Manual compression hemostasis using a hemostatic pad for the distal radial artery approach.

BACKGROUND: The method of hemostasis for the distal radial approach has not been standardized, although this approach has become increasingly popular due to its advantages. In this study, we investigated the feasibility of manual compression hemostasis using a calcium alginate pad after coronary angiography via the distal radial approach. METHODS: We retrospectively collected 150 consecutive patients (mean age, 74.9 ± 8.0 years; male, 75 %) who underwent coronary angiography via the distal radial artery with a predominantly 4 Fr sheath from April 2021 to December 2022 and were hemostatic according to the following methods. After sheath removal, hemostasis was achieved by manual compression for 10 min using a hemostatic pad containing calcium alginate. When hemostasis was confirmed, a small log-shaped gauze was placed over the pad and fixed using a self-adhesive elastic bandage for 2 h. All procedures were performed by four fellows just beginning the distal radial approach. RESULTS: The mean compression time was 12.4 ± 4.8 min, and hemostasis was successfully achieved in all patients, allowing the release of the elastic bandage after 2 h, with only one patient oozing the next morning. There were no major complications, while one patient had a >10 cm hematoma. Compared to that of the first 15 patients, for each fellow, the compression time of the subsequent patients was significantly shorter (14.5 ± 6.7 vs 11.1 ± 2.1 min, p < 0.01). CONCLUSIONS: Manual compression hemostasis using calcium alginate pads for the distal radial artery approach appears feasible with a simple learning.

Mapping of Purkinje-related ventricular arrhythmias by a multispline catheter with small and close-paired electrodes: Comparison with conventional catheters.

BACKGROUND: Precise mapping of the Purkinje fiber network is essential in catheter ablation of Purkinje-related ventricular arrhythmias (PrVAs). We sought to evaluate the mapping ability of a multi-spline duodecapolar catheter (PentaRay) for PrVAs. METHODS: Mappings of Purkinje fibers by PentaRay catheters were compared with those by conventional mapping catheters in consecutive patients undergoing catheter ablation of PrVAs from 2015 to 2022. RESULTS: Sixteen PrVAs (7 premature ventricular contractions or non-reentrant fascicular tachycardias [PVCs/NRFTs] and 9 fascicular ventricular tachycardias [FVTs]) were retrospectively studied. In PVCs/NRFTs, earliest preceding Purkinje potentials (PPs) could be recorded by the PentaRay catheters but not by the mapping and ablation catheters in 5 cases. At the earliest PP sites, the precedence from the QRS onset was greater, and the amplitude of the preceding potentials was higher in the PentaRay catheter compared with those in the mapping and ablation catheter (-62.0 ± 42.8 vs. -29.4 ± 34.2 ms, P = 0.02; 0.45 ± 0.43 vs. 0.09 ± 0.08 mV, P = 0.02). In FVTs, late diastolic potentials (P1) were recorded by the PentaRay catheters but not by the mapping and ablation catheters or the linear duodecapolar catheter in 2 cases. The amplitude of P1 was higher in the PentaRay catheter compared with that in the linear duodecapolar catheter and the mapping and ablation catheters (0.72 ± 0.49 vs. 0.17 ± 0.18 vs. 0.27 ± 0.21 mV, P = 0.0006, P = 0.002). The localized critical PPs, defined as the earliest preceding potentials in PVCs/NRFTs and P1 in FVTs, could be recorded in all the patients by the PentaRay catheter. The mapping ability of critical PPs of PrVAs was better with the PentaRay catheter than with the conventional mapping catheters (16/16 vs. 9/16, P = 0.004 by McNemar exact test). CONCLUSIONS: The PentaRay catheter has clinical advantages in mapping of the Purkinje fiber network to reveal critical PPs as ablation targets of PrVAs.

Association of Serum Oxysterols with Cholesterol Metabolism Markers and Clinical Factors in Patients with Coronary Artery Disease: A Covariance Structure Analysis.

Oxysterols have been implicated in the pathogenesis of cardiovascular diseases. Serum levels of oxysterols could be positively correlated with cholesterol absorption and synthesis. However, physiological regulation of various serum oxysterols is largely unknown. The aim of this study was to investigate the relationship between clinical factors and cholesterol metabolism markers, and identify oxysterols associated with cholesterol absorption and synthesis in patients with coronary artery disease. Subjects (n = 207) who underwent coronary stenting between 2011 and 2013 were studied cross-sectionally. We measured lipid profiles including serum oxysterols. As for the serum biomarkers of cholesterol synthesis and absorption, oxysterol levels were positively correlated with campesterol and lathosterol. Covariance structure analysis revealed that dyslipidemia and statin usage had a positive correlation with "cholesterol absorption". Statin usage also had a positive correlation with "cholesterol synthesis". Several oxysterols associated with cholesterol absorption and/or synthesis. In conclusion, we elucidated the potential clinical factors that may affect cholesterol metabolism, and the associations between various oxysterols with cholesterol absorption and/or synthesis in patients with coronary artery disease.

Association between Serum Oxysterols and Coronary Plaque Regression during Lipid-Lowering Therapy with Statin and Ezetimibe: Insights from the CuVIC Trial.

AIM: Several clinical trials using intravascular ultrasound (IVUS) evaluation have demonstrated that intensive lipid-lowering therapy by statin or a combination therapy with statin and ezetimibe results in significant regression of coronary plaque volume. However, it remains unclear whether adding ezetimibe to statin therapy affects coronary plaque composition and the molecular mechanisms of plaque regression. We conducted this prospective IVUS analysis in a subgroup from the CuVIC trial. METHODS: The CuVIC trial was a prospective randomized, open, blinded-endpoint trial conducted among 11 cardiovascular centers, where 260 patients with coronary artery disease who received coronary stenting were randomly allocated into either the statin group (S) or the combined statin and ezetimibe group (S＋E). We enrolled 79 patients (S group, 39 patients; S＋E group, 40 patients) in this substudy, for whom serial IVUS images of nonculprit lesion were available at both baseline and after 6-8 months of follow-up. RESULTS: After the treatment period, the S＋E group had significantly lower level of low-density lipoprotein cholesterol (LDL-C; 80.9±3.7 vs. 67.7±3.8 mg/dL, p=0.0143). Campesterol, a marker of cholesterol absorption, and oxysterols (ß-epoxycholesterol, 4ß-hydroxycholesterol, and 27-hydroxycholesterol) were also lower in the S＋E group. IVUS analyses revealed greater plaque regression in the S＋E group than in the S group (-6.14% vs. -1.18% for each group, p=0.042). It was noteworthy that the lowering of campesterol and 27-hydroxycholesterol, but not LDL-C, had a significant positive correlation with plaque regression. CONCLUSIONS: Compared with statin monotherapy, ezetimibe in combination with statin achieved significantly lower LDL-C, campesterol, and 27-hydroxycholesterol, which resulted in greater coronary plaque regression.

Practical utilization of cardiac computed tomography for the success in complex coronary intervention.

Percutaneous coronary intervention (PCI) for complex lesions is still technically demanding and is associated with less favorable procedural parameters such as lower success rate, longer procedural time, higher contrast volume and unexpected complications. Because the conventional angiographic analysis is limited by the inability to visualize the plaque information and the occluded segment, cardiac computed tomography has evolved as an adjunct to invasive angiography to better characterize coronary lesions to improve success rates of PCI. Adding to routine image reconstructions by coronary computed tomography angiography, the thin-slab maximum intensity projection method, which is a handy reconstruction technique on an ordinary workstation, could provide easy-to-understand images to reveal the anatomical characteristics and the lumen and plaque information simultaneously, and then assist to build an in-depth strategy for PCI. Especially in the treatment of chronic total occlusion lesion, these informations have big advantages in the visualization of the morphologies of entry and exit, the occluded segment and the distribution of calcium compared to invasive coronary angiography. Despite of the additional radiation exposure, contrast use and cost for cardiac computed tomography, the precise analysis of lesion characteristics would consequently improve the procedural success and prevent the complication in complex PCI.

The Functional Severity Assessment of Coronary Stenosis Using Coronary Computed Tomography Angiography-Based Myocardial Mass at Risk and Minimal Lumen Diameter.

BACKGROUND: We investigated whether or not the addition of myocardial mass at risk (MMAR) to quantitative coronary angiography was useful for diagnosing functionally significant coronary stenosis in the daily practice. METHODS: We retrospectively enrolled 111 consecutive patients with 149 lesions who underwent clinically indicated coronary computed tomography angiography and subsequent elective coronary angiography with fractional flow reserve (FFR) measurement. MMAR was calculated using a workstation-based software program with ordinary thin slice images acquired for the computed tomography, and the minimal lumen diameter (MLD) and the diameter stenosis were measured with quantitative coronary angiography. RESULTS: The MLD and MMAR were significantly correlated with the FFR, and the MMAR-to-MLD ratio (MMAR/MLD) showed a good correlation. The area under the receiver operating characteristic curve (AUC) of MMAR/MLD for FFR ≤ 0.8 was 0.746, and the sensitivity, specificity, positive predictive value, and negative predictive value were 60%, 83%, 68%, and 77%, respectively, at a cut-off value of 29.5 ml/mm. The addition of MMAR/MLD to diameter stenosis thus made it possible to further discriminate lesions with FFR ≤ 0.8 (AUC = 0.750). For the proximal left coronary artery lesions, in particular, MMAR/MLD showed a better correlation with the FFR, and the AUC of MMAR/MLD for FFR ≤ 0.8 was 0.919 at a cut-off value of 31.7 ml/mm. CONCLUSIONS: The index of MMAR/MLD correlated well with the physiological severity of coronary stenosis and showed good accuracy for detecting functional significance. The MMAR/MLD might be a useful parameter to consider when deciding the indication for revascularization.

Meteorological and chronobiological factors and the occurrence of acute aortic dissection.

Although a number of studies have demonstrated seasonal variations in acute cardiovascular events, the association between winter and low temperatures and the incidence rate of acute aortic dissection has not been fully elucidated. In this study, we investigated the association between meteorological and chronobiological factors and the occurrence of acute aortic dissection classified by the Stanford type, sex and age. We retrospectively collected 131 patients who had been admitted consecutively to our institution with acute aortic dissection, including 58 type A patients and 73 type B patients, from January 2013 to December 2017. The meteorological data were downloaded from the homepage of the Japan Meteorological Agency. The daily incidence of aortic dissection was higher in winter (10.2%) than in fall (5.3%) (P = 0.04), and a significant winter peak was also observed in the sub-groups of males and type B, while there were no significant differences in the proportions of type A, female, and ≤ 70- and > 70-year-old patients. The maximum, mean and minimum temperatures on the days with aortic dissection were significantly lower than on the days without aortic dissection. Divided into four seasons, lower temperatures were found only in spring. The most significant and greatest difference was observed between the maximum temperature on the day of aortic dissection and that at 2 days earlier. The multivariate logistic regression analysis showed that the difference in the maximum temperature between the day of and 2 days before the incident (odds ratio 0.91; 95% confidence interval 0.87-0.96; P < 0.01) as well as the maximum temperature (odds ratio 0.97; 95% confidence interval 0.95-0.99; P = 0.02) were significantly associated with the incidence of aortic dissection. Cold weather and a sudden decrease in temperature might trigger aortic dissection, although the influence might differ among sub-groups.

Initial medical management in acute type A aortic dissection patients with a thrombosed false lumen in the ascending aorta combining intramural hematoma and retrograde dissection from the descending to the ascending aorta.

BACKGROUND: The feasibility of medical management for select patients with acute type A aortic dissection has been reported from a few institutions. In this study, we retrospectively investigated the safety and feasibility of our conservative approach for patients with type A aortic dissection in daily practice. METHODS: From January 2013 to December 2017, 131 consecutive patients were admitted to our institution for acute aortic dissection, including 58 patients of type A. Initial medical management was attempted in select patients who were clinically stable and had a thrombosed false lumen of the ascending aorta without ulcer-like projections in the ascending aorta. RESULTS: Except for nine patients contraindicated for surgery, urgent surgery was performed in 26 patients (SRG group), while 23 patients (MED group) were treated with the initial medical management. The maximum diameter of the ascending aorta was significantly larger in the SRG group than in the MED group. In the MED group, the heart rate and blood pressures were well-controlled at admission to the intensive-care unit, and the systolic blood pressure was further reduced at 24 h after. The in-hospital mortality rates of the MED and SRG groups were 0% and 15%, respectively. During the follow-up period, the survival rate was significantly higher in the MED group than in the SRG group, and the aortic event-free survival at one year was 80%. CONCLUSIONS: The initial medical management for select patients with a thrombosed false lumen in the ascending aorta was a safe and feasible strategy in real-world practice.

Good neointimal coverage of a crushed stent segment protruding into the main vessel by follow-up optical coherence tomography in a patient with a diagonal branch lesion.

There is currently no consensus regarding the optimum treatment strategy for an isolated side branch lesion. The usefulness of a side branch stenting technique with a balloon crushing the segment protruding into the main vessel has been reported; however, there remain concerns about malapposition of crushed stent struts and a consequent risk of stent thrombosis. We herein report a case with a diagonal branch lesion that was successfully treated with this technique. Follow-up optical coherence tomography clearly revealed that the protruding stent struts in the main vessel were crushed and covered almost completely. Our findings may support the feasibility of this treatment in the mid-term period. .

Retrograde balloon crossing to overcome antegrade delivery failure for a heavily calcified chronic total occlusion.

We herein report a case of percutaneous coronary intervention to a heavily calcified chronic total occlusion in the left anterior descending artery. Although we successfully performed retrograde wire crossing and wire externalization, we were unable to deliver small-sized balloon catheters in the lesion antegradely, even with strong back-up of wire externalization because of the heavy calcium mass. However, a balloon catheter was easily crossed retrogradely, and the lesion was successfully treated. Thus, retrograde balloon crossing might be a way to overcome device delivery failure in calcified lesions. .

Impact of intravascular ultrasound-guided minimum-contrast coronary intervention on 1-year clinical outcomes in patients with stage 4 or 5 advanced chronic kidney disease.

This study aims to elucidate 1-year clinical outcomes using this technique for patients with stage 4 or 5 advanced chronic kidney disease (CKD). Research has proven that imaging-guided percutaneous coronary intervention (PCI) reduces contrast volume significantly; however, only short-term clinical benefits have been reported. Minimum-contrast (MINICON) studies are based on the registry design pattern to enroll PCI results in patients with advanced CKD stage 4 or 5 comorbid with coronary artery disease. We excluded cases of emergency PCI or maintenance dialysis from this study. In this study, we compared the intravascular ultrasound (IVUS)-guided MINICON PCI group (n = 98) with the angiography-guided standard PCI group (n = 86). Enrollment of the MINICON studies started in 2006. Before 2012, IVUS-guided MINICON PCI was performed only in 14% (stage 1), but it was 100% after 2012 (stage 2). The enrollment finished in 2016. The IVUS-guided MINICON PCI group exhibited a significantly reduced contrast volume (22 ± 20 vs. 130 ± 105 mL; P < 0.0001) and contrast-induced acute kidney injury (CI-AKI; 2% vs. 15%; P = 0.001). The PCI success rate was similarly high (100% vs. 99%; P = 0.35). At 1 year (follow-up rate, 100%), we observed less induction of renal replacement therapy (RRT; 2.7% vs. 13.6%; P = 0.01), but all-cause mortality or myocardial infarction was similar in both groups. The IVUS-guided MINICON PCI reduces CI-AKI significantly and induction of RRT at 1 year in patients with stage 4 or 5 advanced CKD.

Ezetimibe in Combination With Statins Ameliorates Endothelial Dysfunction in Coronary Arteries After Stenting: The CuVIC Trial (Effect of Cholesterol Absorption Inhibitor Usage on Target Vessel Dysfunction After Coronary Stenting), a Multicenter Randomized Controlled Trial.

OBJECTIVES: We sought to investigate whether treatment with ezetimibe in combination with statins improves coronary endothelial function in target vessels in coronary artery disease patients after coronary stenting. APPROACH AND RESULTS: We conducted a multicenter, prospective, randomized, open-label, blinded-end point trial among 11 cardiovascular treatment centers. From 2011 to 2013, 260 coronary artery disease patients who underwent coronary stenting were randomly allocated to 2 arms (statin monotherapy, S versus ezetimibe [10 mg/d]+statin combinational therapy, E+S). We defined target vessel dysfunction as the primary composite outcome, which comprised target vessel failure during treatment and at the 6- to 8-month follow-up coronary angiography and coronary endothelial dysfunction determined via intracoronary acetylcholine testing performed in cases without target vessel failure at the follow-up coronary angiography. Coadministration of ezetimibe with statins further lowered low-density lipoprotein cholesterol levels (83±23 mg/dL in S versus 67±23 mg/dL in E+S; P<0.0001), with significant decreases in oxidized low-density lipoprotein and oxysterol levels. Among patients without target vessel failure, 46 out of 89 patients (52%) in the S arm and 34 out of 96 patients (35%) in the E+S arm were found to have coronary endothelial dysfunction (P=0.0256), and the incidence of target vessel dysfunction at follow-up was significantly decreased in the E+S arm (69/112 (62%) in S versus 47/109 (43%) in E+S; P=0.0059). A post hoc analysis of post-treatment low-density lipoprotein cholesterol-matched subgroups revealed that the incidence of both target vessel dysfunction and coronary endothelial dysfunction significantly decreased in the E+S arm, with significant reductions in oxysterol levels. CONCLUSIONS: The CuVIC trial (Effect of Cholesterol Absorption Inhibitor Usage on Target Vessel Dysfunction after Coronary Stenting) has shown that ezetimibe with statins, compared with statin monotherapy, improves functional prognoses, ameliorating endothelial dysfunction in stented coronary arteries, and was associated with larger decreases in oxysterol levels.