Differential Pacing Maneuver From the Vein of Marshall.

BACKGROUND: Bidirectional mitral isthmus (MI) block is conventionally verified by differential pacing from the coronary sinus (CS) and its sequence change. This study aimed to evaluate the ability of differential pacing from the vein of Marshall (VOM) to detect epicardial MI connections. METHODS: Radiofrequency and VOM ethanol MI ablation were performed with a VOM electrode catheter inserted to the septal side of the ablation line. MI block was verified using conventional CS pacing. To perform differential VOM pacing analysis, initial pacing was delivered from a distal VOM bipole closer to the block line, and then from a proximal VOM bipole. The intervals from pacing stimulus during different VOM pacing sites to the electrogram recorded through the CS catheter on the opposite side of the line were compared. When the interval during distal VOM pacing was longer than that during proximal VOM pacing, it indicated a VOM connection block; however, if the former interval was shorter, the connection through the VOM was considered persistent. RESULTS: Overall, 50 patients were evaluated. According to CS pacing, MI ablation was incomplete in 9 patients, in whom the analysis indicated persistent VOM connection. Among 41 patients with complete MI block, confirmed by CS finding, in 30 (73%) patients, the interval during distal VOM pacing was longer than that during proximal VOM pacing by 11±5 ms. However, in 11 patients (27%) the former interval was revealed to be shorter than the latter by 16±8 ms, indicating residual VOM connection. Conduction time across the line was significantly shorter in 11 patients than in the other 30 (166±21 versus 197±36 ms; P<0.01). Ten successful reevaluated analyses after VOM ethanol and further radiofrequency ablation of the connection indicated VOM block achievement. CONCLUSIONS: Differential VOM pacing maneuver reflects the VOM conduction status. This maneuver can uncover residual epicardial connections that are missing with CS pacing.

Impact of the downstream myocardial mass on values of coronary microvascular resistance.

The assessment of hyperemic microvascular resistance (HMR) may be dependent on the assessment location in the coronary artery and the amount of partial myocardial mass (PMM) distal to the assessment locations. The aim of this study was to investigate the differences in HMR values between the distal and proximal sites in the same coronary arteries as well as the relationship between HMR and PMM. Twenty-nine vessels from 26 patients who had undergone intracoronary physiological assessments including Doppler flow velocity at the distal third part and the proximal third part in the same vessels were assessed. The mean values of HMR and PMM at the distal sites were 2.08 ± 0.75 mmHg/cm/sec and 22.2 ± 10.4 g, respectively. At the proximal sites, the values of HMR and PMM were 1.19 ± 0.33 mmHg/cm/sec and 59.9 ± 18.3 g, respectively. All HMR values at the distal sites were significantly higher than those at the proximal sites (p < 0.001). Smaller PMM at the distal sites was significantly associated with higher HMR (r = -0.544, p = 0.002) and was the strongest factor affecting the HMR values (p = 0.009), while this relationship was not observed at the proximal sites (r = -0.262, p = 0.17). The impact of PMM on HMR was diminished at assessment locations where PMM was greater than 35 g. In conclusion, a small amount of downstream myocardial mass could be related to high HMR values. The assessment location around the proximal coronary artery with over 35 g of myocardium would be appropriate to assess HMR because it minimizes the influence of the assessment location.

High-sensitivity cardiac troponin serving as a useful marker for the early recognition of relapse of isolated cardiac sarcoidosis: a case report.

Background: Isolated cardiac sarcoidosis is a relatively rare disease that is difficult to manage because of challenges in determining the progression and flare-up of cardiac lesions. Routine reduction of glucocorticoid doses may lead to treatment failure and disease relapse, which are associated with increased mortality. Case summary: Herein, we present the case of a 49-year-old woman with isolated cardiac sarcoidosis in whom high-sensitivity cardiac troponin served as a biomarker for tailoring immunosuppressive therapy. She presented with progressive dyspnoea on exertion for 2 months and had elevated levels of high-sensitivity cardiac troponin I (hs-cTnI) at presentation. A diagnosis of isolated cardiac sarcoidosis was made based on the finding of electrocardiography, echocardiography, cardiac magnetic resonance imaging, and 18F-fluorodeoxyglucose (FDG) positron emission tomography. After the introduction of glucocorticoids, the hs-cTnI concentration immediately decreased, followed by the disappearance of FDG uptake in the heart. However, 2 months after oral prednisolone was reduced to the maintenance dose, the hs-cTnI concentration began to increase gradually, and 2 months later, worsening heart failure, progression of impaired left ventricular function, and de novo accumulation of FDG in the heart were observed, confirming the relapse of cardiac sarcoidosis. Intensified glucocorticoid therapy resulted in another immediate decrease in hs-cTnI concentration and improved heart failure management. Discussion: This case highlights the potential of hs-cTnI to serve as a serum biomarker for monitoring disease activity and response to immunosuppressive therapy in patients with cardiac sarcoidosis. The hs-cTnI could be a highly sensitive and cost-effective biomarker reflecting the inflammatory status of cardiac sarcoidosis.

Effect of radiofrequency and ethanol ablation on epicardial conduction through the vein of Marshall: How to detect and manage epicardial connection across the mitral isthmus.

BACKGROUND: The vein of Marshall (VOM), which is surrounded by the Marshall bundle (MB), behaves as an epicardial connection bypassing the mitral isthmus. The influence of radiofrequency ablation and VOM ethanol infusion (VOM-EI) on epicardial MB conduction remains unclear. OBJECTIVE: The purpose of this study was to evaluate MB conduction status during mitral isthmus ablation. METHODS: Of 57 consecutive patients undergoing mitral isthmus ablation, 50 with electrode catheter cannulation into the VOM were analyzed. MB conduction was investigated by evaluating electrograms inside the VOM. Endocardial ablation was initially performed, followed by ablation inside the coronary sinus (CS), if required. Selective VOM-EI was performed if the MB potentials still exhibited early activation after radiofrequency ablation, suggesting the presence of MB connection bridging the mitral isthmus. RESULTS: VOM electrograms composed of near-field MB and far-field left atrial potentials were recorded in all patients. Solely with endocardial ablation, 33 patients (66%) achieved entire mitral isthmus block, and 43 patients (86%) achieved an epicardial MB conduction block. MB potentials exhibited early activation in the remaining 7 (14%), even after requiring CS ablation. VOM-EI then was performed. Elimination of MB potentials was verified by electrode catheter reinsertion after VOM-EI. Mitral isthmus conduction was successfully blocked during VOM-EI in 4 patients and during additional radiofrequency ablation in the remaining 3. All patients finally achieved entire mitral isthmus block. CONCLUSION: MB is effectively ablated by radiofrequency ablation. Continuous evaluation of MB conduction can reveal epicardial conduction and ablation effect. A residual MB epicardial connection is relatively rare but can be ablated by VOM-EI.

Impact of Hemodialysis Duration on Coronary Artery Calcification Among Hemodialysis Patients Who Underwent Percutaneous Coronary Intervention.

Our study aimed to evaluate the prevalence and impact of coronary artery calcification (CAC) on hemodialysis (HD) patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI). We enrolled 211 HD patients who underwent PCI (men: n = 155, age: 71 ± 1 0 years). Severe CAC was defined as calcification with an arc of 360° on intravascular ultrasound. Multivariate analysis was performed to determine the predictors of severe CAC. The impact of severe CAC on target lesion revascularization (TLR) was evaluated. Patients with severe CAC (46%) had a higher incidence of diabetes mellitus (DM) (79 vs 59%, P = .003) and longer HD duration (7.7 vs 3.4 years, P < .001) than those with non-severe CAC. Multivariate analysis demonstrated that DM, HD duration, and angiographic calcification were significant predictors for severe CAC (odds ratio 4.42, 1.13, and 6.62; P < .001, P < .001, and P < .001, respectively). After the median follow-up period of 580 days (interquartile range, 302-730 days), Kaplan-Meier curve analysis revealed that severe CAC was associated with an increased risk for TLR (χ2 12.7; P = .002). In HD patients with CAD after PCI, DM and HD duration were significant predictors for severe CAC. Furthermore, severe CAC was associated with an increased risk for TLR.

Elevated Remnant Lipoprotein Related to Adverse Events in Patients with Chronic Limb-Threatening Ischemia after Endovascular Therapy for Below-the-Knee Lesions.

BACKGROUND: The prognosis of patients with chronic limb-threatening ischemia (CLTI) is unacceptably poor, and risk factors are unknown. Serum remnant lipoprotein has been associated with cardiovascular events. The aim of our study was to test the hypothesis that remnant lipoprotein is associated with the prognosis of patients with CLTI. METHODS: This retrospective study included 67 patients with CLTI who had received endovascular therapy (EVT) for de novo below-the-knee lesions. Patients were divided into 2 groups using fasting preoperative value of remnant-like particle cholesterol (RLP-C) with a cutoff value of 5.1 mg/dL into LOW RLP-C (n = 46) and HIGH RLP-C (n = 21). We assessed the differences between the 2 groups in the prevalence of major adverse limb events (MALE), composed of target lesion revascularization and major amputation. RESULTS: At a median follow-up period of 12 months, MALE had occurred in 11 LOW RLP-C patients (23.9%) and 11 HIGH RLP-C patients (52.4%; P = 0.03). Kaplan-Meier analysis showed the prevalence of MALE was significantly higher in HIGH RLP-C than LOW RLP-C (log-rank χ2 = 5.2, P = 0.02). Multivariate analysis found HIGH RLP-C to be an independent predictor for MALE (hazard ratio, 2.6; 95% confidence interval, 1.1-6.1; P = 0.02) along with history of coronary artery disease. CONCLUSIONS: Preoperative remnant lipoprotein was associated with the prognosis of patients with CLTI who had received EVT for de novo below-the-knee lesions.

Intuitive diagnosis of complex atrial tachycardia mechanisms using a novel histogram module of an ultra-high-resolution mapping system.

PURPOSE: The LUMIPOINT™ software module was developed to aid the physician in determining the mechanism of individual atrial tachycardias (ATs). The purpose of this study was to assess the clinical utility of the SKYLINE™ histogram that is a part of LUMIPOINT™. METHODS: This study included consecutive patients with iatrogenic sustained AT who underwent catheter ablation using conventional mapping (RHYTHMIA™). SKYLINE™ patterns were analyzed offline and classified into two types: (1) focal type (type-F) exhibiting a low-amplitude (relative activating surface area < 10%) plateau period and (2) reentrant type (type-R) showing no plateau period. How well the two patterns distinguished between focal and macroreentrant ATs as determined by conventional mapping was evaluated. RESULTS: We studied 101 iatrogenic ATs in 91 patients (female: 24, mean age: 67.3 ± 9.1 years). Activation mapping revealed 79 (78.2%) macroreentrant, 6 (5.9%) localized reentrant, and 16 (15.8%) focal ATs. Among the 72 type-R ATs, the mechanism was truly a macroreentry in 70 ATs. However, one focal AT and one localized reentrant AT displayed a type-R pattern (pseudo-reentry pattern). In the 29 type-F ATs, nine macroreentrant ATs were recognized (pseudo-focal pattern). Using SKYLINE™ type-R to differentiate macroreentrant AT from AT with centrifugal activation (focal or localized reentry), the sensitivity and specificity were 88.6% and 90.9%, respectively. Even when the SKYLINE™ type did not match the mapping-based AT mechanism, all discrepancies were electrophysiologically explicable using the SKYLINE™ histograms. CONCLUSIONS: SKYLINE™ histograms are a useful tool for the intuitive diagnosis of AT mechanisms.

Angiographic flow velocity predicts lower limb outcomes after endovascular therapy: Application of the frame count method.

INTRODUCTION: Several factors related to lesion characteristics and endovascular therapy (EVT) procedures have been reported to affect primary patency after EVT. However, it is unknown why these factors were associated with primary patency. We hypothesized patency failure was related to poor blood flow in affected arteries. METHODS: This retrospective study included 131 consecutive patients who had received EVT with bare metal stents for peripheral artery disease caused by femoropopliteal artery lesions. Based on the tertile post-EVT flow velocity of the superficial femoral artery (SFA), patients were divided into high (n = 43), middle (n = 44), and low (n = 44) flow velocity groups. Flow velocity was measured using the frame count method. We measured incidence of major adverse limb events (MALE), composed of target lesion revascularization (TLR), non-TLR, and major amputation. RESULTS: At a median follow-up period of 22.7 months, MALE had occurred in 7 (16.3%), 10 (22.7%), and 29 (65.9%) of patients from the high, middle, and low SFA flow velocity groups, respectively (p < 0.001). Kaplan-Meier analysis showed incidence of MALE was significantly higher in the patients of low SFA flow velocity (log-rank test χ2 = 38.8, p < 0.001). Multivariate analysis found low SFA flow velocity to be an independent predictor for MALE (hazard ratio: 4.42; 95% CI: 2.27 to 8.60; p < 0.001) as was ankle-brachial index. CONCLUSION: Post-EVT SFA flow velocity for femoropopliteal artery lesions treated with bare metal stents is an independent predictor of limb patency. The frame count method for assessing arterial flow velocity is convenient and has potential for wide applications in EVT.

Vascular Responses to First-Generation Sirolimus-Eluting Stents and Bare-Metal Stents Beyond 10 Years.

Background: There are limited data regarding differences in vascular responses between first-generation sirolimus-eluting stents (1G-SES) and bare-metal stents (BMS) >10 years after implantation. Methods and Results: We retrospectively investigated 223 stents (105 1G-SES, 118 BMS) from 131 patients examined by optical coherence tomography (OCT) >10 years after implantation. OCT analysis included determining the presence or absence of a lipid-laden neointima, calcified neointima, macrophage accumulation, malapposition, and strut coverage. Neoatherosclerosis was defined as having lipid-laden neointima. OCT findings were compared between the 1G-SES and BMS groups, and the predictors of neoatherosclerosis were determined. The median stent age at the time of OCT examinations was 12.3 years (interquartile range 11.0-13.2 years). There were no significant differences in patient characteristics between the 1G-SES and BMS groups. On OCT analysis, there was no difference in the prevalence of neoatherosclerosis and calcification between 1G-SES and BMS. Multivariable logistic regression analysis revealed that stent size, stent length, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use were significant predictors of neoatherosclerosis. In addition, uncovered and malapposed struts were more prevalent with 1G-SES than BMS. Conclusions: After >10 years since implantation, the prevalence of neoatherosclerosis was no different between 1G-SES and BMS, whereas uncovered struts and malapposition were significantly more frequent with 1G-SESs.

Risk factors and prognostic impact of post-discharge bleeding after endovascular therapy for peripheral artery disease.

This study evaluated the incidence, predictors, and impact of bleeding requiring hospitalization following successful endovascular therapy (EVT) for peripheral artery disease. Platelet inhibition after EVT reduces the risk of major adverse limb events but increases the risk of bleeding. The incidence of post-discharge bleeding after EVT, its independent predictors, and its prognostic importance in clinical practice have not been fully addressed. We evaluated 779 consecutive patients who underwent EVT. We found that 77 patients (9.9%) were hospitalized for major bleeding during follow-up after EVT (median 39 months, range 22-66 months), with almost half (48.1%) of the bleeding categorized as gastrointestinal bleeding. Significant predictors of post-discharge bleeding were hemodialysis (hazard ratio (HR), 3.12; 95% CI: 1.93 to 5.05; p < 0.001) and dual antiplatelet therapy (DAPT) use (HR, 1.87; 95% CI: 1.03 to 3.41; p = 0.041). During follow-up, the all-cause mortality-free survival rate was significantly worse in patients who had experienced major bleeding than in those who had not (log-rank test χ2 = 54.6; p < 0.001). Cox proportional hazards analysis showed that major bleeding (HR, 2.78; 95% CI: 1.90 to 4.06; p < 0.001) was an independent predictor of all-cause death after EVT. Hospitalization for post-discharge bleeding after EVT is associated with a substantially increased risk of death, even after successful EVT. We concluded that patients' predicted bleeding risk should be considered when selecting patients likely to benefit from EVT, and that the risk should be considered especially thoroughly in hemodialysis patients.

Eicosapentaenoic acid levels predict prognosis of peripheral artery disease caused by aortoiliac artery lesions.

BACKGROUND AND AIM: Eicosapentaenoic acid (EPA) has been reported to improve clinical outcome of high-risk atherosclerotic patients. We investigated whether endogenous EPA values predict prognosis of peripheral artery disease (PAD) patients. METHODS AND RESULTS: This retrospective study included 166 consecutive patients who had received endovascular therapy (EVT) for PAD caused by aortoiliac artery lesions. Patients were divided into 2 groups using median preoperative EPA value (57 µg/ml): LOW EPA (n = 83) and HIGH EPA (n = 83). We compared differences between the 2 groups in prevalence of major adverse limb events (MALE) which included target lesion revascularization (TLR), non-TLR, and major amputation, and major adverse events (MAE) which included MALE and all cause death. At a median follow-up period of 20 months, MALE had occurred in 24 LOW EPA patients (28.9%) and in 12 HIGH EPA patients (14.5%) (p = 0.04), and MAE had occurred in 41 LOW EPA patients (49.4%) and in 21 HIGH EPA patients (25.3%) (p < 0.01). Kaplan-Meier analysis showed prevalence of MALE and MAE was significantly higher in LOW EPA than in HIGH EPA (long-rank test χ2 = 8.5, p < 0.01, log-rank test χ2 = 13.2, p < 0.01, respectively). Multivariate Cox regression revealed preoperative EPA value < 57 µg/ml was an independent predictor for MALE (hazard ratio [HR]: 2.70; 95% CI: 1.35 to 5.4; p < 0.01) and MAE (HR: 2.86; 95% CI: 1.67 to 4.91; p < 0.01). CONCLUSIONS: Endogenous EPA value seems to be associated with risk of MALE and MAE after EVT in patients with PAD caused by aortoiliac artery lesions.

Clinical Outcomes after Endovascular Therapy Among Hemodialysis Patients with Peripheral Artery Disease Stratified by the Primary Kidney Disease.

OBJECTIVES: The objective of this study was to investigate the clinical characteristics of hemodialysis patients with peripheral artery disease (PAD) and the outcomes after endovascular therapy (EVT) in such patients stratified by the primary kidney disease. METHODS: This retrospective observational study evaluated 142 consecutive hemodialysis patients with symptomatic PAD who underwent EVT (men: n = 103, age: 74 ± 8 years). Patients were divided into 3 groups in accordance with the reason for hemodialysis: hypertensive nephrosclerosis (HTN [n = 26]), diabetic nephropathy (DN [n = 85]), and chronic glomerulosclerosis (CGN [n = 31]). The primary outcome was major adverse event(s) (MAEs), including target lesion revascularization, major amputation, and all-cause death. Clinical characteristics and outcomes were compared among the 3 groups. RESULTS: Patients with HTN were older (81 ± 6 years vs. 72 ± 8 years vs. 74 ± 8 years; P < 0.001) and had a shorter hemodialysis vintage (2.4 years vs. 6.8 years vs. 11.2 years; P < 0.001) than those with DN and CGN. Critical limb ischemia (CLI) affected 15 (58%) patients in the HTN group, 52 (61%) in the DN group, and 10 (32%) in the CGN group. Target lesion length was longer in patients with HTN than in those in the other groups (155 ± 101 mm vs. 108 ± 77 mm [DN] vs. 98 ± 76 mm [CGN]; P = 0.020). During a median follow-up period of 372 days (interquartile range, 198-730 days), Kaplan-Meier curve analysis revealed that HTN was associated with an increased risk for MAEs (χ2 11.6; P = 0.003). Furthermore, multivariate Cox regression analysis revealed that CLI, HTN, and B-type natriuretic peptide levels were independent predictors of MAE (hazard ratio 3.91, 2.88, and 1.00; P < 0.001, P < 0.001, and P = 0.001, respectively). CONCLUSIONS: Among hemodialysis patients with PAD, HTN was associated with an increased risk for MAEs after EVT.

Diagnosis of Acute Gastroenteritis with Immunochromatography and Effectiveness of Rotavirus Vaccine in a Japanese Clinic.

Despite the well known effectiveness of two licensed live attenuated oral rotavirus (RV)-vaccines, Rotarix and RotaTeq, constant monitoring of vaccine effectiveness (VE) is essential considering the evolving power and reassortment capability of RVs. In this study, we detected RV, norovirus (NV) and adenovirus (AV) infections using immunochromatography (IC)-based kits in children with acute gastroenteritis (AGE) who attended a pediatric clinic in Kiryu city, Gunma, Japan during June, 2014-September, 2018. VEs were determined using a test-negative study design. Among 1658 AGE-children, RV, NV and AV were detected in 96 (5.8 %), 146 (8.8 %) and 46 (2.8 %) children, respectively. Interestingly, the distributions of infections were found to be associated with age and sex. Namely, RV infections were significantly higher in female (P=0.02) and in the 19-30 month age group children, while NV and AV infections predominated in the 13-24 month and 7-18 month age groups, respectively. The disease severity for RV and NV infections remained similar and significantly higher than that of AV infections. The VE of RV-vaccines was 49.8 % (95 % CI: 22.7 to 67.3 %) against all RV infections, which was increased up to 67.2 % (95 % CI: 35.3 to 83.4 %) against severe RV infections. RV-vaccinated children experienced less severe symptoms in RV-infections while non-RV AGE remained less serious for both RV-vaccinated and unvaccinated children. Finally, the prevalence of RV infection remained minimized (≤5.4 %) in this population since 2015. Thus, this study provided important information on distribution of major AGEs in young children and exhibited the effective role of RV vaccines in post-vaccine era.

Usefulness of Lipoprotein (a) for Predicting Outcomes After Percutaneous Coronary Intervention for Stable Angina Pectoris in Patients on Hemodialysis.

Serum lipoprotein (a) level is genetically determined and remains consistent during a person's life. Previous studies have reported that people with high lipoprotein (a) level are at a high risk of cardiac events. We investigated the association between lipoprotein (a) levels and clinical outcomes after percutaneous coronary intervention (PCI) for stable angina pectoris (SAP) in hemodialysis (HD) patients. Serum lipoprotein (a) levels were measured on admission in 410 consecutive HD patients who underwent successful PCI for SAP. Patients were divided into 2 groups: low and high group having lipoprotein (a) level <40 mg/dL (n = 297) and ≧40 mg/dL (n = 113) respectively. After PCI, the incidence of major adverse cardiac event (MACE) including cardiac death, nonfatal myocardial infarction, necessity of a new coronary revascularization procedure (coronary bypass surgery, repeat target lesion PCI, PCI for a new non-target lesion) was analyzed. At a median follow-up of 24 months (12 to 37 months), MACE occurred in 188 patients (45.6%). The rate of MACE rate was significantly higher in the high lipoprotein (a) group than in the low lipoprotein (a) group (59.2% vs 40.7%, long-rank test chi-square = 12.3; p < 0.001). Cox analysis showed that high lipoprotein (a) level (Hazard Ratio, 1.62; 95% Confidence Interval, 1.19 to 2.20; p = 0.002) was an independent predictor for MACE after PCI. In conclusion, high lipoprotein (a) level was associated with a higher incidence of MACE after PCI for SAP in HD patients.

Restenosis of a Polytetrafluoroethylene-Covered Stent Visualized by Coronary Angioscopy and Optical Coherence Tomography: A Case Report.

An expandable polytetrafluoroethylene (PTFE)-covered stent graft is beneficial for the treatment of coronary perforations. However, several reports have shown that restenosis and thrombotic occlusion occasionally occur in the stented segment after PTFE-covered stent implantation. A restenosis case after treatment with PTFE-covered stent against saphenous vein graft (SVG) perforation has never been evaluated with optical coherence tomography (OCT) or coronary angioscopy (CAS). This case report presents a 75-year-old man treated with a PTFE-covered stent after he suffered from SVG perforation 6 months ago. He was found to have a focal restenosis of the distal edge of the PTFE-covered stent and underwent percutaneous coronary intervention. OCT showed focal restenosis with homogeneous neointima and exposed struts in the middle and proximal part of the PTFE-covered stent. CAS showed white neointima with a smooth surface at the restenosis site and a sharp border against proximal exposed struts with characteristic links. This case study showed, for the first time in vivo and in a human, the neointimal characteristics of restenosis and uncovered stent struts in a PTFE-covered stent which had been implanted 6 months before. The delayed endothelialization was sustained until 12 months after implantation.

Relationship of systemic pentraxin-3 values with coronary plaque components on optical coherence tomography and post-percutaneous coronary intervention outcomes in patients with stable angina pectoris.

BACKGROUND AND AIMS: Elevated pentraxin-3 (PTX3) values are associated with vulnerable plaque existence and poor outcomes in acute coronary syndrome patients. The clinical significance of PTX3 values in stable angina pectoris (SAP) patients is, however, undetermined. We investigated the relationship of systemic PTX3 values and coronary plaque components and post-percutaneous coronary intervention (PCI) outcomes in SAP patients. METHODS: We included 93 consecutive de-novo lesions in 93 SAP patients with a normal pre-PCI high-sensitivity cardiac troponin-T (<0.014 ng/mL), undergoing pre- and post-PCI optical coherence tomography (OCT). Systemic PTX3 values were obtained immediately pre- and post-PCI, at 24-h and 9-month post-PCI. RESULTS: Peak post-PCI PTX3 values correlated with thinnest fibrous cap thickness (r = -0.23, p = 0.03) and lipid length (r = 0.24, p = 0.03), and were higher in patients with lesions having OCT-derived thin-cap fibroatheroma (6.67 (3.19-7.33) vs. 3.13 (2.34-4.11) ng/mL, p = 0.04) and post-stenting irregular tissue protrusion (4.76 (3.31-6.80) vs. 2.98 (2.23-4.06) ng/mL, p = 0.003) than in those without. At 9-month follow-up, cardiac event-free survival was poorer in patients with a peak post-PCI PTX3 value ≥ 4.08 ng/mL (upper tertile) (log-rank test χ2 = 9.0; p = 0.003). Multivariate Cox regression analysis showed a peak post-PCI PTX3 value ≥ 4.08 ng/mL as an independent predictor of MACE (hazard ratio, 3.915; 95% CI, 1.129-13.583; p = 0.03). CONCLUSIONS: Peak post-PCI PTX3 values correlated with pre-PCI plaque characteristics and post-PCI outcomes, providing a good prognostic factor of outcomes in SAP patients undergoing elective PCI.

Clinical significance of the presence of puff-chandelier ruptures detected by nonobstructive aortic angioscopy.

OBJECTIVE: This study aimed to investigate the prevalence and prognostic significance of atherosclerotic aortic plaques (AAPs) or specific AAP types detected by nonobstructive angioscopy (NOA) in patients who underwent percutaneous coronary intervention (PCI). BACKGROUND: Although recent studies have reported the presence of various patterns of AAPs, identified by NOA, the clinical significance of the presence of AAPs remains elusive. METHODS: In this retrospective, multicenter cohort study, a total of 167 patients who underwent PCI and intra-aortic scans with NOA were studied. The association between AAPs and the incidence of major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, stroke, and clinically driven unplanned revascularizations, was assessed. RESULTS: AAPs were detected in 126 patients (75%) who underwent NOA. MACEs occurred in 28 (17%) patients during the follow-up (median 2.9 years [range 2.1-3.8]). Among all types of AAPs, only puff-chandelier rupture (PCR) showed a significant difference in frequency between patients with and those without MACEs: 21 (75%) and 49 (35%), respectively (p < .001). Multivariable Cox proportional hazard analysis revealed that PCR (hazard ratio [HR] 3.73, 95% confidence interval [CI] 1.57-8.87, p = .004) and chronic kidney disease (HR 2.97, 95% CI 1.37-6.44, p = .010) were independent predictors of MACEs. Kaplan-Meier analysis revealed that PCR was significantly associated with more frequent MACEs. CONCLUSION: The detection of PCR in the aorta using NOA was significantly associated with an increased risk of subsequent adverse events after PCI.

Impact of lesion angle on optical coherence tomography findings and clinical outcomes after drug-eluting stent implantation in curved vessels.

Tortuous coronary lesions are associated with adverse outcomes after implantation of bare metal or first-generation drug-eluting stents (DESs). We investigated the impact of lesion angle on vessel wall injuries and stent apposition as assessed by optical coherence tomography (OCT) after second- and newer-generation DES implantation. We investigated 95 de novo lesions treated with a single DES (62 platinum-chromium everolimus-eluting stents and 33 bioresorbable-polymer sirolimus-eluting stents). Post-intervention OCT findings were compared between angled lesions (≥ 45°; n = 33) and non-angled lesions (< 45°; n = 62). The 12-month clinical outcomes were also compared between the groups. Cross-sectional OCT analysis revealed that compared to non-angled lesions, angled ones had a significantly higher incidence of intra-stent dissection around the centre of the angle (19.7% vs. 10.8%, p = 0.01) and incomplete stent apposition (ISA) in the distal and proximal sub-segments (10.0% vs. 4.1%, p = 0.002; 15.3% vs. 7.9%, p < 0.001, respectively). Strut-based analysis also showed that angled lesions demonstrated a higher rate of malapposed strut in the distal and proximal sub-segments (3.0% vs. 0.9%, p < 0.001; 4.3% vs. 1.8%, p < 0.001, respectively). The 12 month clinical outcomes were comparable between the groups. Compared to non-angled lesions, angled coronary lesions were associated with a higher incidence of intra-stent dissection and ISA on post-intervention OCT after implantation of second- and newer-generation DESs.

Aortic Plaque Distribution, and Association between Aortic Plaque and Atherosclerotic Risk Factors: An Aortic Angioscopy Study.

AIM: Knowledge of subclinical plaque morphology and plaque distribution in the aorta in vivo remains unclear. This study aimed to increase the body of knowledge in this area. METHODS: We enrolled 37 consecutive patients with stable angina pectoris patients who underwent non-obstructive angioscopy for both the coronary artery and aorta immediately after percutaneous coronary intervention. We evaluated the presence of aortic plaques and the distribution of plaque instability. Patients were allocated into two groups according to the number of vulnerable plaques in whole aorta (a low [0-11] and high [≥ 12] group). We evaluated the relationships between the two groups in terms of cardiovascular risk factors. RESULTS: Aortic plaques were identified using non-obstructive angioscopy in all patients, and the greatest number of plaques was found at the infrarenal abdominal aorta (IAA) (the aortic arch, the descending thoracic aorta, the suprarenal abdominal aorta, the IAA, and common iliac artery; 65%, 76%, 65%, 95%, and 49%, respectively; p＜0.001). The maximum yellow grade, and the number of intense yellow plaques, ruptured plaques, and thrombi were highest at the IAA (p＜0.001). The prevalence of diabetes mellitus and peripheral arterial disease was higher in the high vulnerable plaque group (83.3% vs. 40.0%, p=0.010, 50.0% vs. 8.0%, p=0.005, respectively). CONCLUSIONS: Aortic atherosclerosis was the most severe at the IAA, and aortic plaque vulnerability and distribution were associated with the prevalence of diabetes mellitus and peripheral artery disease in patients with stable angina pectoris. Non-obstructive angioscopy may identify patients at high risk of future aortic events.

Balloon-Anchored CoKatte ® for Successfully Delivering Balloons for an Occluded Anomalous Right Coronary Artery.

Percutaneous coronary intervention (PCI) for anomalous right coronary artery (RCA), originating from the left coronary cusp is challenging, because of the difficulty in engaging the guiding catheter coaxially, and delivering balloons and stents. A 65-year-old man with effort angina underwent PCI for anomalous RCA. This report describes the method we used. Although, delivering the balloon was difficult in short of the guiding catheter's backup force, we finally succeeded by using one more guiding catheter and the balloon-anchored CoKatte ® , a novel, straight 4.5-French child catheter, to strengthen the backup force.