Relationship between early drop in systolic blood pressure, worsening renal function, and in-hospital mortality in patients with heart failure: a retrospective, observational study.

This study aimed to determine the optimal cut-off value of the early drop in systolic blood pressure (SBP) for worsening renal function (WRF) in hospitalized patients with heart failure (HF) and analyze predictors of WRF and the early drop in SBP at that threshold. We retrospectively enrolled 396 patients with acute decompensated HF. The early drop in SBP was defined as the difference between baseline and SBP measured 24 h after hospitalization. We performed receiver operating characteristic (ROC) analysis to determine the optimal cut-off value of the early drop in SBP for WRF and evaluated the effect of the early drop in SBP on in-hospital mortality by multivariate logistic regression analyses. The mean age of the patients was 73.4 ± 14.7 years, and 61.2% were men. A 14.0% drop in SBP was identified as the optimal cut-off value for WRF from the ROC curve analysis. An early drop in SBP ≥ 14.0% was associated with WRF in multivariate logistic regression analysis (odds ratio 7.84; 95% confidence interval 4.06-15.14; P < 0.0001). The dose of intravenous furosemide within 24 h of admission was one of the predictors of the early drop in SBP ≥ 14.0%, while no early drop in SBP was a predictor of in-hospital mortality in multivariate logistic regression models. In conclusion, the optimal cut-off value for WRF in patients with HF was a 14.0% drop in SBP within 24 h of admission. The early drop in SBP ≥ 14.0% was one of the predictors of WRF in patients with HF. However, no early drop in SBP was associated with in-hospital mortality. This study was registered with the University Hospital Medical Information Network in Japan (UMIN000035989).

Zinc supplementation in patients with acute myocardial infarction.

This single-centre prospective feasibility study (UMIN000030232) evaluated whether zinc supplementation was safe and effective for improving outcomes among patients with acute myocardial infarction (AMI). Within 24 h after successful primary percutaneous coronary intervention, consenting patients with AMI were randomly assigned 1:1 to receive conventional treatment (conventional treatment group) or conventional treatment plus zinc acetate supplementation (zinc supplementation group). The two groups were compared in terms of major adverse cardiovascular events (MACE), and scar size, which was evaluated using cardiac magnetic resonance imaging (CMR) at 4 weeks after discharge. A total of 56 patients underwent randomization (with 26 assigned to the zinc supplementation group and 27 to the conventional treatment group). The two groups had generally similar laboratory findings and clinical characteristics. The two groups also had similar lengths of hospital stay and rates of MACE. Forty of the 53 patients underwent CMR and it revealed that % core zone was numerically lower in the zinc supplementation group than in the conventional treatment group (9.3 ± 6.9% vs. 14.2 ± 9.1%, P = 0.07). This small single-centre study failed to detect a significant reduction in mid-term MACE after AMI among patients who received zinc supplementation.

Grid-mapping catheters versus PentaRay catheters for left atrial mapping on ensite precision mapping system.

INTRODUCTION: Areas displaying reduced bipolar voltage are defined as low-voltage areas (LVAs). Moreover, left atrial (LA) LVAs after pulmonary vein isolation (PVI) have been reported as a predictor of recurrent atrial fibrillation (AF). In this study, we compared grid mapping catheter (GMC) with PentaRay catheter (PC) for LA voltage mapping on Ensite Precision mapping system. METHODS: Twenty-six consecutive patients with LVAs and border zone within the LA were enrolled. After achieving PVI, voltage mapping under high right atrial pacing for 600 ms was performed twice using each catheter type (GMC first, PC next). Furthermore, LVA was defined as a region with a bipolar voltage of <0.50, and border zone was defined as a region with a bipolar voltage of <1.0, or <1.5 mV. RESULTS: Compared with PC, using GMC, voltage mapping contained more mapping points (20 242 [15 859, 26 013] vs. 5589 [4088, 7649]; p < .0001), and more mapping points per minute(1428 [1275, 1803] vs. 558 [372, 783]; p < .0001). In addition, LVA and border zone size using GMC was significantly less than that reported using PC: <1.0 mV (5.9 cm2 [2.9, 20.2] vs. 13.9 cm2 [6.3, 24.1], p = .018) and <1.5 mV voltage cutoff (10.6 cm2 [6.6, 27.2] vs. 21.6 cm2 [12.6, 35.0], p = .005). CONCLUSION: Bipolar voltage amplitude estimated by GMC was significantly larger than that estimated by PC on Ensite Precision mapping system. GMC may be able to find highly selective identification of LVAs with lower prevalence and smaller LVA and border zone size.

Early Vascular Healing Following Bioresorbable-Polymer Sirolimus-Eluting Stent Placement Compared to That with Durable-Polymer Everolimus-Eluting Stent.

A recent thinner strut drug-eluting stent might facilitate early strut coverage after its placement. We aimed to investigate early vascular healing responses after the placement of an ultrathin-strut bioresorbable-polymer sirolimus-eluting stent (BP-SES) compared to those with a durable-polymer everolimus-eluting stent (DP-EES) using optical coherence tomography (OCT) imaging.This study included 40 patients with chronic coronary syndrome (CCS) who underwent OCT-guided percutaneous coronary intervention (PCI). Twenty patients each received either BP-SES or DP-EES implantation. OCT was performed immediately after stent placement (baseline) and at 1-month follow-up.At one month, the percentage of uncovered struts reduced significantly in both the BP-SES (80.9 ± 10.3% to 2.9 ± 1.7%; P < 0.001) and DP-EES (81.9 ± 13.0% to 5.7 ± 1.8%; P < 0.001) groups, and the percentage was lower in the BP-SES group than in the DP-EES group (P < 0.001). In the BP-SES group, the percentage of malapposed struts also decreased significantly at 1 month (4.9 ± 3.7% to 2.6 ± 3.0%; P = 0.025), which was comparable to that of the DP-EES group (2.5 ± 2.2%; P = 0.860). The optimal cut-off value of the distance between the strut and vessel surface immediately after the placement to predict resolved malapposed struts was ≤ 160 µm for BP-SES and ≤ 190 µm for DP-EES.Compared to DP-EES, ultrathin-strut BP-SES demonstrated favorable vascular responses at one month, with a lower rate of uncovered struts and a comparable rate of malapposed struts.

Early Vascular Response to Ultrathin Biodegradable Polymer Sirolimus-Eluting Stents for the Treatment of ST-Elevation Myocardial Infarction After Plaque Rupture.

Recent clinical studies suggest that newer-generation drug-eluting stents that combine ultrathin struts and nanocoating (biodegradable polymer sirolimus-eluting stents, BP-SES) could improve long-term clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). However, the early vascular response to BP-SES in these patients has not been investigated so far.We examined this response in 20 patients with STEMI caused by plaque rupture using frequency-domain optical coherence tomography (OCT) to understand the underlying mechanisms. Plaque rupture was diagnosed by OCT before PCI with BP-SES implantation was performed. OCT was again performed before the final angiography (post-PCI) and after 2 weeks (2W-OCT).BP-SES placement caused protrusion of atherothrombotic material into the stent lumen and incomplete stent apposition in all patients. After 2 weeks, incomplete stent apposition was significantly reduced (% malapposed struts: post-PCI 4.7 ± 3.3%; 2W-OCT 0.9 ± 1.2%; P < 0.0001), and the percentage of uncovered struts also significantly decreased (% uncovered struts: post-PCI; 69.8 ± 18.3%: 2W-OCT; 29.6 ± 11.0%, P < 0.0001). The maximum protrusion area of the atherothrombotic burden was significantly reduced (post-PCI 1.36 ± 0.70 mm2; 2W-OCT 0.98 ± 0.55 mm2; P = 0.004).This study on the early vascular responses following BP-SES implantation showed rapid resolution of atherothrombotic material and progression of strut apposition and coverage. (UMIN000041324).

Effect of cutting balloon after rotational atherectomy in severely calcified coronary artery lesions as assessed by optical coherence tomography.

OBJECTIVES: Using optical coherence tomography (OCT), we evaluated the effect of a cutting balloon (CB) compared with a conventional balloon after rotational atherectomy (RA) and before stenting in severely calcified coronary lesions. BACKGROUND: A CB is designed to create discrete incisions to facilitate fracture of severely calcified plaque. METHODS: OCT was performed preintervention (if possible), post-RA, and poststent implantation. RA modification of calcium was defined as a polished, concave, round-shaped surface. Calcium fracture was defined as a break in the calcium plate. The effects of calcium modification and stent expansion between CB (n = 18) versus conventional balloon (n = 23) following RA were compared. RESULTS: Median patient age was 72 years with 24% on hemodialysis. The amount of calcium and the length of RA modification were comparable between the CB and conventional balloon groups. Final poststent OCT showed that the number and thickness of calcium fracture were greater after CB versus conventional balloon, resulting better stent expansion (78.9% [IQR: 72.4-88.1] vs. 66.7% [IQR: 55.0-76.7], p < 0.01). In the multivariable model, after adjusting for the amount of calcium, CB use was an independent predictor of the presence of calcium fracture (odds ratio 30.0; 95% confidence interval 2.7-994.1, p = 0.004) and an independent predictor for greater stent expansion (regression coefficient 7.4; 95% confidence interval 0.5-14.3, p = 0.04). CONCLUSION: In severely calcified lesions calcium fracture was more often associated with RA followed by CB compared with RA followed by conventional balloon predilation before stenting. CB use was also a determinant of greater stent expansion.

Association between J-CTO score and long-term target lesion revascularization rate after successful chronic total coronary occlusion angioplasty (from the J-CTO Registry).

OBJECTIVES: The aim of this study was to evaluate the impact of the J-CTO score on long-term target lesion revascularization (TLR) after successful native chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). BACKGROUND: We previously reported that the J-CTO score could be used to stratify the lesion complexity and procedural success rate in CTO lesions. METHODS: We evaluated the prognostic significance of a high J-CTO score for long-term TLR rate in the J-CTO Registry. RESULTS: In the 425 lesions of 408 patients who underwent successful CTO-PCI during a median follow-up of 63.0 (interquartile range: 21.2-72.9) months in the J-CTO Registry, the cumulative incidence of TLR of lesions with a J-CTO score ≥ 2 (n = 216) was significantly higher than in those with a J-CTO score ≤ 1 (n = 209) (27.0 versus 19.4% at 5 years, respectively, P = 0.04). Among 323 lesions of 309 patients with a complete 5-year follow-up, the rate of TLR was 28% (n = 91). A J-CTO score ≥ 2 was independently associated with a higher risk of TLR (odds ratio, 1.73; 95% confidence interval, 1.01-2.99, P = 0.048) even after adjustment for clinically relevant baseline factors. CONCLUSIONS: Patients with high J-CTO score lesions had a higher 5-year risk of TLR.

Impact of recanalization of chronic total occlusion on left ventricular electrical remodeling.

BACKGROUND: Successful percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is associated with reduction of cardiac mortality, as well as reducing fatal ventricular arrhythmias. The aim of this study was to evaluate the effect of recanalization of CTO on endocardial left ventricular voltages by paired electrophysiological studies. METHODS: Sixteen consecutive patients who underwent PCI for de novo CTO lesions were included. High-density mapping was performed during sinus rhythm before and 8 months after PCI. According to the amplitude of bipolar electrograms, the left ventricular endocardium was classified into a preserved normal voltage (>1.5 mV), border zone (0.5-1.5 mV), and dense scar areas (<0.5 mV). RESULTS: The border zone area had a significant positive correlation with CTO length, as well as a significant negative correlation observed in the preserved voltage region. In the successful PCI patient, the median dense scar area did not change significantly (reported as [median difference: 95% confidence interval]) between baseline and after PCI (0.1 cm2 : -2.8 to 2.9). However, the area of the border zone decreased (-10.5 cm2 : -16.8 to -4.1) and the preserved voltage area increased significantly (19.2 cm2 : 7.7-30.6). In addition, successful PCI was related to slight, but significant, increase in the amplitude of unipolar and bipolar voltage (1.55 mV: 0.88-3.33, 0.23 mV: 0.08-0.36). CONCLUSIONS: Recanalization of CTO may promote reverse electrical remodeling in the border zone of the left ventricle, without affecting the dense scar tissue.

Vascular response to biolimus A-9 eluting stent in patients with shorter and prolonged dual antiplatelet therapy: optical coherence tomography sub-study of the NIPPON trial.

Dual antiplatelet therapy (DAPT) with thienopyridine and aspirin is the standard care for the prevention of stent thrombosis. However, the optimal duration and effect of the duration of DAPT on intra-stent thrombus (IS-Th) formation are unknown. The NIPPON study (Nobori Dual Antiplatelet Therapy as Appropriate Duration) was an open label, randomized multicenter, assessor-blinded, trial designed to demonstrate the non-inferiority of shorter (6-month) DAPT to prolonged (18-month) DAPT, after biolimus A9 eluting stent implantation in 3773 patients at 130 sites in Japan. Among them, 101 patients were randomly allocated for an optical coherence tomography (OCT) sub-study to assess the difference of local IS-Th formation between the two groups. In addition to standard OCT parameters, the number of IS-Th formed was counted in each target stent at 8 months. Baseline patient characteristics were not different between the 6- and 18-month groups. IS-Th was detected in 9.8% of the cases and the presence of IS-Th was not significantly different between the two groups (10.9% in 6-month vs. 9.1% in 12-month, P = 0.76). Furthermore, the number of IS-Th formed was not significantly different between the two groups. This OCT sub-study was in line with the main NIPPON study which demonstrated the non-inferiority of 6-month DAPT to 18-month DAPT. Shorter DAPT duration did not promote progressive IS-Th formation at the mid-term time point.

Association of Epicardial Adipose Tissue Volume and Total Coronary Plaque Burden in Patients with Coronary Artery Disease.

The relationship between epicardial adipose tissue volume (EATV) and plaque vulnerability in non-culprit coronary lesions is not clearly understood.Fifty-four consecutive patients/158 lesions with suspected coronary artery disease underwent computed tomography (CT) and 40 MHz intravascular ultrasound imaging (iMap-IVUS) in cardiac catheterization. Cross-sectional CT slices were semiautomatically traced from base to apex of the heart. Using a 3D workstation, EATV was measured as the sum of fat areas (-190 to -30 Hounsfield units [HU]). All coronary vessels were imaged using iMap-IVUS before stenting to analyze coronary plaques as fibrotic, lipidic, necrotic, or calcified tissue.Mean EATV was 73.7 ± 24.6 (range: 30.2 to 131.8) mL. Patients were divided into two groups by mean EATV (group H: n = 27, EATV ≥ 73.7 mL; group L: n = 27, EATV < 73.7 mL). Total luminal volume, total vessel volume, and total plaque volume were significantly larger in group H. Fibrotic plaque and lipidic plaque volumes were also significantly larger in group H. There was a significant negative correlation between EATV and fibrous tissue (r = -0.31, P = 0.02) and a significant positive correlation between EATV and necrotic tissue (r = 0.37, P = 0.007). EATV was related to plaque with vulnerability in the right coronary artery (RCA) (r = 0.57, P = 0.04) and the left anterior descending artery (LAD) (r = 0.53, P = 0.02). In conclusion, increased EATV was associated with the total coronary plaque burden and composition, particularly in the RCA and LAD.

Association between increased epicardial adipose tissue volume and coronary plaque composition.

To assess the relationship between epicardial adipose tissue volume (EATV) and plaque vulnerability in significant coronary stenosis using a 40-MHz intravascular ultrasound (IVUS) imaging system (iMap-IVUS), we analyzed 130 consecutive patients with coronary stenosis who underwent dual-source computed tomography (CT) and cardiac catheterization. Culprit lesions were imaged by iMap-IVUS before stenting. The iMAP-IVUS system classified coronary plaque components as fibrous, lipid, necrotic, or calcified tissue, based on the radiofrequency spectrum. Epicardial adipose tissue was measured as the tissue ranging from -190 to -30 Hounsfield units. EATV, calculated as the sum of the fat areas on short-axis images, was 85.0 ± 34.0 cm(3). There was a positive correlation between EATV and the percentage of necrotic plaque tissue (R (2) = 0.34, P < 0.01), while there was a negative correlation between EATV and the percentage of fibrous tissue (R (2) = 0.24, P < 0.01). Multivariate analysis revealed that an increased low-density lipoprotein cholesterol level (ß = 0.15, P = 0.03) and EATV (ß = 0.14, P = 0.02) were independently associated with the percentage of necrotic plaque tissue. An increase in EATV was associated with the development of coronary atherosclerosis and, potentially, with the most dangerous type of plaque.

Intramural hematoma extending from a dissection within an implanted stent: a case report treated with fenestration using a cutting balloon.

Background: Dissection after balloon dilation or stent implantation is a common complication of percutaneous coronary intervention. In general, coronary stent implantation for coronary artery dissection is safe when the dissection is completely covered by the stent, particularly when dissection occurs during pre-dilation. However, here, we report a case of severe restenosis caused by a pre-dilation hematoma that extended after stent implantation. Case summary: A 76-year-old man was diagnosed with angina on exertion and underwent percutaneous coronary intervention in the right coronary artery. After pre-dilation with a cutting balloon, non-flow-limiting dissection occurred. An everolimus-eluting stent was implanted, completely sealing the dissection, and intravascular ultrasound revealed adequate stent expansion without stent edge dissection. Two weeks after the procedure, confirmatory coronary angiography revealed severe restenosis extending from the distal stent edge to the distal right coronary artery. Intravascular ultrasound revealed a hematoma extending from the middle of the stent to the distal segment. Discussion: The patient had been on steroids for a long time. The cutting balloon used for pre-dilation may have created a deep dissection reaching the tunica media, already rendered vulnerable by steroids, potentially leading to injury to the vasa vasorum. The intramural hematoma from the bleeding vasa vasorum might have been the underlying cause of this phenomenon, as evidenced by its increase in size despite the entry of the dissection being completely sealed. Cardiologists should be aware of this possibility.

Successful Retrieval of a Torn KUSABI Trapping Balloon Catheter From the Coronary Artery and Verification of the Reproducibility of Trapping Balloon Catheter Shaft Tears.

The balloon trapping technique is frequently used during percutaneous coronary intervention, which is a common treatment for ischemic heart disease. A 68-year-old man with induced ischemia, stenotic lesions, and arterial calcifications underwent catheterization of the circumflex artery and debulking of lesions. During the removal of the catheter, the tip of the balloon catheter used in the procedure dislodged and entered the circumflex artery. After successfully retrieving the catheter, we conducted a bench test of the balloon catheter to determine the cause of the tear. The results suggested that the tearing of the KUSABI balloon might have been caused by manual pulling of the shaft quickly at an inflation pressure of 14 atm and that twisted wires were not involved in balloon tearing. The tensile strength of the balloon catheter was 5N. We believe that the balloon tore owing to excessive force applied to dislodge the tip and because the trapping balloons were not properly deflated. As KUSABI trapping balloons have had a rupture rate of just 0.003% since their launch in 2013, we recommend paying attention to KUSABI balloon deflation within the guiding catheter before its retrieval in order to ensure that only a gentle pull is needed. If resistance is felt during the removal of the KUSABI balloon, it should be confirmed that the tip is in place after removing it.

Rituximab and pericardiectomy with waffle procedure in constrictive pericarditis due to IgG4-related disease: A case report.

We should consider IgG4-related disease (IGRD) as one of the potential causes of constrictive pericarditis. In patients with constrictive pericarditis due to IGRD, the combination of surgical treatment and immunosuppressive therapy may be an effective strategy.

Mechanism of Stent Failure in Patients With Eruptive Calcified Nodule Treated With Rotational Atherectomy.

BACKGROUND: Percutaneous coronary intervention (PCI) for lesions with eruptive calcified nodules (CNs) is associated with worse outcomes compared with that for other calcified lesions. We aimed to clarify the relationship between eruptive CNs at index PCI, optical coherence tomography (OCT) findings at the 8-month follow-up, and clinical outcomes using serial OCT. METHODS: This retrospective observational study used data from a prospective, single-centre registry. We conducted consecutive PCI for calcified lesions requiring rotational atherectomy (RA) with OCT guidance. We categorized 51 patients (54 lesions) into those with (16 patients [16 lesions]) and without eruptive CNs (35 patients [38 lesions]). RESULTS: Post-PCI, stent expansion was comparable between the 2 groups, and CN-like protrusion was found in 75% of lesions with eruptive CNs. Follow-up OCT at 8 months revealed in-stent CNs in 54% of treated eruptive CN lesions, whereas lesions without eruptive CNs lacked in-stent CNs. Multivariate linear regression analysis demonstrated that eruptive CN was associated with maximum neointimal tissue (NIT) thickness (regression coefficient 0.303; 95% confidence interval, 0.057-0.549; P = 0.02). Consequently, patients with eruptive CNs exhibited a higher clinically driven target lesion revascularization (TLR) rate than did those without at 1 year (31.3% vs 2.9%, P = 0.009) and 5 years (43.8% vs 11.4%, P = 0.02). TLR primarily occurred in lesions with maximum eruptive CN arc angles > 180°. CONCLUSIONS: Following RA treatment with acceptable stent expansion, eruptive CNs before PCI correlated with greater NIT formation with in-stent CNs, resulting in a higher TLR rate, particularly in lesions with maximum eruptive CN arc angles exceeding 180°.

Presence and Relevance of Myocardial Bridge in LAD-PCI of CTO and Non-CTO Lesions.

BACKGROUND: Intravascular ultrasound (IVUS) studies show that one-quarter of left anterior descending (LAD) arteries have a myocardial bridge. An MB may be associated with stent failure when the stent extends into the MB. OBJECTIVES: The aim of this study was to investigate: 1) the association between an MB and chronic total occlusion (CTO) in any LAD lesions; and 2) the association between an MB and subsequent clinical outcomes after percutaneous coronary intervention in LAD CTOs. METHODS: A total of 3,342 LAD lesions with IVUS-guided percutaneous coronary intervention (280 CTO and 3,062 non-CTO lesions) were included. The primary outcome was target lesion failure (cardiac death, target vessel myocardial infarction, definite stent thrombosis, and ischemic-driven target lesion revascularization). RESULTS: An MB by IVUS was significantly more prevalent in LAD CTOs than LAD non-CTOs (40.4% [113/280] vs 25.8% [789/3,062]; P < 0.0001). The discrepancy in CTO length between angiography and IVUS was greater in 113 LAD CTOs with an MB than 167 LAD CTOs without an MB (6.0 [Q1, Q3: 0.1, 12.2] mm vs 0.2 [Q1, Q3: -1.4, 8.4] mm; P < 0.0001). Overall, 48.7% (55/113) of LAD CTOs had a stent that extended into an MB after which target lesion failure was significantly higher compared to a stent that did not extend into an MB (26.3% vs 0%; P = 0.0004) or compared to an LAD CTO without an MB (26.3% vs 9.6%; P = 0.02). CONCLUSIONS: An MB was more common in LAD CTO than non-CTO LAD lesions. If present, approximately one-half of LAD CTOs had a stent extending into an MB that, in turn, was associated with worse outcomes.

Three-dimensional intravascular ultrasound evaluation of carina and plaque shift at the distal left main coronary artery bifurcation after treatment with a one-stent cross-over technique.

OBJECTIVE: To assess the geometrical changes in the distal left main coronary artery (LMCA), left anterior descending (LAD), and left circumflex (LCX) that occur after a distal LMCA lesion is treated using a one-stent cross-over strategy. BACKGROUND: Morphological changes after stent implantation into distal LMCA lesions are not fully understood. METHODS: We used pre- and postintervention three-dimensional intravascular ultrasound of both the LAD and LCX as well as of the LMCA to evaluate distal LMCA lesions after a 1-stent cross-over strategy. In 38 distal LMCA bifurcation lesions, cross-sectional measurements were performed every 1 mm over a 5-mm segment in the LAD and LCX distal to the carina and over the entire LMCA proximal to the carina. RESULTS: The increase in lumen volume correlated with the increase in external elastic membrane volumes: R = 0.917, P < 0.001, in the LMCA and R = 0.785, P < 0.001, in the LAD with no decrease in plaque volume except at the distal end of the LMCA (P = 0.081) and at the LAD carina (P = 0.11). The LCX lumen area decreased significantly at the LCX carina from 5.9 ± 2.0 mm(2) to 5.3 ± 1.9 mm(2) (P < 0.01); however, the response was variable from a 4.0 mm(2) decrease to a 1.8 mm(2) increase in lumen area. While the change in LCX lumen area at the carina correlated with the change in vessel area (R = 0.791, P < 0.001), there was also a small increase in plaque area at the LCX carina from 6.4 ± 2.9 mm(2) to 6.8 ± 2.9 mm(2) (P < 0.01). CONCLUSIONS: LMCA bifurcation lumen changes after cross-over single-stent implantation were determined primarily by conformational changes in vessel geometry.

A virtual histology intravascular ultrasound analysis of coronary chronic total occlusions.

OBJECTIVES: We used virtual histology intravascular ultrasound (VH-IVUS) to investigate plaque composition of chronic total occlusions (CTO). BACKGROUND: There are limited data on the composition of CTOs, especially in vivo. METHODS: VH-IVUS was performed in 50 CTO lesions (49 patients) after guidewire crossing or pre-dilation using a 1.5-2 mm balloon. Plaque composition in the proximal reference, distal reference, and CTO segment (subsequently divided into proximal, middle, and distal subsegments) was analyzed and reported as median and interquartile range. VH-IVUS phenotype was also assessed. The definition of a fibroatheroma was >10% confluent necrotic core (NC) in more than three consecutive frames. RESULTS: Overall, the maximum NC within the CTO [35.5% (28.7, 44.3%)] was similar to the proximal reference [35.6% (24.1, 42.1%)] and greater than the distal reference [31.5% (22.6, 35.2%), P < 0.01]. There was no difference in maximum NC observed among proximal [31.4% (25.2, 10.4%)], middle [31.0% (23.3, 38.3%)], and distal CTO subsegments [30.4% (22.0, 39.5%)]. Overall, 42/50 CTOs contained a VH-fibroathroma; and 8/50 did not. CTOs containing a VH-fibroatheroma had more NC and dense calcium while CTOs not containing a fibroatheroma had more fibrotic and fibrofatty plaque. Importantly, 60.5% of VH-fibroatheroma-containing CTOs had a thin-cap fibroatheroma (NC abutted to the lumen) in the proximal reference. CONCLUSIONS: Using VH-IVUS, CTO morphology can be divided into two patterns: (1) CTO with VH-fibroatheroma or (2) CTO without VH-fibroatheroma. This suggests two mechanisms of CTO formation-the majority evolving from acute coronary syndrome and thrombosis and the minority from atherosclerosis progression.

Massive pulmonary thrombosis caused by a popliteal venous aneurysm: A case report.

A venous aneurysm is characterized by a localized dilated lesion in most major veins. Popliteal venous aneurysms (PVAs) are rare; however, they are one of the causes of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE), which can be critical due to the high mortality risk. We present a 21-year-old woman without prior medical history, who arrived by ambulance after having a transient cardio-pulmonary arrest. Contrast computed tomography revealed a massive PTE and a right PVA with a thrombus. Laboratory data suggested that she had no thrombotic predisposition. Therefore, we diagnosed her condition as a massive PTE that derived from a thrombus, which arose from the right PVA. After successful intravenous thrombolysis of the PTE and DVT, surgical plication of the right PVA was performed to prevent the recurrence of PTE. She has had no recurrence of PTE or DVT two years after surgical treatment. This case suggests that surgical plication might be an effective way of preventing recurrence in patients with PVA. Learning objective: Popliteal venous aneurysm (PVA) occurrence is rare, but it can result in deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE). To treat our patient who suffered transient cardiac-pulmonary arrest caused by a massive PTE, we first used a recombinant tissue plasminogen activator and anticoagulant therapy. After the condition was stabilized, surgical plication of the right PVA was performed to prevent DVT recurrence. The present case suggests that surgical plication might be beneficial.

Diagnosis and Prognostic Value of the Underlying Cause of Acute Coronary Syndrome in Optical Coherence Tomography-Guided Emergency Percutaneous Coronary Intervention.

Background The prognostic impact of optical coherence tomography-diagnosed culprit lesion morphology in acute coronary syndrome (ACS) has not been systematically examined in real-world settings. Methods and Results This investigator-initiated, prospective, multicenter, observational study was conducted at 22 Japanese hospitals to identify the prevalence of underlying ACS causes (plaque rupture [PR], plaque erosion [PE], and calcified nodules [CN]) and their impact on clinical outcomes. Patients with ACS diagnosed within 24 hours of symptom onset undergoing emergency percutaneous coronary intervention were enrolled. Optical coherence tomography-guided percutaneous coronary intervention recipients were assessed for underlying ACS causes and followed up for major adverse cardiac events (cardiovascular death, myocardial infarction, heart failure, or ischemia-driven revascularization) at 1 year. Of 1702 patients with ACS, 702 (40.7%) underwent optical coherence tomography-guided percutaneous coronary intervention for analysis. PR, PE, and CN prevalence was 59.1%, 25.6%, and 4.0%, respectively. One-year major adverse cardiac events occurred most frequently in patients with CN (32.1%), followed by PR (12.4%) and PE (6.2%) (log-rank P<0.0001), primarily driven by increased cardiovascular death (CN, 25.0%; PR, 0.7%; PE, 1.1%; log-rank P<0.0001) and heart failure trend (CN, 7.1%; PR, 6.8%; PE, 2.2%; log-rank P<0.075). On multivariate Cox regression analysis, the underlying ACS cause was associated with 1-year major adverse cardiac events (CN [hazard ratio (HR), 4.49 [95% CI, 1.35-14.89], P=0.014]; PR (HR, 2.18 [95% CI, 1.05-4.53], P=0.036]; PE as reference). Conclusions Despite being the least common, CN was a clinically significant underlying ACS cause, associated with the highest future major adverse cardiac events risk, followed by PR and PE. Future studies should evaluate the possibility of ACS underlying cause-based optical coherence tomography-guided optimization.