Optimal Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients With Multivessel Disease and Diabetes.

There is a scarcity of data on clinical outcomes after intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) in patients with multivessel disease and diabetes. The Optimal Intravascular Ultrasound Guided Complex Percutaneous Coronary Intervention study multivessel cohort was a prospective, multicenter, single-arm trial enrolling 1,021 patients who underwent multivessel PCI, including left anterior descending coronary artery using IVUS, aiming to meet the prespecified OPTIVUS criteria for optimal stent expansion. We compared the clinical outcomes between those patients with and without diabetes. The primary end point was a composite of death, myocardial infarction, stroke, or any coronary revascularization. There were 560 patients (54.8%) with diabetes and 461 patients (45.2%) without diabetes. The mean age was not different between the 2 groups (70.9 ± 9.7 vs 71.7 ± 10.4 years, p = 0.17). Patients with diabetes more often had chronic kidney disease and complex coronary artery disease, as indicated by the greater total number of stents and longer total stent length. The rate of meeting the OPTIVUS criteria was not different between the 2 groups (61.2% vs 60.7%, p = 0.83). The cumulative 1-year incidence of the primary end point was not different between the 2 groups (10.8% vs 9.8%, log-rank p = 0.65). After adjusting for confounders, the risk of diabetes relative to nondiabetes remained insignificant for the primary end point (hazard ratio 0.97, 95% confidence interval 0.65 to 1.44, p = 0.88). In conclusion, in patients who underwent multivessel IVUS-guided PCI and were managed with contemporary clinical practice, patients with diabetes had similar 1-year outcomes to patients without diabetes.

The Clock-Drawing Test as a Useful Screening Assessment of Preoperative Cognitive Impairment with Readmission After Transcatheter Aortic Valve Implantation.

Background: Transcatheter aortic valve implantation (TAVI) has recently become more common as a treatment for severe, symptomatic aortic stenosis (AS). Cognitive impairment (CI) is strongly associated with the prognosis of TAVI patients. However, some cognitive assessments currently in use are difficult to perform routinely in the clinical setting. To easier CI evaluation, we investigated whether CI using the clock-drawing test (CDT), one part of the Mini-Cog, affects the postoperative prognosis of TAVI patients with AS. Methods: The present study enrolled 52 patients (median age, 85 years; 28.8% male) who underwent TAVI and were discharged between 2019 and 2021. The outcome was readmission for all causes within one year of discharge and patients were grouped according to whether they were readmitted or not. Cognitive function was assessed using the Mini-Cog which combines verbal playback and CDT. Results: Of the 52, 11 patients (21.2%) comprised readmission group, including 4 (36.4%) each for fracture and infection, and 1 (9.1%) each for heart failure, subdural hematoma, and pneumothorax. Median Mini-Cog score was lower in the readmission group than in the non-readmission group (4 vs. 5; P < 0.05). The frequency of Mini-Cog score < 3 (indicative of CI) and CDT failure were significantly higher in the readmission group than in the non-readmission group, respectively (46% vs. 7%, P < 0.01) (46% vs. 12%, P < 0.05). Both of Mini-Cog score < 3 and CDT failure were independently associated with readmission. The areas under the curve showed CDT was an indicator of readmission with similar accuracy to the Mini-Cog score < 3. Kaplan-Meier curves showed significant differences in readmission after 1 year between the 2 Mini-Cog groups with scores of < 3 or ≥ 3 points and CDT failure and success. Conclusion: The CDT may be a very easy and simple screening assessment of preoperative CI with readmission within one year after TAVI.

Early detachment of prosthetic aortic valve one year after replacement for severe aortic regurgitation due to perforated aortic valve aneurysm; a case of suspected HLA-B52 positive Behçet's disease.

Herein, we report a case of 61-year-old male with congestive heart failure (HF) due to severe aortic regurgitation (AR) caused by ruptured aortic valve aneurysm (VA). Aortic valve replacement (AVR) was performed after improvement of HF symptoms. Pathological examination of resected aortic VA showed neutrophil infiltration. Although he did not have typical clinical features associated with infective endocarditis (IE) such as fever, leukocytosis, or positive blood culture, we misdiagnosed this case as "concealed IE". However, we reconsidered the etiology because prosthetic aortic valve detachment occurred only one year after AVR. When considering causes except IE for perforated aortic VA and early prosthetic valve detachment, Behçet's disease (BD) was more likely based on the clinical course, echocardiography, and pathological findings in this case. The inflammatory process of BD is associated with aortic valvulitis/aortitis, leading to a possible cause of aortic regurgitation due to aortic VA or early prosthetic valve detachment. The diagnosis of BD was challenging in this case because he did not have predominant clinical findings, including recurrent oral ulcer which is a mandatory criterion for the diagnosis by the International Study Group, however, cardiac involvement may have been the initial presentation of BD. .

Neurological Prognostic Value of Adjusted Ca2+ Concentration in Adult Patients with Out-of-Hospital Cardiac Arrest.

Many patients are transferred to hospital due to out-of-hospital cardiac arrest (OHCA), and, unfortunately, most suffer from cerebral damage. Currently, it is difficult to predict the recovery of neurological function after return of spontaneous circulation (ROSC) in the acute phase. Increased intracellular Ca2+ induces cell death in the acute phase. Accordingly, we predicted that serum adjusted Ca2+ will decrease following Ca2+ influx into cells. Consequently, serum adjusted Ca2+ in the acute phase may be able to predict recovery of neurological function in patients with ROSC from OHCA. This is a retrospective and observational study from 2 centers. A total of 190 consecutive patients with ROSC from OHCA were recruited, with 33 patients meeting the inclusion criteria. The relationship between serum adjusted Ca2+ within 48 hours after ROSC and neurological function at discharge (as evaluated by the Glasgow-Pittsburgh cerebral performance category) was examined. Serum adjusted Ca2+ was measured every 4 hours within a 48-hour period after ROSC. There were no significant differences in hemodynamical state and laboratory data between the 2 groups. However, lowest serum adjusted Ca2+ within 48 hours after ROSC was significantly lower in the poor neurological outcome group (0.96 ± 0.06 versus 1.02 ± 0.06 mmol/L, P = 0.011). Thus, lowest serum adjusted Ca2+ within 48 hours after ROSC may be a predictive factor for recovery of neurological function at discharge in patients with ROSC from OHCA.

Child ego state is associated with high prevalence of repeated hospitalizations in patients with heart failure.

AIMS: Inadequate self-care management is a leading cause of re-hospitalization in patients with heart failure (HF). Psychological factors such as some ego functions interfere with self-care behaviour modification, leading to poor outcomes in patients with several chronic diseases. However, characteristics of ego states in patients with repeated hospitalization for HF remain undefined. METHODS AND RESULTS: The present study enrolled 40 HF outpatients with previous history of HF hospitalization and receiving self-care management. Patients' psychological characteristics were assessed by Patient Health Questionnaire (PHQ-9) for screening depressive symptoms, and the Tokyo University Egogram (TEG) New Version II for analysing human behaviour based on five functional ego states; critical parent, nurturing parent, adult, free child, and adapted child (AC). Twelve patients (30.0%) had previous history of repeated (two or more) HF hospitalization. Most of them (75%) had a history of at least one or more re-hospitalizations related to inadequate self-care. Patients with repeated HF hospitalization had significantly lower AC score, which represents uncooperative and uncompromising behaviours, compared with those without repeated HF hospitalization (P < 0.05). There were no significant differences in other parameters, including PHQ-9, between the two groups. CONCLUSIONS: Low AC ego state was associated with high prevalence of repeated hospitalization in patients with HF. Assessing ego functions may be helpful to tailor educational approaches in these patients.

Type II endoleak repair after endovascular abdominal aortic repair using a computed tomography-guided percutaneous transabdominal approach.

The current treatment of type II endoleaks includes either transarterial or sac puncture techniques. Sac puncture can be further divided into translumbar, transabdominal, and transcaval approaches.1 However, transabdominal techniques for the treatment of type II leak are not well established. Herein, we report a case of a type II endoleak repaired in a 76-year-old woman using a computed tomography-guided percutaneous transabdominal approach. This type of transabdominal repair is easy and safe because punctures to the aneurysm sac are visualized in real time by computed tomography. It is possible to selectively embolize persistent blood flow in arteries in either the sac or main artery.

Efficacy of anti-tachycardia pacing for terminating fast ventricular tachycardia in Japanese implantable cardioverter defibrillator patients. Primary results of the SATISFACTION study.

BACKGROUND: Anti-tachycardia pacing (ATP) delivered by implantable cardioverter defibrillators (ICD) safely avoids painful shocks with minimum risk of tachycardia acceleration. The etiology of ventricular tachycardia (VT) in those studies, however, was predominantly coronary artery disease (CAD). Patient etiology differs by geography and could affect ATP efficacy rate. The primary objective of this study was to examine how often the first ATP therapy terminates fast VT (FVT) in Japanese ICD patients with regional etiologies. METHODS AND RESULTS: Seven hundred and fifteen patients received ICD or cardiac resynchronization therapy defibrillator with the function of ATP during capacitor charging. The primary endpoint was the first ATP success rate for terminating FVT with cycle length 240-320 ms. During a mean follow-up of 11.3 months, 888 spontaneous VT episodes were detected, including 276 FVT (31.1%) in 42 patients. The first-ATP success rate for FVT in the overall group (41% CAD, 59% non-CAD including 23% idiopathic VT) was 62.1% (61.7% adjusted). Success rate was not different between non-CAD and CAD patients (61.4% adjusted and 57.5% adjusted, respectively, P=0.75). Eight FVT episodes (2.9%) accelerated after the first ATP attempt, all of which were terminated by subsequent device therapy (additional ATP or shock). CONCLUSIONS: ATP efficacy for FVT was similar between ICD patients with and without CAD etiology.

Pinhole balloon rupture and stuck stent: case report of a new and simple bailout technique for incomplete stent dilatation caused by rupture from a highly calcified lesion.

We report a case of highly calcified 75% stenotic lesion in the proximal left anterior descending coronary artery. During stenting, the balloon incurred a pinhole rupture at the moment of dilatation and the stent expanded only at both ends. This caused the balloon and stent to become lodged in the coronary artery. An attempt to dilate the balloon using rapid inflation alone was not successful, but we succeeded in dilating the stent with rapid balloon inflation by increasing the concentration of the contrast medium. We confirmed the occurrence of this phenomenon in vitro.

Impact of angiographic peri-stent contrast staining (PSS) on late adverse events after sirolimus-eluting stent implantation: an observation from the multicenter j-Cypher registry PSS substudy.

This study sought to assess clinical significance of angiographic peri-stent contrast staining (PSS) after sirolimus-eluting stent (SES) implantation in a large multicenter study with 5-year follow-up. The j-Cypher PSS substudy is a multicenter study including 5712 patients (7838 lesions) who underwent follow-up angiographic study within 12 months after SES implantation. Late acquired PSS was observed in 184 patients (3.2 %) or 194 lesions (2.5 %). Independent risk factors of PSS were chronic total occlusion and left anterior descending artery lesion, while negative risk factors were in-stent restenosis, diabetes mellitus, ≥70 years of age, and left circumflex coronary artery lesion. Cumulative incidence of definite very late stent thrombosis (VLST) at 4 years after the index follow-up angiography in lesions with PSS was significantly higher than that in lesions without PSS (5.3 versus 0.7 %, P < 0.0001). Late target-lesion revascularization (TLR) was also more frequently observed in the PSS group (13 versus 6.9 %, P = 0.01), while late TLR for restenosis excluding those TLR procedures for VLST tended to be higher in the PSS group (9.9 versus 6.3 %; P = 0.15). PSS found in 2.5 % of lesions within 12 months after SES implantation was associated with higher risk for subsequent VLST.

Comparison of 5-year outcomes in patients with and without unprotected left main coronary artery disease after treatment with sirolimus-eluting stents: insights from the j-Cypher registry.

OBJECTIVES: This study assessed 5-year outcomes after implantation of sirolimus-eluting stents (SES) for unprotected left main coronary artery (ULMCA) disease in comparison with that for non-left main disease. BACKGROUND: More information on long-term outcomes after ULMCA stenting is needed. METHODS: The j-Cypher is a multicenter prospective registry of consecutive patients undergoing SES implantation in Japan. RESULTS: Among 12,812 patients enrolled in the j-Cypher registry, the unadjusted mortality rate at 5 years was significantly higher in patients with ULMCA stenting than in patients without ULMCA stenting (22.8% vs. 14.1%; p < 0.0001); however, the risk for death with ULMCA stenting was no longer significant after adjusting for confounders (hazard ratio: 1.18, 95% confidence interval: 0.95 to 1.46; p = 0.14). In the lesion-level comparison, the nonbifurcation ULMCA lesions treated exclusively with SES had a significantly lower rate of target lesion revascularization (TLR) than those in non-ULMCA nonbifurcation lesions (2.4% vs. 12.7%; p = 0.04). Among bifurcation lesions, those treated with a provisional 2-stent approach had similar rates of TLR (12.1% vs. 11.4%; p = 0.79) between the ULMCA and non-ULMCA groups. Lesions treated with an elective 2-stent approach had higher TLR rates in the ULMCA group as compared with the non-ULMCA group (33.5% vs. 19.7%; p = 0.002). CONCLUSIONS: The safety of ULMCA stenting relative to non-LMCA stenting was maintained through 5 years follow-up. In terms of efficacy, SES implantation in nonbifurcation ULMCA lesions was associated with an extremely low cumulative incidence of TLR, whereas the elective 2-stent approach for ULMCA bifurcation lesions was associated with a markedly higher cumulative incidence of TLR as compared with that for non-ULMCA bifurcation lesions.

Antiplatelet therapy and long-term clinical outcome after sirolimus-eluting stent implantation: 5-year outcome of the j-Cypher registry.

Due to serious concerns on very late stent thrombosis (VLST), extended use of dual antiplatelet therapy (DAPT) beyond 1 year after DES implantation has become a common clinical practice despite apparent lack of evidence suggesting its efficacy in reducing VLST. The study population consisted of 12812 patients in the j-Cypher registry who were treated with at least one sirolimus-eluting stent (SES). We assessed the relation between duration of thienopyridine therapy and clinical outcomes with a landmark analysis at 1 year after SES implantation. Among 11713 patients without myocardial infarction (MI), stent thrombosis and stroke at 1 year who were eligible for the landmark analysis, 7414 patients (63 %) were maintained on thienopyridine at 1-year landmark point, while 4299 patients (37 %) had discontinued thienopyridine before 1-year landmark point. Patients in the on-thienopyridine group had more complex characteristics than patients in the off-thienopyridine group. Cumulative incidence of and the risk for definite VLST in the on-thienopyridine group relative to the off-thienopyridine group favored prolonged DAPT, but were not significant [0.9 and 1.2 %, P = 0.1, and adjusted HR (95 % CI): 0.71 (0.47-1.06), P = 0.11]. Cumulative incidence of and the risk for a composite of death, MI, or stroke in the on-thienopyridine group relative to the off-thienopyridine group were also not significant [15.3 and 14.3 %, P = 0.15, and adjusted HR (95 % CI): 0.99 (0.89-1.11), P = 0.89]. Prolonged use of thienopyridine beyond 1 year after SES implantation was not associated with significant decrease in the risks for VLST or for serious cardiovascular events including death, MI or stroke.

Moderate stenosis in left main trunk side branches treated with single sirolimus-eluting stents should be observed without additional stenting.

The sirolimus-eluting stent (SES) has dramatically reduced restenosis in patients with most types of coronary lesions, but bifurcation lesions remain a predictor of poor prognosis even in SES implantation. We aimed to determine the clinical outcomes of the left main trunk (LMT) side branches (SB) treated with a single SES strategy. SES implantation was successfully performed on 70 patients with LMT stenosis from August 2005 to August 2008. Of the 70 patients, 55 patients (59 SB) were treated with a single SES and a jailed SB. The 56 SB were divided into two groups according to percent diameter stenosis immediately following percutaneous coronary intervention (PCI) (Group 1: >50%; Group 2: <50%). Quantitative coronary angiography (QCA) data was evaluated. One year angiographic follow-up was performed on 23 patients (82.1%) in Group 1, and 21 patients (78.6%) in Group 2. Group 1 MLD was significantly larger at follow up than that post-PCI (0.9 ± 0.4 vs. 1.2 mm ± 0.6 mm, p < 0.01). In Group 2, MLD and percent diameter stenosis did not change significantly. SB revascularization was not performed on either group at follow-up. Clinical outcomes of moderate stenosis in LMT SB treated with a single SES were acceptable, and stenosis progression within 1 year was minimal. We concluded that patients who present moderate residual stenosis in LMT SB with no presentation of ischemic symptoms should be observed rather than re-stented.

Late progression after sirolimus-eluting stent implantation for de novo lesions--comparison with bare metal stent implantation.

BACKGROUND: In previous studies, the minimal luminal diameter (MLD) of lesions treated with a bare metal stent (BMS) was shown to improve from 6 months to 3 years. However, the long-term response to a sirolimus-eluting stent (SES) implantation remains unclear. METHODS AND RESULTS: To evaluate 6-month, 12-month and 3-year outcomes, clinical and angiographic follow-up data were analyzed for 367 consecutive patients (506 de novo lesions) who underwent successful SES implantation compared to follow-up data for 617 consecutive patients (802 de novo lesions) who underwent BMS implantation. Clinical follow-up information was obtained for 363 SES-treated patients (98.9%) and 581 BMS-treated patients (94.2%) at 1 year, and 334 SES-treated patients (91.0%) and 566 BMS-treated patients (91.7%) at 3 years. At 3 years, there were no significant differences in the cumulative cardiac death and myocardial infarction. Target lesion revascularization (TLR) rates were significantly higher in BMS-treated patients than in SES-treated patients. In BMS-treated patients, most TLR was performed within 450 days, however, after 450 days, the TLR rate was significantly lower than that for the SES-treated patients. In quantitative coronary angiographic data, among lesions that required no revascularization at the initial 12-month follow up, MLD increased significantly from the 12-month to the 3-year follow-up angiography in BMS-treated lesions. However, MLD decreased significantly in SES-treated lesions. CONCLUSIONS: From a 12-month follow-up to a 3-year follow-up, stenosis in BMS-treated lesions regressed, but stenosis in SES-treated lesions progressed. And late TLR was more frequently required in the SES-treated patients.

Pathological finding of sirolimus-eluting stent (SES) restenosis lesion with black hole appearance on intravascular ultrasound.

Restenosis still occurs, even with the sirolimus-eluting stent (SES), and the precise mechanisms have not yet been elucidated. In the present case, focal in-stent stenosis was discovered on angiography 16 months after SES implantation. Intravascular ultrasound revealed an echolucent homogeneous zone, which has been termed "black hole". A sample of stenotic tissue retrieved by aspiration revealed neointimal hyperplasia, composed of proteoglycans and smooth muscle cells with scanty cellularity. Furthermore, infiltration of many macrophages and T lymphocytes coexisted in the restenotic tissue. These findings suggest that delayed healing is 1 of the mechanisms of SES restenosis.

Predictors and long-term prognostic implications of angiographic slow/no-flow during percutaneous coronary intervention for acute myocardial infarction.

OBJECTIVE: In patients with acute myocardial infarction (AMI), angiographic slow/no-flow during percutaneous coronary intervention (PCI) may lead to unfavorable outcomes. The aim of our study was to investigate the predictors and long-term prognosis of AMI patients with angiographic slow/no-flow. METHODS: We evaluated 228 consecutive AMI patients with either normal flow (Thrombolysis in Myocardial Infarction [TIMI] flow grade 3)(n=192) or slow/no-flow (< or =TIMI-2)(n=36) based on cineangiograms performed during PCI. RESULTS: Multivariable analysis demonstrated that a long lesion (> or =10 mm)(odds ratio [OR], 3.514; 95% confidence interval [CI], 1.505-8.206; p=0.004) and acute hyperglycemia (> or =180 mg/dl)(OR, 3.011; 95% CI, 1.211-7.485; p=0.018) were significant and independent predictors of angiographic slow/no-flow. Further, we found that there was a high correlation (89%) for predicting angiographic slow/no-flow when the optimal cut-off values of lesion length (10.45 mm) and blood glucose levels on admission (187.5 mg/dl) were combined as identified by analysis of the receiver operating characteristic curves. One-year mortality and incidence of major adverse cardiac and cerebrovascular events (MACCE) were significantly higher in the slow/no-flow group than that in the normal flow group. Angiographic slow/no-flow was independently predictive of MACCE (hazard ratio [HR], 3.642; 95% CI, 1.208-10.980; p=0.022) and cardiac death (HR, 5.287; 95% CI, 1.155-24.204; p=0.032). CONCLUSIONS: Lesion length and blood glucose level on admission can be used to stratify AMI patients into a lower or higher risk for angiographic slow/no-flow before optimal coronary intervention. In addition, angiographic slow/no-flow predicts an adverse outcome in AMI patients.

Impact of impaired renal function and diabetes on long-term prognosis in patients undergoing primary angioplasty for acute coronary syndrome.

OBJECTIVE: We sought to determine the effect of impaired renal function (IRF) and diabetes on the long-term outcome in patients undergoing primary angioplasty for acute coronary syndrome (ACS). Background Diabetes and IRF occur frequently in patients presenting with ACS. However, the prognostic importance of IRF in comparison with diabetes after primary angioplasty has not been specifically studied. METHODS: A total of 742 patients with ACS treated by primary angioplasty were evaluated. Study endpoints were major adverse cardiac events (MACE), a composite of all-cause mortality, ACS, and target vessel revascularization (TVR). RESULTS: During an average follow-up period of 6.8 years, we documented 13 cardiovascular deaths, 27 non-cardiovascular deaths, 12 incidents of ACS, and 165 incidences of TVR. Six-year rates of MACE were significantly higher in diabetics with IRF (47.6%), nondiabetics with IRF (36.4%), and diabetics without IRF (36.0%) than in nondiabetics without IRF (28.4%, Log-rank test: p=0.0057). Nondiabetics with IRF, diabetics without IRF, and diabetics with IRF had a relative hazard ratio for MACE of 1.63 (95% confidence interval (CI) 1.04 to 2.54, p=0.033), 1.47 (95% CI, 1.03 to 2.11; p=0.036), and 1.97 (95% CI, 1.12 to 3.48; p=0.019), respectively, compared with nondiabetics without IRF. CONCLUSIONS: IRF has an important association with MACE after primary angioplasty in patients with ACS and may be nearly as predictive of long-term outcome as is diabetes.

Comparison of long-term angiographic follow-up after sirolimus-eluting stent and bare-metal stent implantation.

BACKGROUND: The sirolimus-eluting stent (SES) has dramatically reduced the rate of restenosis in comparison to that with the bare-metal stent (BMS). In previous studies, the minimal luminal diameter (MLD) of lesions treated with a BMS was shown to improve from 6 months to 1 year. METHODS: To evaluate 6-month and 1-year outcomes, angiographic follow-up data were analyzed for 285 patients (451 lesions) who underwent successful SES implantation compared to follow-up data for 2,561 patients (3,367 lesions) who underwent BMS implantation. RESULTS: Angiographic follow-up was performed at 6 months for 396 SES-treated lesions and 2,628 BMS-treated lesions and at 1 year for 322 SES-treated lesions and 1,540 BMS-treated lesions. The 6-month angiographic restenosis rate was significantly lower for SES-treated lesions than for BMS-treated lesions (4.8% vs. 23.4%, p<0.01). From immediately after stent implantation to 6 months, quantitative coronary angiography revealed a significantly larger decrease in MLD of BMS-treated lesions than in MLD of SES-treated lesions (p<0.01). In BMS-treated lesions in which repeat revascularization was not performed at 6 months, MLD increased significantly from 2.08+/-0.63 mm at 6 months to 2.11+/-0.61 mm at 1 year (p<0.01). In SES-treated lesions, however, MLD decreased significantly from 2.55+/-0.56 mm at 6 months to 2.44+/-0.61 mm at 1 year (p<0.05). CONCLUSIONS: From 6 months to 1 year, stenosis of BMS-treated lesions regressed, but stenosis of SES-treated lesions progressed.