Evaluation of the Determinant Factors and Clinical Implications of Self-Care Agency Among Patients with Acute Myocardial Infarction.

In patients with acute myocardial infarction treated with percutaneous coronary intervention (PCI), effective post-hospital care, partially determined by self-care agency, is critical for long-term prognosis. However, the relationship between agency and sociodemographic characteristics requires elucidation. One hundred and six outpatients participated in our study. Self-care agency was assessed with the Self-care Agency Questionnaire (SCAQ). We evaluated its correlation with patients' sociodemographic characteristics and morale on the Ikigai-9 Questionnaire. Mean SCAQ scores were higher in those who were younger, male, living with someone, and more educated compared to their counterparts. Furthermore, SCAQ scores were correlated with Ikigai-9 scores. Multivariate logistic regression analyses indicated that social participation, employment status, and morale were independent predictors of high SCAQ scores. A comprehensive approach utilizing medical professionals, families, and the local community is needed to promote self-care agency in patients receiving primary PCI.

Efficacy and safety of the distal transradial approach in coronary angiography and percutaneous coronary intervention: a Japanese multicenter experience.

The novel distal transradial approach (dTRA) is expected to further build upon the advantages of transradial access. However, the incidence of radial artery occlusion (RAO) and hemorrhagic events with the dTRA has not been fully elucidated. The objective of this study was to investigate the effects of using the dTRA on RAO and postprocedural hemorrhage. From April 2018 to July 2018, 228 consecutive patients who underwent coronary angiography or intervention through the dTRA at two hospitals were analyzed. The RAO rate, change in the forearm and distal radial artery diameter and cross-section area after the dTRA (at 1 day and 1 month) on vascular ultrasonography, and incidence of hemorrhagic complications were investigated. Forearm and distal RAO occurred in 1 (0.4%) and 8 (3.1%) patients at 1 month, respectively. No forearm hematomas occurred. Ultrasonographic findings indicated that the radial artery diameter and cross-section area were significantly larger after the dTRA (2.9 ± 0.5 mm vs. 2.7 ± 0.5 mm, p < 0.001 and 6.5 ± 2.4 mm2 vs. 5.6 ± 2.0 mm2, p < 0.001, respectively). The distal radial artery diameter and cross-section area in the anatomical snuffbox were also significantly larger after the dTRA (2.5 ± 0.5 mm vs. 2.3 ± 0.4 mm, p < 0.001 and 4.7 ± 2.0 mm2 vs. 4.2 ± 1.6 mm2, p < 0.001, respectively). The DTRA was associated with a low incidence of RAO at both the puncture site and the forearm, postprocedural dilatation of the radial artery, and no bleeding complications extending to the forearm.

Impact of living alone on the care and outcomes of patients with ST-elevation myocardial infarction.

BACKGROUND: This study aimed to investigate the association between living alone at home and the care and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (pPCI). METHODS: In total, 557 patients with STEMI underwent pPCI between January 2008 and September 2017. Among them, we included 208 patients who were transferred directly by emergency medical services from their home to the hospital. RESULTS: Patients were classified into two groups, namely living alone (n = 45) and living with others (n = 163). There were no significant differences in age, sex, and cardiovascular risk factors between the two groups. The onset-to-door (OTD) and onset-to-balloon times were significantly shorter in patients living with others than in those living alone (106.4 vs. 190.8 min, p < 0.01 and 152.3 vs. 236.9 min; p < 0.01, respectively). The left ventricular ejection fraction after pPCI was significantly lower in patients living alone than in those living with others (48.7 % vs. 54.9 %, p < 0.01). Multivariate logistic regression analysis indicated that living alone and the incidence of congestive heart failure were independent predictors of a longer OTD time. CONCLUSIONS: Patients living alone were less likely to arrive early at the hospital than those living with others. A greater understanding of the inter-relationships among living alone, access to acute cardiac care, and outcomes is essential.

Pseudoaneurysm Formation After Cardiac Catheterization Using the Distal Transradial Approach.

This is the first case report of pseudoaneurysm formation after cardiac catheterization through the distal radial artery, which was easily treated by external compression.

Impact of shorter door-to-balloon time on prognosis of patients with STEMI-single-center analysis with a large proportion of the patients treated within 30 min.

Several recent studies suggested that the door-to-balloon time (DTBT) for patients with ST-segment elevation myocardial infarction (STEMI) should be as short as possible, despite the existing guideline for STEMI. This study aimed to evaluate the clinical outcomes of the STEMI patient cohort having the highest proportion of patients treated with a DTBT of ≤ 30 min ever reported. We evaluated 527 consecutive patients with STEMI who underwent percutaneous coronary intervention between 2007 and 2015. The mean age was 68.0 ± 12.7 years, and the mean DTBT was 44.4 ± 33.1 min. The patients were classified into four groups according to the DTBT, and the relationship between the DTBT and clinical outcome was investigated. DTBTs were ≤ 30 min in 146 patients (27.7%), 31-60 min in 297 patients (56.4%), 61-90 min in 60 patients (11.4%), and > 90 min in 24 patients (4.6%). In-hospital mortality rates were 0.7, 5.0, 11.7, and 12.5% for DTBTs of ≤ 30, 31-60, 61-90, and > 90 min, respectively. In multivariate analysis, a DTBT ≤ 30 min (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.01-0.91, p = 0.041), shock on arrival (OR 2.74, 95% CI 1.02-7.37, p = 0.046), and blood transfusion (OR 49.60, 95% CI 13.90-177.00, p < 0.001) were the independent predictors of in-hospital mortality. Patients with STEMI treated with a DTBT ≤ 30 min showed significantly better clinical outcomes than those treated with a DTBT > 30 min.

The impact of tissue characterization for in-stent restenosis with optical coherence tomography during excimer laser coronary angioplasty.

We aimed to evaluate the impact of tissue characterization for in-stent restenosis (ISR) with optical computed tomography (OCT) during excimer laser coronary angioplasty (ELCA) in the drug-eluting stent (DES) era. The effect of ELCA for ISR according to differences in tissue characteristics is unclear. Fifty-three ISR lesions (7 bare metal stents and 46 drug-eluting stents) were treated with an ELCA catheter. After ELCA, balloon dilatation with either the scoring or non-compliant balloons was conducted. The procedure was completed by applying a drug-coated balloon. Tissue characterization and lumen measurement with OCT were performed thrice: (1) before percutaneous coronary intervention (PCI), (2) after ELCA, and (3) and after the procedure. Lesions were categorized into the homogenous, layered, and mixed groups. Follow-up angiograms were conducted 6-12 months after PCI. No significant differences in minimal lumen area (MLA) were observed before PCI. A significant difference was observed in MLA after ELCA among the three groups (homogeneous group: 1.75 ± 0.84 mm2, layered group: 1.72 ± 0.45 mm2, mixed group: 2.24 ± 0.70 mm2, P = 0.048). Final MLA was larger in the mixed group than in the homogeneous group (P = 0.028). No significant difference was observed in binary restenosis in the follow-up angiogram (homogeneous group 55.5%, layered group 33.3%, mixed group 33.3%; P = 0.311) and the target lesion revascularization rate (homogeneous 30.0%, layered 23.8%, mixed 25.0%; P = 0.923). Tissue characterization by OCT may predict the efficacy of ELCA and balloon angioplasty for ISR during the acute phase.

Successful treatment of out-of-hospital cardiopulmonary arrest due to streptococcal toxic shock syndrome - effectiveness of extracorporeal membrane oxygenation and the rapid antigen group A streptococcus test: a case report.

BACKGROUND: Streptococcal toxic shock syndrome caused by Streptococcus pyogenes, a group A streptococcus, infection is a rare condition that rapidly progresses to multiple organ failure, shock, and death. It is thus important to promptly establish a diagnosis, provide hemodynamic support, and initiate appropriate antibiotics therapy. CASE PRESENTATION: A 70-year-old Asian man presented with ventricular fibrillation. Extracorporeal membrane oxygenation was initiated 20 minutes after admission after unsuccessful conventional cardiopulmonary resuscitation including five attempts of electrical cardioversion. On the sixth attempt, a sinus rhythm was obtained. A physical examination revealed a large abscess in his right gluteal region, and computed tomography showed a large low-density area in the right gluteus maximus. Blood examination revealed elevated levels of inflammatory markers, hepatic enzymes, creatinine, and creatinine kinase. Transthoracic echocardiography demonstrated diffuse hypokinesis with an ejection fraction of 25%. A subsequent coronary angiography revealed normal findings. Therefore, we diagnosed our patient as having septic shock and conducted surgical drainage. A rapid antigen group A streptococcus test yielded positive results, which necessitated treatment comprising benzylpenicillin and clindamycin. He was successfully weaned from extracorporeal membrane oxygenation and continuous hemodiafiltration 4 days later and ventilation 9 days later; he was later transferred to another hospital to receive a skin graft. CONCLUSIONS: Our case report is the first to demonstrate the successful treatment of cardiac arrest caused by streptococcal toxic shock syndrome via extracorporeal membrane oxygenation and prompt initiation of antibiotic therapy. The rapid antigen group A streptococcus test may be an effective approach to promptly diagnose streptococcal toxic shock syndrome caused by group A streptococcus infection.

Usefulness of the twin guidewire method during retrieval of the broken tip of a microcatheter entrapped in a heavily calcified coronary artery.

During percutaneous coronary intervention performed for a stenotic lesion with heavy calcification in the left coronary artery, the microcatheter tip became transected in the vessel. The fragment was successfully retrieved using the twin guidewire method after negotiating to cross a chronic total occlusion-dedicated guidewire outside the retained tip.

Examination of the appropriate timing of reperfusion therapy for recent myocardial infarction: a Japanese single-center retrospective study.

BACKGROUND: The various guidelines clearly mention the treatment strategies for in patient of acute myocardial infarction (MI) presenting more than 24h from symptom onset (recent myocardial infarction, RMI). However, the appropriate timing of reperfusion for RMI is unclear. METHODS: We retrospectively evaluated 525 consecutive MI patients who underwent percutaneous coronary intervention (PCI) in our hospital between January 2008 and December 2012. RESULTS: Sixty RMI patients were more frequently associated with cardiac complications such as myocardial rupture (3.3% vs. 0%; p<0.01), ventricular septal rupture (3.3% vs. 0.4%; p<0.05), and congestive heart failure (15% vs. 2.6%; p<0.001) than 272 consecutive ST-elevation myocardial infarction (STEMI) patients. Of the 60 RMI patients, 33 (55.0%) underwent PCI within 7days (early-PCI group) and 27 (45.0%) underwent PCI after 7days (late-PCI group). Left ventricular ejection fraction measured by echocardiography at second hospital day was similar between the groups. The early-PCI group was more significantly associated with cardiogenic shock and heart failure and more frequently required intra-aortic balloon pumping (24.2% vs. 3.7%; p<0.05) than the late-PCI group. There were no significant differences in 30-day mortality, cardiac complications, and major cardiac events during long-term follow-up (12-36 months) between the groups. CONCLUSION: RMI patients had a higher incidence of cardiac complications than AMI patients. Clinical outcomes were similar between patients undergoing early revascularization and those undergoing late revascularization, although the former group included a higher proportion of patients with severe cardiac failure.

Spontaneous rotation of the monorail-type guide extension support catheter during advancement of a curved guiding catheter: the potential hazard of twisting with the coronary guidewire.

The extension support guiding catheter has been used to perform complex percutaneous coronary intervention to increase back-up support for the guiding catheter or to ensure deep intubation for device delivery. However, because of its monorail design, advancement of the stent into the distal extension tubing segment is sometimes problematic. Although this problem is considered due to simple collision of the stent, operators have observed tangling between a monorail extension catheter and coronary guidewire in some patients. To examine movement of the collar of the extension guide catheter during advancement of the guiding catheter, we set up an in vitro model in which the guiding catheter had two curves. Rotation of the extension guide catheter was examined by both fluoroscopic imaging and movement of the hub of the proximal end of the catheter. During advancement in the first curve, the collar moved toward the outer side of the curve of the guiding catheter as the operator pushed the shaft of the extension guiding catheter, which overrode the guidewire. After crossing the first curve, the collar moved again to the outer side of the second curve (the inner side of the first curve) of the mother catheter, and then, another clockwise rotation was observed in the proximal hub. Consequently, the collar and tubing portion of the extension guide catheter rotated 360° around the coronary guidewire, and the monorail extension catheter and guidewire became tangled. There is a potential risk of unintentional twisting with the guidewire during advancement into the curved guiding catheter because of its monorail design.

Severe catheter kinking and entrapment during transbrachial angiography: percutaneous retrieval with a slender approach.

A 74-year-old man previously treated with bilateral femoro-popliteal bypass was referred to our hospital for the treatment of a severely tangled 4-Fr diagnostic catheter in the right brachial artery. We inserted a 5-Fr sheath introducer from the proximal right femoral artery and advanced a 5-Fr JR catheter to the right brachial artery. A Sion coronary guidewire was then advanced for the tip of the tangled catheter, and a 4-mm gooseneck snare catheter was inserted through the guidewire. The tip of the catheter was caught and successfully removed after clockwise untwisting. The patient was discharged the next day without any complications.

Successful treatment of a nonagenarian patient with acute coronary syndrome complicated with chronic total occlusion of the left main coronary artery.

Although chronic total occlusion of the left main coronary artery (LMCA) is considered very rare, this condition could be fatal if it becomes complicated with an acute coronary syndrome lesion in the right coronary artery (RCA) which is usually the only remaining coronary artery for the myocardium. We reported a successfully treated case of a nonagenarian patient with ST-segment elevation myocardial infarction, who had subtotal occlusion of the RCA and total occlusion of the LMCA with Rentrop grade 2 collateral coronary artery supply from the RCA.

Onset-to-device time of patients who arrive at off-hours: Importance of prehospital management and public awareness for patients with ST-segment elevation myocardial infarction.

AIM: The influence of the time of arrival at the hospital on the door-to-device (DTD) time has been investigated; however, the influence on the onset-to-device (OTD) time is unclear in ST-segment elevation myocardial infarction (STEMI) patients. The aim of this study was to investigate the relationship between the time of arrival at the hospital and the OTD time in STEMI patients. METHODS: We evaluated 377 STEMI patients who underwent primary percutaneous coronary intervention (pPCI) between January 2008 and December 2014. RESULTS: During the study period, 222 patients arrived at our hospital between 9 AM and 9 PM (on-hours group) and 155 patients arrived between 9 PM and 9 AM (off-hours group). The DTD time was longer in the off-hours group than in the on-hours group (50.4 vs 39.3 minutes; P<.001), while the OTD time was longer in the on-hours group than in the off-hours group (285.7 vs 184.5 minutes, P<.001). The 30-day mortality and peak creatinine kinase levels were similar between the groups. Transfer from a non-pPCI-capable facility to our hospital was more common in the on-hours group than in the off-hours group (49.1% vs 15.5%, P<.001). The OTD time was shorter in patients who directly visited our hospital than in those who were transferred (172.9 vs 338.5 minutes, P<.001). CONCLUSIONS: The OTD time might be markedly longer in STEMI patients who arrive at the hospital during on-hours than in those who arrive at the hospital during off-hours because of the underuse of emergency medical services at STEMI onset.

Challenges for 'diastology': contributions from Japanese researchers.

Diastology is a study to treat diastole of the heart. Transmitral flow and pulmonary venous flow velocities recorded by pulsed Doppler echocardiography provide more important information about left ventricular (LV) diastolic dysfunction [left atrial (LA)-LV coupling] than cardiac catheterization in clinical practice; however, these waveforms are influenced by loading conditions, particularly preload. The early diastolic mitral annular and LV wall motion indices measured by tissue Doppler echocardiography can evaluate LV relaxation abnormality and filling pressure by being relatively preload independent. In addition, the role of concomitant systolic longitudinal dysfunction is well characterized in asymptomatic patients and in patients with heart failure and preserved ejection fraction. Two-dimensional speckle tracking echocardiography is an angle-independent method, and has the potential to evaluate the contraction and relaxation abnormalities in the longitudinal, circumferential, and radial directions of the LV myocardium as well as LV torsion/untwisting and, moreover, deformation of the LA myocardium and large arterial wall. As a result, this new technique can facilitate the early detection of impaired LA-LV-arterial coupling in patients before occurrence of overt heart failure symptoms.

Percutaneous coronary intervention for nonagenarian patients with ST-segment elevation myocardial infarction: Experience of a single Japanese center.

BACKGROUND: Old age is a prognostic risk factor for patients with ST elevation acute myocardial infarction (STEMI); however, few data exist describing STEMI patients aged over 90 years. METHODS: We retrospectively evaluated the clinical indices and outcomes of 282 consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) in our hospital between January 2008 and December 2012. Patients with acute myocardial infarction complicated by out-of-hospital cardiopulmonary arrest, patients with a left main trunk culprit lesion, and patients diagnosed more than 24h after symptom onset were excluded. RESULTS: Of the patients treated during the study period, 11 (3.8%) were >90 years old. The mean door-to-balloon time was significantly longer for nonagenarians than younger patients (66.2 vs. 44.0minutes; p<0.001). This was mainly attributed to delays in decision-making regarding invasive treatment by both the doctors and families. Nonagenarians had multiple coronary artery stenoses more frequently (36.4% vs. 15.0%; p<0.05) and required intra-aortic balloon pumping more often (36.4% vs. 18.9%; p=0.15) compared with patients aged ≤89 years. However, the peak creatinine kinase levels and the left ventricular ejection fractions were similar between the groups. Moreover, the in-hospital and 30-day mortality rates were similar (9.1% vs. 4.6%, p=0.50; 9.1% vs. 3.6%, p=0.34, respectively) between the groups. The two-year survival rate was 81.8% in nonagenarians. CONCLUSIONS: Despite the longer door-to-balloon time, higher use of intra-aortic balloon pumping, and larger number of diseased vessels, the 30-day and 2-year survival rates of nonagenarians with STEMI were comparable to those of younger patients.

Minimally invasive atherectomy with a virtual 3-Fr sheathless guiding catheter and a 0.9-mm excimer laser catheter for the treatment of coronary in-stent restenosis: a case report.

A 50-year-old man underwent percutaneous coronary intervention for stent restenosis in his left anterior descending artery. After insertion of a 5-Fr sheathless guiding catheter through the right radial artery, optical coherence tomography (OCT) revealed a circumferential dense fibrotic plaque in the distal part of the stent. Therefore, we performed excimer laser coronary atherectomy using a 0.9-mm concentric catheter and dilatation with a drug-coated balloon catheter. Subsequent OCT revealed a circumferential reduction of the neointimal material. The patient's clinical course was uneventful, and he was discharged 2 days after the percutaneous coronary intervention without any access site complications.

Impact of the Presence of Chronic Total Occlusion in a Non-Infarct-Related Coronary Artery in Acute Myocardial Infarction Patients.

Chronic total occlusion (CTO) in a non-infarcted-related artery was reported to worsen immediate clinical outcome in acute myocardial infarction (AMI) patients. However, the prognosis of such patients with preserved left ventricular function after successful primary percutaneous coronary intervention (PCI) has not yet been clarified. The aim of the present study was to evaluate whether the presence of CTO contributes to a worse prognosis even in patients with preserved left ventricular function after primary PCI.We retrospectively analyzed 353 consecutive patients with acute myocardial infarction, whose left ventricular ejection fraction (LVEF) was not less than 40% in the echocardiography performed 1 day after primary PCI. We divided the patients into two groups according to the presence (n = 25) or absence (n = 328) of CTO in the non-infarct-related coronary artery, and compared the clinical outcome of patients between the two groups.The LVEF estimated by echocardiography after primary PCI was similar between patients with and without CTO (55.1 ± 8.6% versus 58.0 ± 9.4%; P = 0.07). The peak creatine kinase value was also similar between the two groups (1539 versus 1921 U/L; P = 0.33); however, CTO patients were significantly more likely to undergo intra-aortic balloon pumping (56.0% versus 12.5%; P < 0.001) during primary PCI, and 30-day mortality was significantly higher in CTO patients (12.0% versus 0.9%; P < 0.001). By multivariate analysis, cardiogenic shock at arrival was significantly correlated with 30-day mortality.Even though the LVEF of AMI patients with CTO was preserved after successful PCI, a high mortality rate was observed.

Virtual 5-French intra-aortic pumping using a Glidesheath Slender and 6-French intra-aortic balloon catheter.

OBJECTIVES: The aim of this study was to evaluate the feasibility and safety of the 6-Fr Glidesheath Slender, which has equivalent outer size to the conventional 5-Fr sheath, for use with the 6-Fr intra-aortic balloon pump (IABP) catheter. METHODS: Between May 2014 and March 2015, 24 patients with acute coronary syndrome underwent percutaneous coronary intervention using a 6-Fr IABP catheter through a 6-Fr Glidesheath Slender for support. The adverse events, including access site complications, kinking of the sheath during the procedure, and any evidence of balloon pump failure, were retrospectively investigated. RESULTS: Insertion of the IABP catheter through either the femoral or brachial artery was successful in all patients. The mean support time was 32.4±22.0h. No major hemorrhagic event or severe limb ischemia was observed. Kinking of the shaft occurred during insertion in one patient; however, the subsequent balloon pumping was well maintained and did not require exchange of the sheath or IABP catheter. No kind of IABP failure was observed. CONCLUSION: Although this sheath was originally designed to allow radial access, our results suggest that the use of the Glidesheath Slender is feasible for insertion of the 6-Fr IABP catheter through the brachial and femoral arteries, and may reduce vascular complications in patients who undergo percutaneous coronary intervention.