Sustained Lumen Area by Paclitaxel-Coated Balloon Following Rotational Atherectomy for Napkin-Ring Left Main Trunk Ostial Lesion.

Late lumen enlargement after percutaneous coronary intervention (PCI) with drug-coated balloon has contributed to good clinical results. However, late lumen enlargement with drug-coated balloon following rotational atherectomy has not been well reported. This report describes a case of calcified napkin-ring ostial lesion at the left main trunk that showed a sustained lumen area after PCI with drug-coated balloon following rotational atherectomy. An 85-year-old female patient was admitted to the hospital with dyspnea. Echocardiography showed hypokinesis in the anteroseptal and inferior walls. Electrocardiograph-gated cardiac computed tomography showed a calcified ostial lesion in the left main trunk. Invasive angiography of the coronary artery showed severe stenosis in the left main trunk ostium. Percutaneous coronary intervention was performed with a drug-coated balloon after rotational atherectomy. The minimal lumen area measured by intravascular ultrasound grew mildly from 4.09 to 4.17 mm2 immediately after PCI. Follow-up angiography and intravascular ultrasound performed after 6 months showed that the minimal lumen area in the left main trunk ostium was further enlarged from 4.17 to 4.69 mm2. The presence of sustained lumen area after PCI with drug-coated balloon following rotational atherectomy for a napkin-ring left main trunk ostial lesion was confirmed. This case demonstrates sustained lumen area after drug-coated balloon following rotational atherectomy in the left main trunk ostium, improving the patient's chest symptom. Hence, drug-coated balloon after rotational atherectomy may be an option for complex stent sites, such as the left main trunk ostium in geriatric patients and sites with highly calcified lesions.

Macrophage behaviour 72 hours after implantation of biodegradable polymer-based sirolimus-eluting stent in a case of ST elevation myocardial infarction.

While the vascular healing process after drug-eluting stent implantation is not fully elucidated, it is generally accepted that macrophages play an important role in inflammation. It is also known that macrophages involved in the pathogenesis of atherosclerosis may stem from several origins, that is, monocyte-derived macrophages versus resident macrophages. However, little is known about the role of human macrophages on reperfusion of culprit coronary arteries in patients with atherosclerotic disease who have sustained acute coronary syndrome. In this present case report, we describe the presence of cluster of differentiation (CD) 163-positive macrophages in close proximity to the stent struts at the luminal site 72 hours after drug-eluting stent implantation in the culprit coronary lesion for ST elevation myocardial infarction by postmortem examination.

Soluble vascular endothelial growth factor receptor 2 and prognosis in patients with chronic heart failure.

AIMS: Endothelial cell vascular endothelial growth factor receptor 2 (VEGFR-2) plays a pivotal role in angiogenesis, which induces physiological cardiomyocyte hypertrophy via paracrine signalling between endothelial cells and cardiomyocytes. We investigated whether a decrease in circulating soluble VEGFR-2 (sVEGFR-2) levels is associated with poor prognosis in patients with chronic heart failure (HF). METHODS AND RESULTS: We performed a multicentre prospective cohort study of 1024 consecutive patients with HF, who were admitted to hospitals due to acute decompensated HF and were stabilized after initial management. Serum levels of sVEGFR-2 were measured at discharge. Patients were followed up over 2 years. The outcomes were cardiovascular death, all-cause death, major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death and HF hospitalization, and HF hospitalization. The mean age of the patients was 75.5 (standard deviation, 12.6) years, and 57% were male. Patients with lower sVEGFR-2 levels were older and more likely to be female, and had greater proportions of atrial fibrillation and anaemia, and lower proportions of diabetes, dyslipidaemia, and HF with reduced ejection fraction (<40%). During the follow-up, 113 cardiovascular deaths, 211 all-cause deaths, 350 MACE, and 309 HF hospitalizations occurred. After adjustment for potential clinical confounders and established biomarkers [N-terminal B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin I, and high-sensitivity C-reactive protein], a low sVEGFR-2 level below the 25th percentile was significantly associated with cardiovascular death [hazard ratio (HR), 1.79; 95% confidence interval (CI), 1.16-2.74] and all-cause death (HR, 1.43; 95% CI, 1.04-1.94), but not with MACE (HR, 1.11; 95% CI, 0.86-1.43) or HF hospitalization (HR, 1.03; 95% CI, 0.78-1.35). The stratified analyses revealed that a low sVEGFR-2 level below the 25th percentile was significantly associated with cardiovascular death (HR, 1.76; 95% CI, 1.07-2.85) and all-cause death (HR, 1.49; 95% CI, 1.03-2.15) in the high-NT-proBNP group (above the median), but not in the low-NT-proBNP group. Notably, the patients with high-NT-proBNP and low-sVEGFR-2 (below the 25th percentile) had a 2.96-fold higher risk (95% CI, 1.56-5.85) for cardiovascular death and a 2.40-fold higher risk (95% CI, 1.52-3.83) for all-cause death compared with those with low-NT-proBNP and high-sVEGFR-2. CONCLUSIONS: A low sVEGFR-2 value was independently associated with cardiovascular death and all-cause death in patients with chronic HF. These associations were pronounced in those with high NT-proBNP levels.

Rare case of congenital coronary artery fistula coexistent and coalesced with aortopulmonary fistula.

Coronary artery fistula (CAF) is an uncommon congenital heart disease. Furthermore, aortopulmonary fistula is a rare congenital heart disease of adult onset. We report the case of a 79-year-old man who presented with chest pain. ECG-gated cardiac CT and coronary artery angiography revealed an anomalous vessel arising from the right coronary cusp and a CAF from the left coronary descending artery. These fistulas coalesced and drained into the same portion of the pulmonary artery. Haemodynamic studies revealed that the estimated systemic-to-pulmonary flow ratio was 1.18. The mean pulmonary pressure was 14 mm Hg. We decided against surgical intervention due to his advanced age and lack of heart failure symptoms. The patient did not have any worsening heart failure and chest pain on follow-up. This was a rare case of CAF coexistent and coalesced with an aortopulmonary fistula.

Lipoprotein Profiles before Heparin Administration in Patients with or without Coronary Thrombosis Following Atherosclerosis.

Objective: The correlation between lipoproteins and arterial thrombosis is not fully elucidated, and no data exist in terms of lipoprotein profiles before heparin administration in patients with coronary arterial thrombosis (CAT). This cross-sectional study aimed to evaluate the lipoprotein profile before heparin administration in 63 ST-segment elevation myocardial infarction (STEMI) patients with CAT. Methods: The lipoprotein profile was measured via polyacrylamide gel electrophoresis prior to heparin administration for primary percutaneous coronary intervention for STEMI. Age- and sex-matched subjects with <25% stenosis in stable coronary artery disease were enrolled as controls. Results: In the pre-heparin serum, the fraction of very-low-density lipoprotein (P=0.75) in STEMI patients was not different from that in controls, and the fraction of intermediate-density lipoprotein (P<0.01) in STEMI patients was significantly lower than that in controls. Although the fraction of small dense low-density lipoprotein (s-LDL) in STEMI patients was significantly higher than that in controls (P<0.01), 44% (28/63) of STEMI patients were negative for s-LDL. Conclusion: Although lipoproteins are a risk factor for atherosclerosis, lipoprotein profiles with CAT following atherosclerosis in STEMI are different from those profiles without CAT in stable coronary artery disease.

In Vivo Illustration of Dendrite Formation on a Mobile Thrombus within a Wallstent in an Iliac Artery: A Fractal Phenomenon.

The mechanism of stent thrombus formation following percutaneous transluminal stent implantation in an artery is unclear. This case report describes a 72-year-old man who had a mobile thrombus in a Wallstent in the right iliac artery despite daily oral administration of 100 mg of aspirin. This Wallstent was implanted 14 years ago. The unique in vivo angioscopic images show a solid mobile thrombus with some projections which rubbed yellow plaque on the stent struts.

Assumed Lighting Direction in the Interpretation of Cast Shadows.

Assumed lighting direction in cast-shadow interpretation was investigated. Experiment 1 used an ambiguous object-shadow-matching task to measure bias in shadow-matching direction. The shadow-matching bias was largest when the lighting direction was on average 38.3° left from above (a median of 25.1°). Experiment 2 tested the effect of body posture (head orientation) on cast-shadow interpretation using stimuli aligned in a head-centrically vertical or horizontal orientation. The below-shadow (light-from-above) bias in the head-centric frame was robust across the sitting upright, reclining-on-the-left-side, reclining-on-the-right-side, and supine conditions. A right-shadow (light-from-left) bias in the head-centric frame was found for the sitting upright and reclining-on-the-right-side conditions. In the reclining-on-the-left-side condition, shadow biases to the gravitational below direction and head-centric right direction may have cancelled each other out. These results are consistent with findings from previous shape-from-shading studies, suggesting that the same light-source assumption is applied to shading and shadow interpretations.

Directional Bias in the Perception of Cast Shadows.

Previous studies have demonstrated that the perception of shading is based upon assumptions about lighting direction, for example, light from above. However, it is not clear whether these assumptions are used in the perception of cast shadows. Moreover, it is unclear whether a perceptual interaction exists between shading and cast shadows because until now they have been studied separately. In this study, we investigated through three experiments whether the light-from-above (or another direction) assumption is used in interpreting ambiguous cast shadows, and whether shading information influences the interpretation of cast shadows. Our results indicate the existence of the light-from-above assumption in interpreting cast shadows. Consistent shading information enhanced the interpretation, and judgments of lighting direction were also based on both cast shadow and shading information. However, the perceptual determination of shape from shading was relatively independent of the cast shadow interpretation or the lighting direction judgments of the scene.

The Peripheral Flicker Illusion.

A new illusion is reported. A visual object suddenly appearing on a red background sometimes causes an impression of flicker or double flash. In Experiment 1, a red, green, or blue object was presented on a red, green, blue, or gray background. Participants evaluated the illusion strength in reference to the physical flicker of a gray object presented in central vision. The results show that the green or blue object presented on the red background caused the illusion. In Experiment 2, the effect of retinal eccentricity on the illusion was tested. The results showed that the illusion was weak in central vision but became stronger as the retinal eccentricity of the objects' presentation increased. In Experiment 3, optimal luminance conditions for the illusion were explored with the green and blue objects. The illusion was strong when object luminance was lower than background luminance and the optimal luminance for the blue object was lower than that for the green object. We propose a tentative theory for the illusion and discuss its cause.

In-Vivo Higher Plasma Levels of Platelet-Derived Growth Factor and Matrix Metalloproteinase-9 in Coronary Artery at the Very Onset of Myocardial Infarction with ST-Segment Elevation.

OBJECTIVE: Platelet-derived growth factor (PDGF) induces matrix metalloproteinase (MMP), which is regarded as a biomarker of plaque rupture or vulnerability. The aim of this study is to investigate those interactions in human coronary arteries at the onset of ST-segment elevation myocardial infarction (STEMI). METHODS: Thirty-two patients with STEMI who underwent primary percutaneous coronary intervention (PCI) were enrolled in this study. Plasma levels of PDGF-BB and MMP-9 were measured from infarct-related artery (IRA) and from femoral artery (FA) during PCI. RESULTS: Plasma levels of PDGF-BB and MMP-9 in the IRA were significantly higher than those in the FA (PDGF-BB: median 3130 pg/ml, IQR (interquartile range): 2020 to 4375 pg/ml vs. median 2605 pg/ml, IQR: 1305 to 3290 pg/ml, p <0.01, MMP-9: median 49 ng/ml, IQR: 35 to 100 ng/ml vs. median 42 ng/ml, IQR: 27 to 78 ng/ml, p = 0.04, IRA and FA, respectively). CONCLUSIONS: This in vivo study demonstrated that PDGF-BB with MMP-9 seems to play a role in coronary plaque instability in acute phase of STEMI.

Intravascular ultrasound insights from the Cobalt Chromium Stent With Antiproliferative for Restenosis II (COSTAR II) trial comparing CoStar and Taxus paclitaxel-eluting stents.

BACKGROUND: Dedicated IVUS analyses of the second CObalt chromium STent with Antiproliferative for Restenosis (COSTAR II) trial have not been documented. We aim to compare IVUS findings between CoStar paclitaxel-eluting stent (PES) and Taxus PES in patients enrolled in the COSTAR II trial. We also attempted to examine the possible regional impact of multiple stenting. METHODS AND MATERIALS: Among the 1700 patients enrolled, 238 were assigned to an IVUS cohort including 168 patients treated by provisional multiple stenting. At 9 months, qualitative and quantitative IVUS observations including incomplete stent apposition (ISA) and neointimal proliferation (neointimal obstruction: neointimal volume/stent volume ×100) were compared between CoStar and Taxus PESs. RESULTS: In qualitative analysis, late-acquired ISA was observed in 1 patient treated by Taxus PES. Impaired strut continuity suggestive of stent fracture was observed in 2 out of 33 patients treated by multiple CoStar, and 4 out of 21 patients treated by multiple Taxus (P=.14). No such findings were found in single-stented patients in either stent subset. Quantitative analysis showed greater neointimal obstruction in CoStar (19.7%±13.4%, n=52) than in Taxus (10.7%±9.9%, n=38), whereas no significant difference in neointimal obstruction was found between single and multiple stenting in either CoStar or Taxus PES. CONCLUSIONS: The CoStar PES exhibits greater neointimal proliferation compared with Taxus PES at 9 months but with similar qualitative outcomes including late-acquired ISA. IVUS findings suggestive of stent fracture were found only in multiple-stenting cases irrespective of the stent used.

Impact of polymer formulations on neointimal proliferation after zotarolimus-eluting stent with different polymers: insights from the RESOLUTE trial.

BACKGROUND: Polymer formulation may affect the efficacy of drug-eluting stents. Resolute, Endeavor, and ZoMaxx are zotarolimus-eluting stents with different stent platforms and different polymer coatings and have been tested in clinical trials. The aim of this analysis was to compare the efficacy of zotarolimus-eluting stents with different polymers. METHODS AND RESULTS: Data were obtained from the first-in man trial or first randomized trials of each stent, The Clinical RESpOnse EvaLUation of the MedTronic Endeavor CR ABT-578 Eluting Coronary Stent System in De Novo Native Coronary Artery Lesions (RESOLUTE), Randomized Controlled Trial to Evaluate the Safety and Efficacy of the Medtronic AVE ABT-578 Eluting Driver Coronary Stent in De Novo Native Coronary Artery Lesions (ENDEAVOR II), and ZoMaxx I trials. Follow-up intravascular ultrasound analyses (8 to 9 months of follow-up) were possible in 353 patients (Resolute: 88, Endeavor: 98, ZoMaxx: 82, Driver: 85). Volume index (volume/stent length) was obtained for vessel, stent, lumen, peristent plaque, and neointima. Cross-sectional narrowing was defined as neointimal area divided by stent area (%). Neointima-free frame ratio was calculated as the number of frames without intravascular ultrasound-detectable neointima divided by the total number of frames within the stent. At baseline, vessel, lumen, and peristent plaque volume index were not significantly different among the 4 stent groups. At follow-up, percent neointimal obstruction was significantly lower in Resolute compared with Endeavor, ZoMaxx, and Driver (Resolute: 3.7±4.0, Endeavor: 17.5±10.1, ZoMaxx: 14.6±8.1, Driver: 29.4±17.2%; P<0.001). Greater maximum cross-sectional narrowing and higher neointima-free frame ratio, suggesting less neointimal coverage, were observed in Resolute compared with other stent groups. Multiple regression analysis confirmed that the biodurable polymer used in Resolute independently correlated with neointimal suppression among 3 zotarolimus-eluting stents. CONCLUSIONS: The different polymer formulations significantly affect the relative amount of neointima for zotarolimus-eluting stents. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00248079.

Short- and mid-term intravascular ultrasound analysis of the new zotarolimus-eluting stent with durable polymer ­ results from the RESOLUTE trial ­.

BACKGROUND: The Resolute stent is a newly developed system with a bio-histocompatible polymer that allows programmed drug delivery up to 180 days. The aim of this intravascular ultrasound (IVUS) analysis was to evaluate the short- (4 months) and mid-term (9 months) efficacy using the Resolute stent. METHODS AND RESULTS: Data were derived from the RESOLUTE trial, a prospective, multicenter, non-randomized, single-arm study to treat de novo native coronary artery lesions. This trial included 2 cohorts with different follow-up periods, and all enrollment patients in this trial received IVUS study. Follow-up IVUS was available in 24 patients (4-month group) and 88 patients (9-month group). Neointimal obstruction (%) was defined as neointimal volume divided by stent volume. Cross-sectional narrowing (CSN, %) was defined as neointimal area divided by stent area. No significant differences in vessel, lumen and stent volume at post-procedure were observed within stented segments between the 4- and 9-month follow-up groups. Although neointimal volume and % neointimal obstruction showed no significant difference between the 2 groups (% neointimal obstruction: 2.2 ± 2.5 vs 3.7 ± 4.0%, P=0.09), maximum CSN was significantly larger in the 9-month group. There were 7 cases of late incomplete stent apposition. CONCLUSIONS: These IVUS results showed minimum growth of neointimal proliferation by the Resolute stent throughout the stented segment up to 9 months follow up.

Vascular responses to the multiple overlapped paclitaxel-eluting stents for the treatment of bare-metal in-stent restenotic lesions: angiographic and intravascular ultrasound analysis from the TAXUS-V ISR trial.

BACKGROUND: Although effective coverage of coronary diffuse in-stent restenosis (ISR) lesions has warranted the use of multiple drug-eluting stents, the vessel response to paclitaxel-eluting stent (PES) overlap is not fully understood. METHODS AND MATERIALS: In the TAXUS-V ISR, i.e., comparing PES versus brachytherapy for the treatment of bare-metal ISR, angiographic analyses at 9-month follow-up were available in 184 ISR lesions treated with PES. RESULTS: In-stent late loss in entire stented segment of multiple PES (n=50) was 0.45+/-0.48 mm, whereas that of single PES (n=134) was 0.3+/-0.47 mm, P=.06. No aneurysm was observed at overlapping PES segments at 9 months. Stent thrombosis up to 9 months was observed in one in each group (single PES, 0.7% vs. multiple PES, 1.8%; P=.47). In a subset of 30 patients, volumetric intravascular ultrasound analysis demonstrated that in-stent net volume obstruction was 12.3+/-12.4 in single PES (n=20) and 14.9+/-9.8 in multiple PES (n=10), P=.60. The changes of vessel and lumen at the overlapping PES segment were similar to those of the adjacent 5-mm segments (Deltaminimum lumen area, mm(2): -1.2+/-1.0, -1.1+/-1.1, -0.8+/-0.9, P=.48; Deltavessel volume, mm(3)/mm: -0.2+/-1.4, 0.1+/-1.7, 0.3+/-1.3, P=.37; proximal, overlap, distal segment, respectively). There was no late incomplete stent apposition at overlapping PES segments. CONCLUSIONS: No in vivo evidence of adverse local vessel response at the site of overlapping PES for the treatment of bare-metal ISR has been demonstrated.

In vivo comparison between optical coherence tomography and intravascular ultrasound for detecting small degrees of in-stent neointima after stent implantation.

OBJECTIVES: The purpose of this study was to evaluate optical coherence tomography (OCT) for detecting small degrees of in-stent neointima (ISN) after stent implantation compared with intravascular ultrasound (IVUS). BACKGROUND: The importance of detecting neointimal coverage of stent struts has grown with the appreciation of the increased risk for late stent thrombosis after drug-eluting stent (DES) implantation. Intravascular ultrasound, the current standard for evaluating the status of DES, lacks the resolution to detect the initial neointimal coverage. Optical coherence tomography has greater resolution but has not yet been compared with IVUS in vivo with histological correlation for validation. METHODS: Intravascular ultrasound and OCT were performed with motorized pullback imaging in 6 pigs across 33 stents, 1 month after implantation. Each pig was euthanized, and histological measurements of vessel, stent, and lumen dimensions were performed in 3 sections of each stent. A small degree of ISN was defined as occupying <30% of the stent area measured with histology. The IVUS, OCT, and histological assessment of ISN were compared in matched cross-sections of the stents with a small degree of ISN. RESULTS: Eleven stents had a small degree of ISN (average ISN area: 1.26 +/- 0.46 mm(2), and percent area obstruction: 21.4 +/- 5.2%). Compared with histology, the diagnostic accuracy of OCT (area under the receiver operating characteristic curve [AUC] = 0.967, 95% confidence interval [CI] 0.914 to 1.019) was higher than that of IVUS (AUC = 0.781, 95% CI 0.621 to 0.838). CONCLUSIONS: Optical coherence tomography detects smaller degrees of ISN more accurately than IVUS and might be a useful method for identifying neointimal coverage of stent struts after DES implantation.