Impact of Scoring Balloon Angioplasty on Lesion Preparation for DCB Treatment of Coronary Lesions.

OBJECTIVE: The aim of this study was to evaluate the efficacy of scoring balloon angioplasty for drug-coated balloon (DCB) treatment in percutaneous coronary intervention. BACKGROUND: The scoring balloon angioplasty may play a pivotal role in enhancing the outcomes of DCB treatment. METHODS: A total of 259 patients (278 lesions) with coronary artery disease successfully treated with DCB were retrospectively enrolled. The mean age of the patients was 62.2 ± 11.1 years, and the majority of patients were men (68.7%). The study's endpoint was defined as achieving an optimal angiographic result, which consisted of Thrombolysis in Myocardial Infarction (TIMI) flow grade 3, residual diameter stenosis ≤ 30%, and dissection less than type C after the procedure. RESULTS: Angioplasty was performed for 61 lesions with a scoring balloon and 217 lesions with a non-scoring balloon. All lesions were TIMI flow grade 3 except two lesions in the non-scoring balloon group. The scoring balloon group had a higher prevalence of residual diameter stenosis ≤ 30% (68.9% vs. 39.6%, p < 0.001), while severe dissection, defined as type C or greater, was observed less frequently (9.8% vs. 31.8%, p = 0.001). Moreover, the scoring balloon group achieved a superior rate of optimal angiographic results (60.7% vs. 28.6%, p < 0.001). In multivariable analysis, scoring balloon (OR: 3.08 [95% confidence interval, 1.47-6.58], p = 0.003) and DCB balloon-to-artery ratios (OR: 5.46 [95% confidence interval, 1.43-21.93], p = 0.014) were independent factors in the increasing rate of optimal angiographic result. CONCLUSIONS: The application of a scoring balloon catheter for lesion preparation, aiming to make them suitable for DCB treatment, was associated with a decreased risk of severe dissection and a greater occurrence of optimal angiographic outcomes compared with non-scoring balloon angioplasty.

Drug-coated balloon-based versus drug-eluting stent-only revascularization in patients with diabetes and multivessel coronary artery disease.

BACKGROUND: Data on drug-coated balloon (DCB) treatment in the context of diabetes mellitus (DM) and multivessel coronary artery disease (CAD) are limited. We aimed to investigate the clinical impact of DCB-based revascularization on percutaneous coronary intervention (PCI) in patients with DM and multivessel CAD. METHODS: A total of 254 patients with multivessel disease (104 patients with DM) successfully treated with DCB alone or combined with drug-eluting stent (DES) were retrospectively enrolled (DCB-based group) and compared with 254 propensity-matched patients treated with second-generation DES from the PTRG-DES registry (n = 13,160 patients) (DES-only group). Major adverse cardiovascular events (MACE) comprised cardiac death, myocardial infarction, stroke, stent or target lesion thrombosis, target vessel revascularization, and major bleeding at 2 years. RESULTS: The DCB-based group was associated with a reduced risk of MACE in patients with DM (hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.05-0.68, p = 0.003], but not in those without DM (HR 0.52, 95% CI 0.20-1.38, p = 0.167) at the 2-year follow-up. In patients with DM, the risk of cardiac death was lower in the DCB-based group than the DES-only group, but not in those without DM. In both patients with or without DM, the burdens of DES and small DES (less than 2.5 mm) used were lower in the DCB-based group than in the DES-only group. CONCLUSIONS: In multivessel CAD, the clinical benefit of a DCB-based revascularization strategy appears to be more evident in patients with DM than in those without DM after 2 years of follow-up. (Impact of Drug-Coated Balloon Treatment in De Novo Coronary Lesion; NCT04619277).

Clinical Impact of Drug-Coated Balloon-Based Percutaneous Coronary Intervention in Patients With Multivessel Coronary Artery Disease.

BACKGROUND: Data on drug-coated balloon (DCB) treatment in the context of multivessel coronary artery disease (CAD) are limited. OBJECTIVES: The purpose of this study was to investigate the impact of DCB-based treatment on percutaneous coronary intervention for multivessel CAD. METHODS: A total of 254 patients with multivessel disease successfully treated with DCBs or in combination with drug-eluting stents (DES) were retrospectively enrolled (DCB-based group) and compared with 254 propensity-matched patients treated with second-generation DES from the PTRG-DES (Platelet Function and Genotype-Related Long-Term Prognosis in Drug-Eluting Stent-Treated Patients With Coronary Artery Disease) registry (n = 13,160) (DES-only group). Major adverse cardiovascular events (MACE) comprised cardiac death, myocardial infarction, stroke, stent thrombosis, target vessel revascularization, and major bleeding at 2 years. RESULTS: Baseline clinical characteristics were comparable between the groups. In the DCB-based group, 34.3% of patients were treated with DCBs only and 65.7% were treated with the DES hybrid approach. The number of stents and total stent length were significantly reduced by 65.4% and 63.7%, respectively, in the DCB-based group compared with the DES-only group. Moreover, the DCB-based group had a lower rate of MACE than the DES-only group (3.9% and 11.0%; P = 0.002) at 2-year follow-up. The DES-only group had a higher risk for cardiac death and major bleeding. CONCLUSIONS: The DCB-based treatment approach showed a significantly reduced stent burden for multivessel percutaneous coronary intervention and led to a lower rate of MACE than the DES-only treatment. This study shows that DCB-based treatment approach safely reduces stent burden in multivessel CAD, and improved long-term outcomes may be expected by reducing stent-related events. (Impact of Drug-Coated Balloon Treatment in De Novo Coronary Lesion; NCT04619277).

Sex-Related Outcomes of Successful Drug-Coated Balloon Treatment in De Novo Coronary Artery Disease.

PURPOSE: Although drug-coated balloon (DCB) treatment is known to be effective for de novo lesions, the influence of sex on angiographic and clinical outcomes remains unknown. This study aimed to investigate the angiographic and clinical impact of DCB treatment in patients with de novo coronary lesions according to sex. MATERIALS AND METHODS: A total of 227 patients successfully treated with DCB were retrospectively enrolled and divided into two groups according to sex. The primary endpoint was late lumen loss (LLL) at 6-month angiography, and the secondary endpoint was target vessel failure (TVF), which included cardiac death, target vessel myocardial infarction, target lesion revascularization, and target vessel thrombosis. RESULTS: The study enrolled 60 women (26.4%) and 167 men (73.6%). Compared to men, women had a smaller vessel size, larger DCB to reference vessel ratio, and more dissections after DCB treatment (55.0% vs. 37.1%, p=0.016). Women also had a significantly higher LLL compared to men (0.12±0.26 mm vs. 0.02±0.22 mm, p=0.012) at the 6-month follow-up angiography. During a median follow-up of 3.4 years (range 12.7-28.9 months), TVF was similar (women 6.7% vs. men 7.8%, p=0.944). In multivariable analysis, women were independently associated with a higher LLL. CONCLUSION: LLL was higher in women, but there was no difference in TVF between women and men. Based on multivariable analysis, the women sex was an independent predictor of higher LLL (Impact of Drug-coated Balloon Treatment in de Novo Coronary Lesion; NCT04619277).

Impact of Dissection after Drug-Coated Balloon Treatment of De Novo Coronary Lesions: Angiographic and Clinical Outcomes.

PURPOSE: Dissection after plain balloon angioplasty is required to achieve adequate luminal area; however, it is associated with a high risk of vascular events. This study aimed to examine the relationship between non-flow limiting coronary dissections and subsequent lumen loss and long-term clinical outcomes following successful drug-coated balloon (DCB) treatment of de novo coronary lesions. MATERIALS AND METHODS: A total of 227 patients with good distal flow (Thrombolysis in Myocardial Infarction flow grade 3) following DCB treatment were retrospectively enrolled and stratified according to the presence or absence of a non-flow limiting dissection. The primary endpoint was late lumen loss (LLL) at 6-month angiography, and the secondary endpoint was target vessel failure (TVF, a composite of cardiac death, target vessel myocardial infarction, target vessel revascularization, and target vessel thrombosis). RESULTS: The cohort consisted of 95 patients with and 132 patients without a dissection. There were no between-group differences in LLL (90.8%) returning for angiography at 6 months (0.05±0.19 mm in non-dissection and 0.05±0.30 mm in dissection group, p=0.886) or in TVF (6.8% in non-dissection and 8.4% in dissection group, p=0.799) at a median follow-up of 3.4 years. In a multivariate analysis, the presence of dissection and its severity were not associated with LLL or TVF. Almost dissections (93.9%) were completely healed, and there was no newly developed dissection at 6-month angiography. CONCLUSION: The presence of a dissection following successful DCB treatment of a de novo coronary lesion may not be associated with an increased risk of LLL or TVF (Impact of Drug-coated Balloon Treatment in de Novo Coronary Lesion; NCT04619277).

Vasoconstrictor component of atherothrombotic culprit lesions in ST-segment elevation myocardial infarction.

OBJECTIVE: The vasoconstrictor component of atherothrombotic culprit lesions in ST-elevation myocardial infarction (STEMI) patients has not been fully investigated. This study was aimed at assessing the vasoconstrictor component of atherothrombotic culprit lesions in patients with STEMI receiving primary percutaneous coronary intervention (PCI). METHODS: A group of 100 patients with STEMI were enrolled prospectively. Baseline coronary angiography achieving normal antegrade flow was followed by 200 µg of intracoronary nitroglycerin (NTG) injection and repeat coronary angiography at the same projection view for culprit lesions was performed. End points were the changes in lesion length, reference vessel diameter, minimal lumen diameter, and diameter stenosis by quantitative coronary analysis before and after NTG injection. RESULTS: Reference vessel diameter (2.7 ±â€¯0.5 mm vs. 2.9 ±â€¯0.5 mm, p < 0.001) and minimal lumen diameter (0.9 ±â€¯0.4 mm vs. 1.2 ±â€¯0.5 mm, p < 0.001) increased after NTG injection, whereas lesion length (24.1 ±â€¯7.4 mm vs. 23.4 ±â€¯7.6 mm, p = 0.001) and diameter stenosis (66.6 ±â€¯14.8% vs. 58.3 ±â€¯16.1%, p < 0.001) decreased. The median percentage change of diameter stenosis was -4.0% (Interquartile range: -13.8% to -1.0%), which was used as the cut-off value to divide the cohort into NTG responder or nonresponder groups accordingly. Total stent length was significantly shorter in the responder group compared with the nonresponder group (27.4 ±â€¯11.6 mm vs. 33.7 ±â€¯16.8 mm, p = 0.042). CONCLUSION: This study showed the presence of a vasoconstrictor component in atherothrombotic culprit lesions in STEMI patients receiving primary PCI. Vasodilating effort by NTG may decrease stent length used for culprit lesions.

The potential utility of iodinated contrast media (ICM) skin testing in patients with ICM hypersensitivity.

Both immediate and delayed hypersensitivity reactions to iodinated contrast media (ICM) are relatively common. However, there are few data to determine the clinical utility of immunologic evaluation of ICM. To evaluate the utility of ICM skin testing in patients with ICM hypersensitivity, 23 patients (17 immediate and 6 delayed reactions) were enrolled from 3 university hospitals in Korea. With 6 commonly used ICM including iopromide, iohexol, ioversol, iomeprol, iopamidol and iodixanol, skin prick (SPT), intradermal (IDT) and patch tests were performed. Of 10 patients with anaphylaxis, 3 (30.0%) and 6 (60.0%) were positive respectively on SPTs and IDTs with the culprit ICM. Three of 6 patients with urticaria showed positive IDTs. In total, 11 (64.7%) had positive on either SPT or IDT. Three of 6 patients with delayed rashes had positive response to patch test and/or delayed IDT. Among 5 patients (3 anaphylaxis, 1 urticaria and 1 delayed rash) taken subsequent radiological examinations, 3 patients administered safe alternatives according to the results of skin testing had no adverse reaction. However, anaphylaxis developed in the other 2 patients administered the culprit ICM again. With 64.7% (11/17) and 50% (3/6) of the sensitivities of corresponding allergic skin tests with culprit ICM for immediate and delayed hypersensitivity reactions, the present study suggests that skin tests is useful for the diagnosis of ICM hypersensitivity and for selecting safe ICM and preventing a recurrence of anaphylaxis caused by the same ICM.

Hypoadiponectinemia in patients with paroxysmal atrial fibrillation.

BACKGROUND AND OBJECTIVES: Adiponectin is an adipose tissue-derived hormone that has beneficial effects on cardiac function and has been reported to be associated with lipid metabolism, glucose metabolism, and insulin resistance. Serum levels of adiponectin are reduced in obese individuals compared with non-obese individuals. Obesity is associated with an increased incidence of atrial fibrillation (AF); however, the role of adiponectin in AF is unclear. The aim of this study is to evaluate the relationship between the plasma adiponectin level and AF. SUBJECTS AND METHODS: Sixty-one consecutive patients were prospectively enrolled for this study. Subjects were divided into two groups: patients with AF (n=30) and controls (n=31). Laboratory evaluation, including levels of plasma adiponectin, was performed and echocardiographic parameters were measured. RESULTS: The baseline characteristics were not different between the two groups. The plasma adiponectin level of patients in the AF group was significantly lower than in the control group (14.9±7.2 vs. 19.±8.9 µg/mL, p<0.05). In addition, when we divided the AF patients into paroxysmal and chronic AF, the plasma adiponectin level was significantly lower in patients with paroxysmal AF, compared with the control group. In multiple binary logistic regression analysis to evaluate the independent predictors for AF, adiponectin and left atrial diameter were strong independent predictors of AF. CONCLUSION: In this study a lower plasma adiponectin concentration was significantly associated with that of paroxysmal AF. Hypoadiponectinemia can potentially be an important risk factor for AF.

Impact of arterial stiffness on regional myocardial function assessed by speckle tracking echocardiography in patients with hypertension.

BACKGROUND: Arterial stiffening may affect regional myocardial function in hypertensive patients with normal ejection fraction (EF). METHODS: Brachial-ankle pulse wave velocity (PWV) was measured in 70 patients, of mean age 48 ± 14 years, with untreated hypertension and EF > 55%. Using two-dimensional-speckle tracking echocardiography, we measured longitudinal and circumferential strain (ε) and strain rate (SR). Basal and apical rotations were measured using short axis views. RESULTS: The mean systolic and diastolic blood pressure in these patients was 152 ± 15 mmHg and 92 ± 11 mmHg, respectively. The mean value of PWV was 1578 ± 274 cm/s. PWV significantly correlated with age (r = 0.682, p < 0.001), body mass index (r = -0.330, p = 0.005), systolic blood pressure (r = 0.386, p = 0.001) and pulse pressure (r = 0.509, p < 0.001). PWV also significantly correlated with septal E' velocity (r = -0.570, p < 0.001), E/A ratio (r = -0.414, p < 0.001), E/E' ratio (r = 0.589, p < 0.001), systolic global longitudinal ε (r = 0.300, p = 0.012) and early diastolic SR (SR(E)) (r = -0.479, p < 0.001) suggesting impaired abnormal relaxation. PWV was also correlated with basal rotation (r = -0.301, p = 0.011) and basal-to-apical twist (r = -0.256, p = 0.032). The increases in apical rotation and basal-to-apical twist were attenuated in patients with PWV > 1700 cm/s compared to those with PWV ≤ 1400 cm/s or those with PWV 1400-1700 cm/s. CONCLUSION: In hypertensive patients with normal ejection fraction, arterial stiffening contributes to impaired systolic and diastolic function of the regional myocardium. Compensatory increases in ventricular twist were diminished in patients with advanced stage of vascular stiffening.

Correlation of right atrial appendage velocity with left atrial appendage velocity and brain natriuretic Peptide.

BACKGROUND: Left atrial appendage (LAA) anatomy and function have been well characterized both in healthy and diseased people, whereas relatively little attention has been focused on the right atrial appendage (RAA). We sought to evaluate RAA flow velocity and to compare these parameters with LAA indices and with a study of biomarkers, such as brain natriuretic peptide, among patients with sinus rhythm (SR) and atrial fibrillation (AF). METHODS: In a series of 79 consecutive patients referred for transesophageal echocardiography, 43 patients (23 with AF and 20 controls) were evaluated. RESULTS: AF was associated with a decrease in flow velocity for both LAA and RAA [LAA velocity-SR vs. AF: 61 ± 22 vs. 29 ± 18 m/sec (p < 0.01), RAA velocity-SR vs. AF: 46 ± 20 vs. 19 ± 8 m/sec (p < 0.01)]. Based on simple linear regression analysis, LAA velocity and RAA velocity were positively correlated, and RAA velocity was inversely correlated with brain natriuretic peptide (BNP). CONCLUSION: AF was associated with decreased RAA and LAA flow velocities. RAA velocity was found to be positively correlated with LAA velocity and negatively correlated with BNP. The plasma BNP concentration may serve as a determinant of LAA and RAA functions.

Impact of right ventricular apical pacing and its frequency on left atrial function.

BACKGROUND: Right ventricular apical (RVA) pacing induces left ventricular (LV) dyssynchrony, increases the risk of persistent atrial fibrillation in the long term. The aim was to investigate the effects of RVA pacing on left atrial (LA) function, which are unknown. METHODS: Echocardiographic evaluation including LV dyssynchrony based on conventional Doppler, tissue Doppler imaging and speckle tracking strain echocardiography was done before and after (12 months) single-chamber ventricular pacemaker implantation in 40 patients with sick sinus syndrome. Patients were divided to 2 groups, according to the RVA pacing frequency (group I had higher pacing rate of more than 50% and group II, less than 50%). RESULTS: There was no significant difference in LV ejection fraction, however, mean global LV strain, myocardial performance index, and parameters of LV dyssynchrony had shown significant changes after 12 months of RVA pacing. There were also significant increase in the LA volume index and the reduction of peak systolic LA strain and strain rate (SR), peak early and late diastolic SR after RVA pacing. Moreover, there was significant deterioration of LV dyssynchrony and both LA and LV longitudinal function in even group II. LA functional deterioration and LA volume was significantly correlated with the frequency of RVA pacing. CONCLUSION: LV dyssynchrony, induced by RVA pacing, significantly impaired active LA contraction and passive stretching, and these findings were shown in the patients with even less than 50% of RVA pacing. Impairment of LA strain/SR was significantly correlated with the frequency of RVA pacing.

A case of a right atrial and inferior vena caval thrombus resembling a right atrial myxoma.

A right atrial and inferior vena caval thrombus in a structurally normal heart is a very rare condition. We report a case of such a thrombus in a 66-year-old woman. She was admitted to our hospital with recent onset dyspnea. Based on echocardiography, we suspected that she had myxoma. We performed an excision of a mass, which was found, by pathologic examination, to be an organized mural thrombus.

Impact of changes in myocardial velocity assessed by tissue Doppler imaging during exercise on dynamic mitral regurgitation in patients with nonischemic cardiomyopathy.

BACKGROUND: We evaluated the myocardial contractile reserve related to exercise-induced changes in functional mitral regurgitation (MR) by tissue Doppler imaging (TDI). METHODS: Supine bicycle exercise was performed in 35 patients with nonischemic cardiomyopathy (age 51 +/- 12 years; EF < 40%) and resting, and peak exercise 2D echocardiographic parameters, and TDI data were obtained. V(avg) was defined as the average of peak systolic velocities of six basal LV segments by TDI. Myocardial contractile reserve, which was calculated by [peak exercise V(avg)- baseline V(avg)], was represented as DeltaV(avg). Dyssynchrony index was derived from the standard deviation of the time to the peak systolic velocity of 12 LV segments. RESULTS: During exercise (9.7 +/- 2.4 minutes), the mean V(avg) increased from 4.0 +/- 0.8 cm/s to 5.5 +/- 1.0 cm/s. The effective regurgitant orifice area (ERO) and the ratio of MR jet area to the left atrial area (JLA%) were 1.9 +/- 2.9 mm(2) and 12 +/- 12%, respectively. During exercise, ERO and JLA% significantly increased to 6.2 +/- 6.4 mm(2) and 21 +/- 13% (P < 0.05), respectively, with individually variable changes. Tenting area was found to be an independent factor that showed a relationship with the baseline severity of MR (r = 0.561, P < 0.001). Dyssynchrony index and DeltaV(avg) were found to correlate with both maximal MR severity at peak exercise and changes in MR during exercise. By multivariate analysis, DeltaV(avg) was found to be an independent determinant of exercise-induced changes in ERO (DeltaERO; r =-0.707, P< 0.001) and changes in JLA% (DeltaJLA%; r =-0.663, P< 0.001). CONCLUSION: In patients with nonischemic cardiomyopathy, impaired contractile reserve assessed by TDI velocity data may be an independent determinant affecting exercise-induced changes in dynamic MR.

Assessment of intraventricular systolic asynchrony in patients with atrial fibrillation using triplane tissue Doppler imaging.

BACKGROUND: Triplane tissue Doppler imaging (TDI) makes it possible to simultaneously obtain three apical view images and to measure the dyssynchrony index (DS) for 12 segments in patients with atrial fibrillation (AF). We evaluated the feasibility of using triplane TDI to assess intraventricular asynchrony in AF. METHODS: In 50 patients with AF, triplane TDI was used for the analysis of myocardial velocity curves of 12 (six basal and six mid) left ventricular (LV) segments by apical two-, three-, and four-chamber views. Time to peak systolic velocity (Ts) was measured, and DS was calculated as the standard deviation (SD) of Ts over 12 segments. The DS(avg) was defined as the average of DS of eight consecutive cycles. To assess the cyclic variability of DS, the coefficient of variation of DS (CoV(DS)) was calculated as the SD of DS for eight cycles divided by DS(avg) [SD(DS)/DS(avg)]. CoV(RR), representing the variability of RR intervals, was defined as [SD(RR)/RR(avg)]. Patients with a left ventricular ejection fraction (LVEF) of 45% or more were classified as group A, and patients with an LVEF less than 45% as were classified as group B. RESULTS: The mean LVEF was 47% +/- 12%. Group B showed larger LV volume and lower sphericity index compared with group A. Intraobserver and interobserver variability of DS(avg) were 6% and 9%, respectively. More severe dyssynchrony was observed in group B (DS(avg); 23.5 +/- 8.5 ms in group B vs. 17.7 +/- 6.1 ms in group A, P = .008). DS(avg) was not related to RR(avg) or CoV(RR). DS(avg) negatively correlated with ejection fraction (r = -0.404, P = .004) and sphericity index (r = -0.317, P = .025) and showed positive correlation with LV volume. CONCLUSION: Analysis of asynchrony by triplane TDI was feasible in patients with AF. DS(avg) correlated with echocardiographic parameters of systolic function.

Fate of collateral circulation after successful coronary angioplasty of total occlusion assessed by coronary angiography and myocardial contrast echocardiography.

A well-developed collateral circulation is frequently observed in patients with total coronary occlusion. However, the fate of the collateral circulation after successful percutaneous transluminal coronary angioplasty (PTCA) has not been fully characterized. The purpose of this study was to compare the efficacy of coronary angiography and myocardial contrast echocardiography (MCE) in the evaluation of the collateral circulation after PTCA and to assess the temporal changes of the collateral circulation after successful PTCA of a totally occluded artery by using these 2 diagnostic methods. The study group was comprised of 20 consecutive patients (16 male, mean age 54 years) who underwent elective PTCA for total coronary occlusion. Coronary angiography was performed before, immediately after, and 24 hours after PTCA. MCE was also performed before, immediately after, and 24 hours after PTCA, by the intracoronary injection of sonicated radiographic contrast medium. According to the angiographic findings, the collateral circulation was graded on a scale of 0 to 3 as follows: 0 = no visible filling; 1 = collateral filling of side branches; 2 = partial collateral filling of the epicardial artery; 3 = complete filling of the epicardial artery. By MCE, myocardial perfusion by the collateral circulation was assessed by scoring the contrast pattern of collateral-dependent myocardial segments as follows: 0 = none; 0.5 = patchy or epicardial; 1 = homogeneous. The left anterior descending artery was occluded in 12 patients and the right coronary artery in 8 patients. Coronary angiographic collateral grades before PTCA were grade 2 in 5 patients and grade 3 in 15. PTCA with stenting was successfully performed in all patients without significant residual stenosis. Coronary angiography showed collateral circulation disappeared after PTCA in all patients. However, residual collateral perfusion was observed in 7 patients by MCE, performed immediately after PTCA (score 1 in 3 patients; score 0.5 in 4 patients). This residual collateral perfusion could be demonstrated even 24 hours after PTCA by MCE in 3 patients (all patients were 0.5 in myocardial perfusion score). In conclusion, successful PTCA with stenting of a totally occluded coronary artery leads to a disappearance of collateral vessels by coronary angiography in most of the patients. However, although angiographically not visible, coronary collateral circulation may persist even 24 hours after successful PTCA of a totally occluded artery demonstrated by MCE.