Enhancement patterns detected by multidetector computed tomography are associated with the long-term prognosis of patients with acute myocardial infarction.

The present study investigated the clinical value of myocardial contrast-delayed enhancement (DE) with multidetector computed tomography (MDCT) without iodine re-injection immediately after primary percutaneous coronary intervention (PCI) for predicting future cardiovascular events after acute myocardial infarction (AMI). We performed a prospective study in which 263 consecutive patients with first AMI successfully treated with primary PCI were enrolled. Sixty-four-slice MDCT without the re-injection of contrast medium was performed immediately after PCI. Myocardial DE was considered to be transmural when involving myocardial thickness ≥ 75% (Group A; n = 104), subendocardial (< 75%, Group B; n = 108), or normal (Group C; n = 51). A semiquantitative scale score was defined for 17 left ventricular segments to investigate the extent of the DE area assessed. We examined the relationship between the presence or absence of transmural DE and long-term cardiovascular event rates. The median follow-up period was 3.5 years. Kaplan-Meier survival curves showed that patient prognosis was poorer in the group with Group A than that in the group with Group B, which was equivalent to that with Group C. A multivariate analysis identified the presence of transmural DE as the strongest predictor for future cardiovascular events (hazard ratio: 3.7; P = 0.023). Transmural myocardial DE immediately following primary PCI without an iodine re-injection for AMI is a major risk factor for future cardiovascular events.

Severe obstructive sleep apnea is associated with coronary microvascular dysfunction and obstruction in patients with ST-elevation myocardial infarction.

BACKGROUND: Coronary microvascular dysfunction and obstruction (CMVO) is a strong predictor of a poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). Although research has suggested that obstructive sleep apnea (OSA) exacerbates CMVO after primary percutaneous coronary intervention, data supporting a correlation between OSA and CMVO are limited. This study was performed to investigate whether OSA is associated with CMVO, detected as microvascular obstruction on cardiovascular magnetic resonance images, in patients with STEMI. METHODS: Patients (N = 249) with a first STEMI underwent primary percutaneous coronary intervention. CMVO was evaluated on cardiovascular magnetic resonance images based on the presence of microvascular obstruction. OSA was classified into four levels of severity based on the respiratory event index (REI): absent (REI of <5), mild (REI of ≥5 to <15), moderate (REI of ≥15 to <30) and severe (REI of ≥30). RESULTS: The REI was significantly higher in the presence of microvascular obstruction (n = 139) than in its absence (n = 110) (REI of 12.8 vs. 10.7, respectively; p = 0.023). Microvascular obstruction was observed in 42%, 58%, 57% and 70% of patients in the absent, mild, moderate and severe OSA groups, respectively. Multiple logistic regression analysis showed that severe OSA was associated with increased odds of microvascular obstruction (odds ratio (OR), 5.10; 95% confidence interval (CI),1.61-16.2; p = 0.006). Mild and moderate OSA were also associated with increased odds of microvascular obstruction (mild OSA: OR, 2.88; 95% CI, 1.19-7.00; p = 0.019 and moderate OSA: OR, 3.79; 95% CI, 1.43-10.1; p = 0.008). CONCLUSION: Severe OSA was associated with CMVO after primary percutaneous coronary intervention in patients with STEMI.

Severe obstructive sleep apnea is associated with coronary microvascular dysfunction and obstruction in patients with ST-elevation myocardial infarction.

BACKGROUND: Coronary microvascular dysfunction and obstruction (CMVO) is a strong predictor of a poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI). Although research has suggested that obstructive sleep apnea (OSA) exacerbates CMVO after primary percutaneous coronary intervention, data supporting a correlation between OSA and CMVO are limited. This study was performed to investigate whether OSA is associated with CMVO, detected as microvascular obstruction on cardiovascular magnetic resonance images, in patients with STEMI. METHODS: Patients (N = 249) with a first STEMI underwent primary percutaneous coronary intervention. CMVO was evaluated on cardiovascular magnetic resonance images based on the presence of microvascular obstruction. OSA was classified into four levels of severity based on the respiratory event index (REI): absent (REI of <5), mild (REI of ≥5 to <15), moderate (REI of ≥15 to <30) and severe (REI of ≥30). RESULTS: The REI was significantly higher in the presence of microvascular obstruction (n = 139) than in its absence (n = 110) (REI of 12.8 vs. 10.7, respectively; p = 0.023). Microvascular obstruction was observed in 42%, 58%, 57% and 70% of patients in the absent, mild, moderate and severe OSA groups, respectively. Multiple logistic regression analysis showed that severe OSA was associated with increased odds of microvascular obstruction (odds ratio (OR), 5.10; 95% confidence interval (CI),1.61-16.2; p = 0.006). Mild and moderate OSA were also associated with increased odds of microvascular obstruction (mild OSA: OR, 2.88; 95% CI, 1.19-7.00; p = 0.019 and moderate OSA: OR, 3.79; 95% CI, 1.43-10.1; p = 0.008). CONCLUSION: Severe OSA was associated with CMVO after primary percutaneous coronary intervention in patients with STEMI.

[Left Ventricular Torsion in Papillary Muscle Relocation for Severe Functional Mitral Regurgitation].

A 42-year-old woman with a history of old myocardial infarction was admitted to our hospital with complaints of worsening orthopnea. Doppler echocardiography exhibited severe functional mitral valve regurgitation. Because of the tethered mitral valve, we performed mitral valve annuloplasty concomitantly with papillary muscle relocation procedure. The patient recovered well. Postoperative echocardiography had not exhibited recurrent mitral valve insufficiency. Moreover, postoperative left ventricular torsion using 2-dimentional speckle tracking imaging, improved at rest and at peak exercise, and this findings suggest that the reversal of left ventricular remodeling in relocation patients following preserved and connected mitral subvalvular apparatus may result from restoration of the global sequence of left ventricular twist mechanics. The analysis of left ventricular torsion may provide a more comprehensive evaluation of left ventricular mechanics and may help understand the effects of papillary muscle relocation with preserving mitral subvalvular apparatus.

Sex-based differences in clinical practice and outcomes for Japanese patients with acute myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: Limited data are available for sex-based differences in Japanese patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: The study patients comprised 1,197 women and 3,182 men who underwent primary PCI for AMI in 2005-2007. Compared with the men, the women were significantly older, and had significantly longer onset-to-balloon time and lower rate of follow-up coronary angiography. In-hospital mortality was higher among women than men (8.7% vs. 4.9%, P<0.001). Although the cumulative incidence of all-cause death at 3 years was also higher for women (17.7% vs. 10.7%, P<0.001), the adjusted risk for all-cause death was comparable [hazard ratio (HR, women vs. men)=0.94, 95% confidence interval (CI): 0.71-1.24, P=0.66]. The incidence (12.1% vs. 12.4%, P=0.77) and the adjusted risk (HR=0.99, 95% CI 0.78-1.24, P=0.92) for any clinically-driven coronary revascularization were both comparable. However, regarding any non-clinically-driven coronary revascularization, the incidence (19.6% vs. 27.8%, P<0.001) and the adjusted risk (HR=0.79, 95% CI 0.65-0.95, P=0.012) were both lower in women relative to men. CONCLUSIONS: In current Japanese clinical practice for AMI, onset-to-balloon time was significantly longer in women than in men. Female sex was associated with lower follow-up coronary angiography rate and lower incidence of any non-clinically-driven coronary revascularization, whereas the incidence of any clinically-driven coronary revascularization was comparable between the sexes.

Progression of left main coronary artery disease 3 years after Bentall operation in a young female with Marfan syndrome.

A 39-year-old woman with Marfan syndrome presented to our hospital with chest oppression on effort. She underwent aortic root remodeling combined with aortic valve replacement 14 years ago and Bentall operation for enlargement of remaining native Valsalva sinus 3 years ago. A coronary computed tomography and a coronary angiography showed left main coronary artery stenosis, which was subsequently treated with percutaneous coronary intervention using a bare-metal stent. Follow-up coronary angiography performed 1 year after stenting revealed no restenosis.

Impact of aortic regurgitation on the prognosisof severe aortic stenosis.

OBJECTIVE: Many patients with aortic stenosis (AS) have coexisting aortic regurgitation (AR). However, few data exist regarding its clinical significance and prognostic value. The aim of this study was to examine the effect of concomitant significant AR on clinical outcomes in patients with non-surgically treated severe AS. DESIGN: A single centre, retrospective cohort study. PATIENTS AND METHODS: We retrospectively reviewed 306 consecutive patients (age, 72±11 years) with severe AS in whom non-surgical management was primarily planned at our institution between January 1999 and December 2011. There were 74 patients with moderate or severe AR (ASR) and 232 patients without significant AR (isolated AS). Clinical outcomes were compared between the two groups. MAIN OUTCOME MEASURES: All-cause mortality and valve-related events, were defined by a composite of cardiac death and hospitalisation because of heart failure. RESULTS: The mean follow-up period was 4.5±3.3 years. Although the overall survival was comparable between the groups (p=0.07), the event-free survival, defined as survival without cardiac death or hospitalisation because of heart failure, was significantly worse in ASR than in isolated AS (p=0.02). Concomitant AR was an independent predictor of adverse events in patients with severe AS (HR, 2.10; p=0.003). Among patients who did not eventually undergo aortic valve replacement, ASR was associated with significantly worse survival and event-free survival than isolated AS (p=0.002 and p=0.03, respectively). CONCLUSIONS: Concomitant AR might worsen the prognosis of severe AS. Greater consideration of surgery might be beneficial in patients with ASR.

Newly diagnosed glucose intolerance and prognosis after acute myocardial infarction: comparison of post-challenge versus fasting glucose concentrations.

BACKGROUND: Recent studies have demonstrated that newly diagnosed glucose intolerance is common among patients with acute myocardial infarction (AMI). The purpose of this study was to assess the long-term clinical cardiovascular outcomes in participants with AMI with abnormal fasting glucose compared with normal fasting glucose and an abnormal oral glucose tolerance test (OGTT) compared with a normal OGTT. METHODS: A prospective study was performed in 275 consecutive patients with AMI, 85 of whom had pre-diagnosed diabetes mellitus (DM). Those without DM were divided into two groups based on the 75 g OGTT at the time of discharge. Abnormal glucose tolerance (AGT) was defined as 2 h glucose ≥140 mg/dl; 78 patients had normal glucose tolerance (NGT) and 112 had AGT. The same patients were also reclassified into the normal fasting glucose group (NFG; n=168) or the impaired fasting glucose group (IFG; n=22). The association between the glucometabolic status and long-term major adverse cardiovascular event rates was evaluated. RESULTS: Kaplan-Meier survival curves showed that the AGT group had a worse prognosis than the NGT group and an equivalent prognosis to the DM group (p<0.0005). Cox proportional hazard model analysis showed that the HR of AGT to NGT for major adverse cardiovascular event rates was 2.65 (95% CI 1.37 to 5.15, p=0.004) while the HR of DM to NGT was 3.27 (1.68 to 6.38, p=0.0005). However, Cox HR of IFG to NFG for major adverse cardiovascular event rates was 1.83 (0.86 to 3.87), which was not significant. CONCLUSION: In patients with AMI, an abnormal OGTT is a better risk factor for future adverse cardiovascular events than impaired fasting blood glucose.

Left atrial volume predicts adverse cardiac and cerebrovascular events in patients with hypertrophic cardiomyopathy.

AIMS: To prospectively evaluate the relationship between left atrial volume (LAV) and the risk of clinical events in patients with hypertrophic cardiomyopathy (HCM). METHODS: We enrolled a total of 141 HCM patients with sinus rhythm and normal pump function, and 102 patients (73 men; mean age, 61±13 years) who met inclusion criteria were followed for 30.8±10.0 months. The patients were divided into two groups with or without major adverse cardiac and cerebrovascular events (MACCE), a composite of stroke, sudden death, and congestive heart failure. Detailed clinical and echocardiographic data were obtained. RESULTS: MACCE occurred in 24 patients (18 strokes, 4 congestive heart failure and 2 sudden deaths). Maximum LAV, minimum LAV, and LAV index (LAVI) corrected for body surface area (BSA) were significantly greater in patients with MACCE than those without MACCE (maximum LAV: 64.3±25.0 vs. 51.9±16.0 ml, p=0.005; minimum LAV: 33.9±15.1 vs. 26.2±10.9 ml, p=0.008; LAVI: 40.1±15.4 vs. 31.5±8.7 ml/mm2, p=0.0009), while there were no differences in the other echocardiographic parameters.LAV/BSA of ≥40.4 ml/m2 to identify patients with cardiovascular complications with a sensitivity of 73% and a specificity of 88%. CONCLUSION: LAVI may be an effective marker for detecting the risk of MACCE in patients with HCM and normal pump function.

Clinical outcomes in non-surgically managed patients with very severe versus severe aortic stenosis.

OBJECTIVE: The management of asymptomatic severe and very severe aortic stenosis (AS) remains unestablished. This study aimed to investigate the clinical outcomes of severe versus very severe AS patients. DESIGN: A single centre, retrospective cohort study. PATIENTS AND METHODS: The study retrospectively reviewed 108 conservatively treated patients with severe AS (a maximal jet velocity ≥ 4.0 m/s, or mean aortic pressure gradient (MPG) ≥ 40 mm Hg, or an aortic valve area (AVA) <1.0 cm(2)) and 58 patients with very severe AS (a maximal jet velocity ≥ 5.0 m/s, or MPG ≥ 50 mm Hg or an AVA <0.6 cm(2)). Clinical outcomes were compared between the two groups, considering the existence of symptoms. MAIN OUTCOME MEASURES: All-cause mortality and valve-related event, defined by a composite of cardiac death and hospitalisation because of heart failure. RESULTS: Mean follow-up was 5.5 ± 3.1 years. Fifty-six patients (52%) with severe AS and 20 patients (34%) with very severe AS were asymptomatic. Very severe AS had poorer survival and valve-related event-free survival than severe AS at 3 years (77% vs 88%, p < 0.01; 75% vs 88%, p < 0.001, respectively). In addition, the 3-year survival and valve-related event-free survival of asymptomatic very severe AS were comparable with symptomatic severe AS, but they were significantly worse than asymptomatic severe AS (p < 0.01 and p < 0.001, respectively). CONCLUSIONS: Surgery should always be considered in very severe AS regardless of symptoms, and particular attention needs to be paid to their extremely poor outcomes.

Detection of intimal defect by 64-row multidetector computed tomography in patients with acute aortic intramural hematoma.

BACKGROUND: Previous pathological and clinical studies demonstrated an intimal defect in patients with acute aortic intramural hematoma (IMH). The purpose of this study was to investigate the prevalence and clinical outcome of intimal defect detected by multidetector computed tomography (MDCT) in patients with IMH. METHODS AND RESULTS: We retrospectively analyzed 38 consecutive patients with IMH in whom 64-row MDCT was performed during the acute phase (median, 5 days from the onset). Intimal defect was defined as continuity disruption of the inner layer of thrombosed false lumen, which could be detected by 1-mm axial and longitudinal interactive multiplanar reformation images. Clinical outcome of intimal defect was assessed in patients with type B IMH (n=32). A total of 48 lesions in 27 (71%) patients were recognized as intimal defects. The incidence of intimal defect was not affected by the timing of MDCT examination (1 to 3 days, 79%; 4 to 7 days, 58%; 8 to 14 days, 75%; P=0.56). In type B IMH, 16 (76%) of 21 patients with intimal defect showed progression (enlargement or progression to aortic aneurysm) in the chronic phase. In contrast, all 11 patients without intimal defect had complete resorption of hematoma. In lesion-based analysis, a depth of intimal defect of ≥ 5 mm predicted progression with sensitivity, specificity, and positive and negative predictive values of 84%, 95%, 94%, and 86%, respectively. CONCLUSIONS: A considerable portion of patients with IMH showed intimal defect detected by MDCT even in the very early stage, and defects frequently enlarged. Patients with intimal defect should be carefully followed up with serial imaging.

Successful thrombus aspiration during primary percutaneous coronary intervention reduces infarct size and preserves myocardial viability: a cardiac magnetic resonance imaging study.

BACKGROUND: The purpose of this study was to evaluate the influence of thrombus aspiration during primary percutaneous coronary intervention (PCI) on myocardial viability in patients with ST-segment elevation myocardial infarction (STEMI) using cardiac magnetic resonance imaging (MRI). METHODS AND RESULTS: We performed cardiac MRI in 62 patients who underwent primary PCI for STEMI with manual thrombus aspiration. We divided the patients into two groups: those who had thrombus aspiration during primary PCI, which resulted in a successful procedure (n=47 patients; TA group) and those who had thrombus aspiration and an unsuccessful procedure (n=15 patients; non-TA group). Thrombus aspiration was defined as successful or unsuccessful, based on the histological evidence of atherothrombotic material in the aspirate samples. The infarct volume was quantified using delayed-contrast enhancement on cardiac MRI. The reference volume was defined as transmural myocardial volume at the infarcted segment. Myocardial viability was assessed by a transmurality index defined as the ratio of the infarct volume to the reference volume. Although baseline characteristics and the reference volume were comparable between the two groups (24.5 ± 12.5 ml for TA group versus 29.0 ± 9.6 ml for non-TA group; p = 0.21), the infarct size was significantly smaller in the TA group than in the non-TA group (12.2 ± 7.1 ml versus 17.4 ± 7.1 ml, respectively; p = 0.01). The transmurality index was also significantly lower in the TA group (49.3 ± 10.6% versus 60.9 ± 13.9%, respectively; p = 0.001). CONCLUSION: Patients with successful TA showed more reduced infarct size and preserved myocardial viability than patients without TA. These effects of TA may lead to preserved left ventricular systolic function and better clinical outcomes.

Clinical characteristics and outcomes of Japanese women undergoing coronary revascularization therapy.

BACKGROUND: Limited data are available for gender-based differences in patients undergoing coronary revascularization. This study aimed to identify gender-based differences in risk factor profiles and outcomes among Japanese patients undergoing coronary revascularization. METHODS AND RESULTS: The subjects consisted of 2,845 women and 6,843 men who underwent first percutaneous coronary intervention or coronary artery bypass grafting in 2000-2002. The outcome measures were all-cause death, major adverse cardiovascular events (MACE) as the composite of cardiovascular death, myocardial infarction and stroke, and any coronary revascularization. The females were older than the males and more frequently had histories of heart failure, diabetes, hypertension, chronic kidney disease, anemia, and dyslipidemia. Unadjusted survival analysis revealed a significantly lower incidence of any revascularization in women (at 3 years: 28.2% vs. 31.2%, P = 0.0037), although no significant gender-based differences were shown in the incidence of all-cause death (at 3 years: 8.8% vs. 8.5%, P = 0.37) or MACE (at 3 years: 12.0% vs. 11.5%, P = 0.61). Multivariate analysis revealed that female gender was associated with significantly lower risks of any revascularization (relative risk = 0.93, 95% confidence interval [CI] = 0.88-0.99, P = 0.014) and all-cause death (relative risk = 0.86, 95%CI = 0.77-0.96, P = 0.005). CONCLUSIONS: In Japanese patients undergoing first coronary revascularization, the coronary risk factor burden appeared greater in women than in men. Despite the greater modifiable risk factor accumulation, female gender was associated with a lower incidence of repeated revascularization relative to male gender.

Impact of early surgery in the active phase on long-term outcomes in left-sided native valve infective endocarditis.

OBJECTIVE: We sought to evaluate the impact of early surgery in the active phase on long-term outcomes in patients with left-sided native valve infective endocarditis. METHODS: Clinical data were retrospectively reviewed in 212 consecutive patients with left-sided native valve infective endocarditis from 1990 to 2009. Early surgery in the active phase (within 2 weeks after the initial diagnosis) was performed in 73 patients, and the conventional treatment strategy was applied in 139 patients. In the conventional treatment group, 99 patients underwent late surgical intervention. To minimize selection bias, propensity score was used to match patients in the early operation and conventional treatment groups. Major adverse cardiac event was defined as a composite of infective endocarditis-related death, repeat surgery, and recurrence of infective endocarditis during follow-up. RESULTS: The mean follow-up period was 5.5 years. In-hospital mortality was lower in the early operation group than in the conventional treatment group (5% vs 13%, P = .08). For 57 propensity score-matched pairs, the estimated actuarial 7-year survivals free from infective endocarditis-related death and major adverse cardiac events were significantly higher in the early operation group than in the conventional treatment group (infective endocarditis-related death: 94% ± 5% vs 82% ± 5%, P = .011, major adverse cardiac events: 88% ± 5% vs 69% ± 7%, P = .006, respectively). CONCLUSIONS: Compared with conventional treatment, early surgery in the active phase was associated with better long-term outcomes in patients with left-sided native valve infective endocarditis. Further prospective randomized studies with large study populations are necessary to evaluate more precisely the optimal timing of surgery in patients with native valve infective endocarditis.

Impact of new development of ulcer-like projection on clinical outcomes in patients with type B aortic dissection with closed and thrombosed false lumen.

BACKGROUND: The purpose of this study was to investigate the clinical importance of newly developed ulcer-like projection (ULP) in patients with type B aortic dissection with closed and thrombosed false lumen (AD with CTFL), which is better known as aortic intramural hematoma. METHODS AND RESULTS: A total of 170 patients with acute type B AD with CTFL were admitted to our institution from 1986 to 2008 and treated initially with medical therapy. There were 31 late deaths, including 9 cases of aortic rupture. The actuarial survival rates of all patients were 99%, 89%, 83% at 1, 5, and 10 years, respectively. A total of 62 (36%) patients showed new ULP development within 30 days from the onset. Patients who had ULP showed significantly poorer survival rates than patients who did not have ULP (P=0.037). Development of ULP was also associated with a significant increase in adverse aorta-related events (P<0.001). In addition, patients with ULP in the proximal descending thoracic aorta (PD) showed significantly higher aorta-related event rates than patients without ULP in the PD (P<0.001). Initial aortic diameter (hazard ratio, 3.55; P<0.001) and development of ULP in PD (hazard ratio, 3.79; P=0.003) were the strongest predictors of adverse aorta-related events. CONCLUSIONS: Initial aortic diameter and development of ULP in the PD are both strong predictors of adverse aorta-related events in patients with type B AD with CTFL. Patients with newly developed ULP should be more carefully followed up with close surveillance imaging than those without ULP.

Clinical outcomes of medical therapy and timely operation in initially diagnosed type a aortic intramural hematoma: a 20-year experience.

BACKGROUND: The management of aortic intramural hematoma (IMH) involving the ascending aorta (type A) has not been well-established. The purpose of this study was to clarify the long-term clinical outcomes of patients with type A IMH who were treated with medical therapy and timely operation. METHODS AND RESULTS: Clinical data including operative mortality, IMH-related events, and long-term survival were retrospectively reviewed in 66 patients with type A IMH, who were admitted to our institution from 1986 to 2006. Emergent surgical repair was performed in 16 (24%) patients because of severe complications, whereas 50 patients were treated with initial medical therapy. In medically treated patients, 15 (30%) patients who demonstrated progression to classic dissection or increase in hematoma size within 30 days underwent surgical repair except for 2 patients who refused surgery. The 30-day mortality rate was 6% with emergent surgery and 4% with supportive medial therapy. There were 7 late deaths and the actuarial survival rates of all patients were 96+/-3%, 94+/-3%, and 89+/-5% at 1, 5, and 10 years, respectively. In medically treated patients, maximum aortic diameter was the only predictor of early and late progression of ascending IMH (hazard ratio, 4.43; 95% CI, 2.04-9.64; P<0.001). Aortic diameter > or =50 mm predicted progression of ascending IMH with the positive and negative value of 83% and 84%, respectively. CONCLUSIONS: Combination of medical therapy and timely operation resulted in favorable long-term clinical outcomes in patients with type A IMH.

A prospective, multicenter, randomized trial to assess efficacy of pioglitazone on in-stent neointimal suppression in type 2 diabetes: POPPS (Prevention of In-Stent Neointimal Proliferation by Pioglitazone Study).

OBJECTIVES: The aim of this study was to clarify whether pioglitazone suppresses in-stent neointimal proliferation and reduces restenosis and target lesion revascularization (TLR) after percutaneous coronary intervention (PCI). BACKGROUND: Previous single-center studies have demonstrated the anti-restenotic effect of a peroxisome proliferator-activated receptor gamma agonist, pioglitazone, after PCI. METHODS: A total of 97 patients with type 2 diabetes mellitus (T2DM) undergoing PCI (bare-metal stents only) were enrolled. After PCI, patients were randomly assigned to either the pioglitazone group (n = 48) or the control group (n = 49). Angiographical and intravascular ultrasound (IVUS) imaging were performed at baseline and repeated at 6-month follow-up. Primary end points included angiographical restenosis and TLR at 6 months follow-up. Secondary end point was in-stent neointimal volume by IVUS. RESULTS: Baseline glucose level and glycosylated hemoglobin (HbA1c) level were similar between the pioglitazone group and the control group. Angiographical restenosis rate was 17% in the pioglitazone group and 35% in control group (p = 0.06). The TLR was significantly lower in pioglitazone group than in control group (12.5% vs. 29.8%, p = 0.04). By IVUS (n = 56), in-stent neointimal volume at 6 months showed a trend toward smaller in the pioglitazone group than in the control group (48.0 +/- 30.2 mm(3) vs. 62.7 +/- 29.0 mm(3), p = 0.07). Neointimal index (neointimal volume/stent volume x 100) was significantly smaller in the pioglitazone group than in the control group (31.1 +/- 14.3% vs. 40.5 +/- 12.9%, p = 0.01). CONCLUSIONS: Pioglitazone treatment might suppress in-stent neointimal proliferation and reduce incidence of TLR after PCI in patients with T2DM.

Detection of severe stenosis and total occlusion in the left anterior descending coronary artery with transthoracic Doppler echocardiography in the emergency room.

BACKGROUND: The noninvasive measurement of coronary flow velocity in the left anterior descending artery (LAD) has recently been realized by using the transthoracic Doppler echocardiography (TTDE). A couple of investigations demonstrated that the diastolic-to-systolic peak velocity ratio (DSVR) by TTDE is a simple and noninvasive method for the detection of severe stenosis in the elective settings. However, the usefulness of DSVR by TTDE in the emergency settings has not been evaluated. OBJECTIVE: The purpose of this study was to assess the clinical feasibility to document the LAD flow by TTDE in emergency patients who complained of chest pain. METHODS: We studied 49 consecutive patients with acute coronary syndrome who were going to undergo emergency coronary angiography (CAG) for the anatomical diagnosis and the facilitated percutaneous coronary intervention (PCI). Prior to CAG, we recorded the LAD flow by TTDE and measured the diastolic peak velocity (DVp), systolic peak velocity (SVp), and their ratio, DSVR (DVp/SVp) of LAD flow. RESULTS: By CAG, the culprit lesions actually resided in the proximal LAD in 36 patients. Among the 36 patients, we detected the Doppler LAD flow in 29. Five out of 7 patients who were unable to detect the LAD flow revealed total occlusions by CAG. DSVR of the LAD is significantly lower in 17 patients who showed severe stenoses (>90%) than those in the rest of 12 patients who did not show such critical stenoses (1.44 +/- 0.16 vs 2.10 +/- 0.26, P < 0.0001). CONCLUSION: In the emergency settings, a noninvasive assessment of the LAD flow by TTDE accurately estimates the critical stenotic lesions of the LAD.

The relationship between coronary plaque characteristics and small embolic particles during coronary stent implantation.

OBJECTIVES: We investigated the relationship between coronary plaque components and small embolic particles during stenting and examined the influence on the coronary microcirculation. BACKGROUND: In vivo tissue characterization of atherosclerotic plaques was introduced by the Virtual Histology intravascular ultrasound (VH-IVUS) system (Volcano Therapeutics, Inc., Rancho Cordova, California). METHODS: The study consisted of 44 patients who underwent elective coronary stenting. Plaque characteristics were identified with VH-IVUS, and small embolic particles liberated during stenting were detected as high-intensity transient signals (HITS) with a Doppler guidewire. Coronary flow velocity reserve (CFVR) was also measured before and after stenting. RESULTS: Patients were divided into the tertiles according to the HITS counts: the lowest, HITS <5 (n = 16); the middle, 5 to 12 (n = 15); and the highest, >12 (n = 13). Dense calcium and necrotic core area identified with VH-IVUS were significantly larger in the highest tertile (lowest vs. middle vs. highest; dense calcium: 0.2 +/- 0.3 mm2 vs. 0.3 +/- 0.6 mm2 vs. 0.8 +/- 0.7 mm2, p = 0.007; necrotic core: 0.5 +/- 0.4 mm2 vs. 0.9 +/- 0.9 mm2 vs. 1.8 +/- 1.0 mm2, p < 0.001, respectively). Multivariate logistic regression analysis revealed only necrotic core area was an independent predictor of high HITS counts (odds ratio 4.41, p = 0.045). Furthermore, there was a significant negative correlation between the HITS count and CFVR after stenting (r = -0.35, p = 0.017). CONCLUSIONS: The necrotic core component identified with VH-IVUS is related to liberation of small embolic particles during coronary stenting, which results in the poorer recovery of CFVR.

Transthoracic Doppler echocardiographic assessment of left anterior descending coronary artery and intramyocardial artery predicts left ventricular remodeling and wall-motion recovery after acute myocardial infarction.

BACKGROUND: Previous studies reported that a coronary flow velocity (FV) pattern with a rapid diastolic deceleration time (DDT) immediately after percutaneous coronary intervention implies advanced microvascular damage in patients who have experienced an acute myocardial infarction (AMI). METHODS: Using transthoracic echocardiography, we recorded the coronary FV in the left anterior descending coronary artery (LAD) and the FV in the intramyocardial artery 2 days after successful percutaneous coronary intervention in 24 patients who had experienced an anterior AMI. We measured the DDT of the LAD and the intramyocardial artery. DDT of the LAD and the intramyocardial artery was detected in the anteroseptal lesion, the wall motion of which revealed severe hypokinesis or akinesis. We performed echocardiography during both the acute phase and 6 months after the AMI. RESULTS: Patients were divided into two groups (group A: DDT of the LAD < or = 600 milliseconds [n = 10], group B: DDT of the LAD > or = 600 milliseconds [n = 14]). DDT of the LAD and the intramyocardial artery was significantly shorter for group A than group B (373 +/- 223 vs 786 +/- 105 milliseconds, P < .0001). In the acute phase, there were no significant differences in left ventricular (LV) wall-motion score index (WMSI), LV end-diastolic volume (EDV), or ejection fraction (WMSI: 2.38 +/- 0.24 vs 2.08 +/- 0.58, P = .20; LV EDV: 160 +/- 41 vs 154 +/- 34 mL; ejection fraction: 45 +/- 11 vs 46 +/- 5%). However, WMSI and LV EDV in group A were significantly greater than in group B (WMSI: 2.47 +/- 0.16 vs 1.84 +/- 0.57, P = .01; LV EDV: 198 +/- 28 vs 132 +/- 37 mL, P = .0004) and the ejection fraction in group A was significantly lower than in group B (38 +/- 9 vs 55 +/- 10%, P = .001) during the chronic phase. CONCLUSIONS: In patients who had experienced an anterior AMI, we could predict wall-motion recovery of the infarcted area by using the coronary FV of the LAD and FV of the intramyocardial artery.