of chest pain or pressure due to myocardial ischemia. We considered the specific symptoms of dyspnea, nausea, or vomiting as atypical symptoms. The primary outcome was 30-day mortality. There were 150 (11.2%) and 1,187 (88.8%) patients who presented with atypical and typical symptoms, respectively. Those who presented with atypical symptoms were significantly older (mean [±SD] age 74±12 vs. 68±13 years; P<0.001) and had a higher Killip class (46.7% vs. 21.8%; P<0.001) than patients presenting with typical symptoms. The prevalence of door-to-balloon time of ≤90 min was significantly lower in patients with atypical than typical symptoms (40.0% vs. 66.3%; P<0.001). At 30 days, there were 55 incidents of all-cause death. Multivariate Cox proportional hazards regression analysis revealed that symptom presentation was associated with 30-day mortality (hazard ratio 2.33; 95% confidence interval 1.20-4.38; P<0.05). Conclusions: Atypical symptoms in patients with AMI are less likely to lead to timely reperfusion and are associated with increased risk of 30-day mortality.

Effect of left ventricular ejection fraction on the prognostic impact of chronic total occlusion in a non-infarct-related artery in patients with acute myocardial infarction.

BACKGROUND: Chronic total occlusion (CTO) in a non-infarct-related artery (IRA) in patients with acute coronary syndrome (ACS) is associated with a poor prognosis. However, whether the prognostic impact of non-IRA CTO differs according to left ventricular ejection fraction (LVEF) is unclear. METHODS AND RESULTS: A total of 2060 consecutive acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) were classified into 2 groups according to their LVEF (reduced EF: LVEF < 50%, preserved EF: LVEF ≥ 50%) and further subdivided according to the presence of concomitant non-IRA CTO. In the reduced EF group, patients with CTO had a higher 1-year all-cause death rate (20.3% vs. 34.3%, P = 0.001) and major adverse cardiac event rate (MACE: 19.6% vs. 39.6%, P < 0.001) compared to those without CTO, but they were similar between patients with and without CTO in the preserved EF group. Non-IRA CTO was an independent predictor of all-cause death (HR 1.58, 95% CI 1.06-2.33, P = 0.02) and MACE (HR 1.67, 95% CI 1.14-2.46, P = 0.009) only in the reduced EF group. In addition, the outcomes of successful CTO-PCI seemed to be similar to those without CTO in the reduced EF group. CONCLUSIONS: CTO in a non-IRA may contribute to a poor prognosis only in AMI patients with reduced LVEF.

Ultrabroadband spectral amplitude modulation using a liquid crystal spatial light modulator with ultraviolet-to-near-infrared bandwidth.

The first demonstration to our knowledge in the spectral range from 300 to 1100 nm is presented for the amplitude modulation characteristics of a two-channel 648-pixel liquid crystal spatial light modulator. The broadest spectral amplitude modulation for UV (380-420 nm) and visible-to-near-IR (500-900 nm) pulses to generate a spectral-shifted pulse pair is experimentally realized. The results show that the liquid crystal spatial light modulator has a potential application for attosecond extreme-UV pulse characterization with the conventional SPIDER algorithm and the capability to shape monocycle optical pulses.

Regional myocardial perfusion reserve determined using myocardial perfusion magnetic resonance imaging showed a direct correlation with coronary flow velocity reserve by Doppler flow wire.

AIMS: Quantitative analysis of rest-stress myocardial perfusion magnetic resonance imaging (MRI) can provide assessments of regional myocardial perfusion reserve (MPR). The purpose of this study was to compare regional MPR determined by myocardial perfusion MRI with coronary flow reserve (CFR) by intracoronary Doppler flow wire. METHODS AND RESULTS: Twenty patients with suspected coronary artery disease (CAD) were studied. Average peak velocity was measured by Doppler flow wire in the resting state and during adenosine triphosphate (ATP) stress in 36 coronary arteries. CFR measurements for each patient were performed in the culprit and one non-culprit non-stenotic artery. First-pass, contrast-enhanced myocardial perfusion MR images were obtained in the resting state and during ATP stress within the week before the Doppler wire procedure. Regional myocardial blood flow (MBF) was quantified in 16 myocardial segments by analysing arterial input and myocardial output using a Patlak plot method. MPR was calculated as stress MBF divided by rest MBF. CFR measured by Doppler flow wire was compared with MPR in the myocardial segments corresponding to vessel territories. The average MPR measured by perfusion MRI was 1.77 +/- 0.62 for the culprit arteries and 3.45 +/- 0.78 for the non-culprit arteries, respectively (P < 0.001). The averaged CFR by Doppler flow wire was 1.72 +/- 0.44 in the culprit arteries and 3.14 +/- 0.74 in the non-culprit arteries, respectively (P < 0.001). For both culprit and non-culprit vessel groups, significant direct correlations were observed between MR assessments of MPR and Doppler assessments of CFR (culprit artery: R = 0.87, Non-culprit artery: R = 0.86) On Bland-Altman analysis, the mean differences between MPR determined by myocardial perfusion MRI and CFR measured by Doppler wire were 0.05 in culprit arteries (95% limit of agreement; -0.65 to 0.56) and 0.36 in non-culprit arteries (95% limit of agreement; -1.24 to 0.44). The sensitivity and specificity of MR measurement of MPR for predicting physiologically significant reduction of Doppler CFR (<2) was 88% (95% CI 61.7-98.5) and 90% (95% CI 68.3-98.8), respectively. CONCLUSION: The current results using Doppler flow wire as a reference method demonstrated that quantitative analysis of stress-rest myocardial perfusion MRI can provide a non-invasive assessment of reduced MPR in patients with CAD.

Clinical usefulness of instantaneous wave-free ratio for the evaluation of coronary artery lesion with prior myocardial infarction: A multi-center study.

BACKGROUND: Fractional flow reserve (FFR) is useful for assessing the functional significance of coronary artery stenosis, even in lesions with prior myocardial infarction (pMI). Instantaneous wave-free ratio (iFR) is a vasodilator-free alternative for the physiological assessment of coronary artery stenosis. In addition, iFR shows good diagnostic agreement with FFR and an iFR-guided revascularization strategy was non-inferior to an FFR-guided revascularization strategy. However, the clinical usefulness of iFR for the evaluation of a coronary artery lesions with pMI has not been evaluated. METHODS AND RESULTS: A total of 200 lesions from 200 patients (44 pMI territories lesions and 156 non-pMI coronary artery lesions) were analyzed retrospectively. Major adverse cardiac events (MACE) were defined as cardiovascular death, non-fatal MI, unstable angina pectoris, fatal arrhythmia and heart failure during 12 months follow-up after the physiological assessment of coronary artery stenosis. iFR was closely correlated with FFR in pMI and non-pMI lesions (r = 0.81 and 0.72; P < 0.001, respectively). In pMI lesions, an iFR cut-off of 0.89 was optimal against a clinical FFR cut-off of 0.80 according to receiver operating characteristics (ROC) curve analysis, whereas in non-pMI lesions, the iFR cut-off value was 0.92 without statistical significance. In addition, the event rate of MACE was similar between pMI and non-pMI patients during follow-up even in the presence or absence of an PCI procedure. CONCLUSIONS: iFR may be a useful alternative method compared with FFR for clinical decision-making even in pMI patients.