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BACKGROUND: The clinical outcomes of ST-segment elevation myocardial infarction (STEMI) due to the occlusion of left coronary artery are worse in patients with proximal occlusion than in those with non-proximal occlusion. However, there are few reports that focus on the comparison of clinical outcomes in patients with STEMI between proximal and non-proximal right coronary artery (RCA) occlusions. METHODS: We included 356 patients with STEMI whose infarct-related artery is RCA and divided them into the proximal group (nâ¯=â¯129) and the non-proximal group (nâ¯=â¯227). We defined segment 1 of RCA as proximal, and segments 2, 3, and 4 as non-proximal according to the reporting system of the American Heart Association. The primary endpoint was major cardiovascular events (MACE), which was defined as the composite of all-cause death, non-fatal myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization. RESULTS: Incidence of shock at admission, requirement for catecholamine during percutaneous coronary intervention (PCI), or mechanical support during PCI tended to be higher in the proximal group (42.6â¯%) than in the non-proximal group (33.5â¯%) (pâ¯=â¯0.088). Although the incidence of right ventricular infarction tended to be higher in the proximal group (17.8â¯%) than in the non-proximal group (10.6â¯%) without reaching statistical significance (pâ¯=â¯0.072), the incidence of in-hospital death was similar between the 2 groups (1.6â¯% versus 1.8â¯%, pâ¯=â¯1.000). The MACE-free survival curves were not different between the 2 groups (pâ¯=â¯0.400). Multivariate Cox hazard analysis revealed that proximal RCA occlusion was not associated with MACE (HR 1.095, 95%CI 0.691-1.737, pâ¯=â¯0.699). CONCLUSIONS: Although the acute phase conditions such as shock or right ventricular infarction tended to be more severe in patients with proximal occlusion, overall clinical outcomes including long-term outcomes were comparable between the proximal and distal RCA occlusions. Furthermore, multivariate analysis showed that the proximal RCA occlusion was not associated with MACE after hospital discharge.
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Although serum troponin level is the gold standard under the universal definition of acute myocardial infarction (AMI), serum creatinine kinase (CK) and creatine kinase-myocardial band (CK-MB) is still measured in clinical practice as the compliment of troponin level. The purpose of this retrospective study is to illustrate the dramatic change of CK-MB/CK ratio by comparing CK-MB/CK ratio in patients with ST-segment elevation myocardial infarction (STEMI) among ≤ 24 h before reaching peak CK, peak CK, ≤ 24 h after reaching peak CK, and 24-48 h after reaching peak CK. We included 502 patients with STEMI. We calculated each average CK-MB/CK ratio at ≤ 24 h before reaching peak CK, peak CK, ≤ 24 h after reaching peak CK, and 24-48 h after reaching peak CK. The average values were compared using Friedman test. The average CK-MB/CK ratio at ≤ 24 h before reaching peak CK, peak CK, ≤ 24 h after reaching peak CK, and 24-48 h after reaching peak CK was 0.096 (9.6% of CK), 0.098 (9.8% of peak CK), 0.076 (7.6% of CK), and 0.028 (2.8% of CK), respectively. The Friedman test suggested that the CK-MB/CK ratio significantly declined after reaching peak CK (p < 0.001). In conclusion, the CK-MB/CK ratio was around 0.1 (10% of CK) until CK-MB and CK reached the peak, but dropped sharply after reaching peak CK. The CK-MB/CK ratio less than 0.1 (10% of CK) cannot be used to rule out the possibility of AMI, when the onset of symptom is unclear or late presentation.
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Killip classification has been used to stratify the risk of patients with acute myocardial infarction (AMI). There were many reports that Killip class 3 or 4 is closely associated with poor clinical outcomes. In other words, Killip class 1 or 2 is associated with favorable clinical outcomes in patients with AMI, especially when patients received primary percutaneous coronary intervention (PCI). However, some patients with Killip class 1/2 suffer from serious in-hospital complications. This study aimed to identify factors associated with serious in-hospital complications of ST-segment elevation myocardial infarction (STEMI) in patients with Killip class 1/2. The primary endpoint was serious in-hospital complications defined as the composite of in-hospital death and mechanical complications. We included 809 patients with STEMI, and divided them into the non-complication group (n = 791) and the complication group (n = 18). In-hospital death was observed in 14 patients (1.7%), and mechanical complications were observed in 4 patients (0.5%). Final TIMI flow ≤ 2 was more frequently observed in the complication group (33.3%) than in the non-complication group (5.4%) (p < 0.001). Multivariate logistic regression analysis revealed that serious in-hospital complication was associated with final TIMI flow grade ≤ 2 (Odds ratio 6.040, 95% confidence interval 2.042-17.870, p = 0.001). In conclusion, serious in-hospital complication of STEMI was associated with insufficient final TIMI flow grade in patients with Killip class 1/2. If final TIMI flow grade is suboptimal after primary PCI, we may recognize the potential risk of serious complications even when patients presented as Killip class 1/2.
Subject(s)
Hospital Mortality , Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction , Humans , Percutaneous Coronary Intervention/adverse effects , ST Elevation Myocardial Infarction/surgery , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/mortality , ST Elevation Myocardial Infarction/complications , Male , Female , Aged , Middle Aged , Risk Factors , Retrospective Studies , Treatment Outcome , Risk Assessment/methods , Postoperative Complications/epidemiology , Coronary Angiography , Severity of Illness IndexABSTRACT
In-stent restenosis with neoatherosclerosis has been known as the predictor of target lesion revascularization (TLR) after percutaneous coronary intervention. However, the impact of in-stent calcification (ISC) alone on clinical outcomes remains unknown since neoatherosclerosis by optical coherence tomography includes in-stent lipid and calcification. We aimed to assess the effect of ISC on clinical outcomes and clinical differences among different types of ISC. We included 126 lesions that underwent optical coherence tomography-guided percutaneous coronary intervention and divided those into the ISC group (n = 38) and the non-ISC group (n = 88) according to the presence of ISC. The cumulative incidence of clinically driven TLR (CD-TLR) was compared between the ISC and non-ISC groups. The impact of in-stent calcified nodule and nodular calcification on CD-TLR was evaluated using the Cox hazard model. The incidence of CD-TLR was significantly higher in the ISC group than in the non-ISC group (p = 0.004). In the multivariate Cox hazard model, ISC was significantly associated with CD-TLR (hazard ratio [HR] 3.58, 95% confidence interval [CI] 1.33 to 9.65, p = 0.01). In-stent calcified nodule/nodular calcification and in-stent nodular calcification alone were also the factors significantly associated with CD-TLR (HR 3.34, 95%CI 1.15 to 9.65, p = 0.03 and HR 5.21, 95%CI 1.82 to 14.91, p = 0.002, respectively). ISC without in-stent calcified nodule/nodular calcification, which was defined as in-stent smooth calcification, was not associated with CD-TLR. In conclusion, ISC was associated with a higher rate of CD-TLR. The types of calcifications that led to a high rate of CD-TLR were in-stent calcified nodule/nodular calcification and in-stent nodular calcification alone but not in-stent smooth calcification. In-stent calcified nodule and nodular calcification should be paid more attention.
Subject(s)
Calcinosis , Coronary Artery Disease , Percutaneous Coronary Intervention , Humans , Coronary Vessels/diagnostic imaging , Coronary Vessels/pathology , Tomography, Optical Coherence , Treatment Outcome , Stents/adverse effects , Calcinosis/epidemiology , Calcinosis/pathology , Coronary Artery Disease/diagnosis , Coronary Artery Disease/surgery , Coronary Artery Disease/pathology , Coronary AngiographyABSTRACT
Objective Patients with acute myocardial infarction (AMI) often have peripheral artery disease (PAD). It is well known that the long-term clinical outcomes of AMI are worse in patients with a low ankle-brachial index (ABI) than in patients with a preserved ABI. Unlike ABI, the association between the inter-arm blood pressure difference (IABPD) and clinical outcomes in patients with AMI has not yet been established. This retrospective study examined whether or not the IABPD is associated with long-term clinical outcomes in patients with AMI. Methods We included 979 patients with AMI and divided them into a high-IABPD group (IABPD ≥10 mmHg, n=31) and a low-IABPD group (IABPD <10 mmHg, n=948) according to the IABPD measured during hospitalization for AMI. The primary endpoint was the all-cause mortality rate. Results During a median follow-up duration of 694 days (Q1, 296 days; Q3, 1,281 days), 82 all-cause deaths were observed. Kaplan-Meier curves showed that all-cause death was more frequently observed in the high-IABPD group than in the low-IABPD group (p<0.001). A multivariate Cox hazard analysis revealed that a high IABPD was significantly associated with all-cause death (hazard ratio 2.061, 95% confidence interval 1.012-4.197, p=0.046) after controlling for multiple confounding factors. Conclusion A high IABPD was significantly associated with long-term all-cause mortality in patients with AMI. Our results suggest the usefulness of the IABPD as a prognostic marker for patients with AMI.
Subject(s)
Hypertension , Myocardial Infarction , Percutaneous Coronary Intervention , Peripheral Arterial Disease , Humans , Risk Factors , Blood Pressure , Retrospective Studies , Myocardial Infarction/surgery , Myocardial Infarction/complications , Hypertension/complicationsABSTRACT
BACKGROUND: Many techniques and concepts have been developed in the field of percutaneous coronary intervention to chronic total occlusion (CTO). Parallel wire technique (PWT) is still an important technique in antegrade approach. The purpose of this study was to identify the determinants of successful PWT in coronary CTO. METHODS: We reviewed consecutive 451 CTO lesions that were treated with PCI in our medical center. The overall success rate of PCI to CTO during the study period was 92.2 % (416/451). Of 451 CTO lesions, we excluded 333 CTO lesions in which PTW was not performed. We included 118 CTO lesions in which PWT was performed, and divided them into the successful PWT group (n = 65) and the unsuccessful PWT group (n = 53) according to the procedure success of PWT. Multivariate logistic regression analysis were performed to find the determinants of successful PWT. RESULTS: The prevalence of the sufficient clarity of CTO exit site was significantly higher in the successful PWT group (46.2 %) than in the unsuccessful PWT group (11.3 %) (p < 0.01). Multivariate logistic regression analysis revealed that the J-CTO score was inversely associated with successful PWT (OR 0.66, 95 % CI 0.44-0.99, P = 0.04), whereas the sufficient clarity of CTO exit site was associated with successful PWT (OR 5.16, 95 % CI 1.75-15.20, P < 0.01). CONCLUSIONS: The J-CTO score was inversely associated with successful PWT, whereas the sufficient clarity of CTO exit site was associated with successful PWT. The low J-CTO score and the sufficient clarity of CTO exit site may be the determinants of successful PWT.
Subject(s)
Coronary Occlusion , Percutaneous Coronary Intervention , Humans , Chronic Disease , Coronary Angiography/methods , Coronary Occlusion/diagnostic imaging , Coronary Occlusion/therapy , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/methods , Registries , Risk Factors , Treatment OutcomeABSTRACT
BACKGROUND: Although major guidelines recommend the routine introduction of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and beta-blockers for patients with ST-segment elevation myocardial infarction (STEMI), evidence regarding the target blood pressure (BP) or pulse rate (PR) at hospital discharge is sparse. This retrospective study aimed to compare the clinical outcomes in patients with STEMI between those with good BP and PR control and those with poor BP or PR control. METHODS: We included 748 patients with STEMI who received both ACE inhibitors/ARBs and beta-blockers at hospital discharge, and divided them into a good control group (systolic BP ≤140â¯mmHg and PR ≤80â¯bpm, nâ¯=â¯564) and a poor control group (systolic BP >140â¯mmHg or PR >80â¯bpm, nâ¯=â¯184). The primary endpoint was major cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction, and re-admission for heart failure. RESULTS: During the median follow-up duration of 568â¯days, a total of 119 MACE were observed. The Kaplan-Meier curves showed that MACE were more frequently observed in the poor control group (pâ¯=â¯0.009). In the multivariate Cox hazard analysis, the good control group was inversely associated with MACE (HR 0.656, 95â¯% CI: 0.444-0.968, pâ¯=â¯0.034) after controlling for multiple confounding factors. CONCLUSIONS: The good control of systolic BP and PR at discharge was inversely associated with long-term adverse events in STEMI patients treated with both ACE inhibitors/ARBs and beta blockers. This study suggests the importance of titration of ACE inhibitors/ARBs and beta-blockers for better clinical outcomes in patients with STEMI.
Subject(s)
Myocardial Infarction , Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction , Humans , ST Elevation Myocardial Infarction/drug therapy , ST Elevation Myocardial Infarction/etiology , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Angiotensin Receptor Antagonists/therapeutic use , Blood Pressure , Heart Rate , Patient Discharge , Retrospective Studies , Percutaneous Coronary Intervention/adverse effects , Myocardial Infarction/etiology , Adrenergic beta-Antagonists/therapeutic use , Treatment OutcomeABSTRACT
Rotational atherectomy (RA) is technically more difficult in a diffuse calcified lesion than in a focal calcified lesion. We hypothesized that taking a halftime can be another option for RA to the diffuse calcified lesions. Halftime was defined as at least one long break during RA, in which an operator pulled out the Rotablator system from the guide catheter before crossing the lesion. This study aimed to compare the complications between RA with and without halftime. We included 177 diffuse long severely calcified lesions (lesion lengths ≥ 30 mm) that required RA, and divided those lesions into a halftime group (n = 29) and a no-halftime group (n = 148). The primary outcome was periprocedural myocardial infarction (MI). The reference diameter was smaller in the halftime group than in the no-halftime group [1.82 (1.70-2.06) mm versus 2.17 (1.89-2.59) mm, p = 0.002]. The total run time was longer in the halftime group than in the non-halftime group [133.0 (102.0-223.0) seconds versus 71.5 (42.0-108.0) seconds, p < 0.001]. Although creatinine kinase (CK) and CK-myocardial band (MB) was significantly higher in the halftime group than in the no-halftime group [CK: 156 (97-308) U/L versus 99 (59-216) U/L, p = 0.021; CK-MB: 15 (8-24) U/L versus 5 (3-15) U/L, p < 0.001], periprocedural MI was not observed in the halftime group. In conclusion, periprocedural MI was not observed in RA with halftime. This preliminary study suggests that halftime RA may be a safe option for diffuse severely calcified lesions.
Subject(s)
Atherectomy, Coronary , Coronary Artery Disease , Myocardial Infarction , Vascular Calcification , Humans , Atherectomy, Coronary/adverse effects , Coronary Artery Disease/diagnosis , Coronary Artery Disease/surgery , Coronary Artery Disease/complications , Coronary Angiography/adverse effects , Myocardial Infarction/diagnosis , Myocardial Infarction/surgery , Myocardial Infarction/etiology , Treatment Outcome , Vascular Calcification/diagnosis , Vascular Calcification/surgery , Vascular Calcification/complications , Retrospective StudiesABSTRACT
Mechanical complication (MC) is a rare but serious complication in patients with ST-segment elevation myocardial infarction (STEMI). Although several risk factors for MC have been reported, a prediction model for MC has not been established. This study aimed to develop a simple prediction model for MC after STEMI. We included 1717 patients with STEMI who underwent primary percutaneous coronary intervention (PCI). Of 1717 patients, 45 MCs occurred after primary PCI. Prespecified predictors were determined to develop a tentative prediction model for MC using multivariable regression analysis. Then, a simple prediction model for MC was generated. Age ≥ 70, Killip class ≥ 2, white blood cell ≥ 10,000/µl, and onset-to-visit time ≥ 8 h were included in a simple prediction model as "point 1" risk score, whereas initial thrombolysis in myocardial infarction (TIMI) flow grade ≤ 1 and final TIMI flow grade ≤ 2 were included as "point 2" risk score. The simple prediction model for MC showed good discrimination with the optimism-corrected area under the receiver-operating characteristic curve of 0.850 (95% CI: 0.798-0.902). The predicted probability for MC was 0-2% in patients with 0-4 points of risk score, whereas that was 6-50% in patients with 5-8 points. In conclusion, we developed a simple prediction model for MC. We may be able to predict the probability for MC by this simple prediction model.
Subject(s)
Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction , Humans , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/surgery , Percutaneous Coronary Intervention/adverse effects , Time Factors , Treatment Outcome , Risk FactorsABSTRACT
Drug-coated balloons (DCBs) have been widely used in endovascular therapy for femoropopliteal arteries with atherosclerotic lesions. Vascular response after DCBs remains unclear. This mini-review proposes a possible mechanism of restenosis after the DCB strategy. Balloon dilatation including DCBs expands the vascular lumen by producing dissections, which is composed of the original vascular lumen and the cavity surrounded by dissected flaps. The cavity surrounded by dissected flaps is eventually replaced with the thrombus in the healing process after balloon dilatation. However, the thrombus may propagate to the expanded vascular lumen through the entry point of the dissection. Subsequently, the thrombus both in the cavity and the expanded lumen would be organized over time. The vascular lumen in the chronic-phase after DCBs may be influenced by the propagated thrombus from the cavity surrounded by dissected flaps.
Subject(s)
Angioplasty, Balloon , Cardiovascular Agents , Coated Materials, Biocompatible , Peripheral Arterial Disease , Recurrence , Tomography, Optical Coherence , Vascular Access Devices , Humans , Angioplasty, Balloon/instrumentation , Angioplasty, Balloon/adverse effects , Peripheral Arterial Disease/therapy , Peripheral Arterial Disease/diagnostic imaging , Peripheral Arterial Disease/physiopathology , Treatment Outcome , Cardiovascular Agents/administration & dosage , Femoral Artery/diagnostic imaging , Femoral Artery/physiopathology , Constriction, Pathologic , Predictive Value of Tests , Popliteal Artery/diagnostic imaging , Popliteal Artery/physiopathology , Thrombosis/diagnostic imaging , Thrombosis/etiology , Thrombosis/physiopathology , Thrombosis/therapy , Equipment DesignABSTRACT
AIMS: Bleeding complications are often observed in patients with ST-segment elevation myocardial infarction (STEMI). Although the Japanese version of the high bleeding risk criteria (J-HBR) were established, it has not been sufficiently validated in patients with STEMI. This retrospective study aims to examine whether J-HBR is associated with cardiovascular and bleeding events in patients with STEMI. METHODS: We included 897 patients with STEMI and divided them into the J-HBR group (n=567) and the non-J-HBR group (n=330). The primary endpoint was the major adverse cardiovascular events (MACE), defined as the composite of all-cause death, non-fatal myocardial infarction, ischemic stroke, and systemic embolism. Another primary endpoint was total bleeding events defined as type 3 or 5 bleeding events as defined by the Bleeding Academic Research Consortium . RESULTS: During the median follow-up duration of 573 days, 187 MACE and 141 total bleeding events were observed. The Kaplan-Meier curves showed that MACE and total bleeding events were more frequently observed in the J-HBR group than in the non-J-HBR group (pï¼0.001). Multivariate Cox hazard analysis revealed that after controlling for multiple confounding factors, the J-HBR group was significantly associated with MACE (hazard ratio [HR] 4.676, 95% confidence interval (CI) 2.936-7.448, pï¼0.001) and total bleeding events (HR 6.325,95% CI 3.376-11.851, pï¼0.001). CONCLUSIONS: J-HBR is significantly associated with MACE and total bleeding events in patients with STEMI. This study validated J-HBR as a risk marker for bleeding events and suggests J-HBR as a potential risk marker for MACE in patients with STEMI.
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BACKGROUND: Temporal trends in the management of acute coronary syndrome complicated with cardiogenic shock after the revision of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella require further investigation, because their impact remains uncertain. METHODS AND RESULTS: Using the Japanese Percutaneous Coronary Intervention (J-PCI) registry database from 2019 to 2021, we identified 12 171 patients undergoing percutaneous coronary intervention for acute coronary syndrome complicated with cardiogenic shock under mechanical circulatory support. The patients were stratified into 3 groups: (1) IABP alone, (2) Impella, and (3) venoarterial extracorporeal membrane oxygenation (VA-ECMO); the VA-ECMO group was further stratified into (3a) VA-ECMO alone, (3b) VA-ECMO in combination with IABP, and (3c) VA-ECMO in combination with Impella. The quarterly prevalence and outcomes were reported. The use of IABP alone decreased significantly from 63.5% in the first quarter of 2019 to 58.3% in the fourth quarter of 2021 (P for trend=0.01). Among 4245 patients requiring VA-ECMO, the use of VA-ECMO in combination with IABP decreased significantly from 78.7% to 67.3%, whereas the use of VA-ECMO in combination with Impella increased significantly from 4.2% to 17.0% (P for trend <0.001 for both). After adjusting for the confounders, the risk difference in the fourth quarter of 2021 relative to the first quarter of 2019 for in-hospital mortality was not significant (adjusted odds ratio, 0.84 [95% CI, 0.69-1.01]). CONCLUSIONS: Our study revealed substantial changes in the use of different mechanical circulatory support modalities in acute coronary syndrome complicated with cardiogenic shock, but they did not significantly improve the outcomes.
Subject(s)
Acute Coronary Syndrome , Heart-Assist Devices , Percutaneous Coronary Intervention , Humans , Shock, Cardiogenic/epidemiology , Shock, Cardiogenic/etiology , Shock, Cardiogenic/therapy , Acute Coronary Syndrome/complications , Acute Coronary Syndrome/therapy , Percutaneous Coronary Intervention/adverse effects , Japan/epidemiology , Registries , Intra-Aortic Balloon Pumping/adverse effects , Heart-Assist Devices/adverse effects , Treatment OutcomeABSTRACT
OBJECTIVE: Although the clinical outcomes for patients with ST-elevation myocardial infarction (STEMI) have improved significantly, some patients still experience poor clinical outcomes. The available risk classifications focus on the short-term outcomes, and it remains important to find high-risk features among patients with STEMI. In Japan, the 200 m walk electrocardiogram (ECG) test is widely performed before discharge. The purpose of this study was to investigate the association between the excessive increase in systolic blood pressure (SBP) following a 200 m walk and the long-term clinical outcomes in patients with STEMI. METHODS: We included 680 patients with STEMI and divided those into an excessive increase in SBP group (n = 144) and a non-excessive increase in SBP group (n = 536) according to the SBP increase after a 200 m walk ECG test. We defined an excessive increase in SBP as SBP ≥ 20 mmHg either just after or 3 min after a 200 m walk ECG test. The primary endpoint consisted of major cardiovascular events (MACE), defined as the composite of all-cause death, non-fatal myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization. RESULTS: The median follow-up duration was 831 days. MACE was more frequently observed in the excessive increase in SBP group (24.3%) than in the non-excessive increase in SBP group (15.1%). Multivariate Cox hazard analysis revealed that the excessive increase in SBP was significantly associated with MACE (HR 1.509, 95% CI: 1.005-2.267, p = 0.047) after controlling for multiple confounding factors. CONCLUSION: An excessive increase in SBP after the 200 m walk ECG test was significantly associated with MACE in patients with STEMI. The 200 m walk ECG test is simple and low-cost, but may help to identify high-risk patients with STEMI.
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BACKGROUND: Recently, the nutritional status of patients has drawn attention in an aging society. Early studies have reported that nutritional status is related to long-term outcomes in patients with acute myocardial infarction (AMI). However, it is not necessarily simple to evaluate the nutritional status of patients with AMI. We hypothesized that appetite before discharge can be a predictor for long-term adverse cardiovascular events in patients with AMI. This retrospective study aimed to investigate whether appetite is related to long-term adverse outcomes in patients with AMI. METHODS: This study included 1006 patients with AMI, and divided them into the good appetite group (n = 860) and the poor appetite group (n = 146) according to the percentage of the dietary intake on the day before discharge. Major adverse cardiac events (MACE), which were defined as a composite of all-cause death, non-fatal MI, and re-admission for heart failure, were set as the primary outcome. RESULTS: The median follow-up duration was 996 days, and a total of 243 MACE was observed during the study period. MACE was more frequently observed in the poor appetite group than in the good appetite group (42.5% versus 21.0%, p < 0.001). In the multivariate COX hazard model, poor appetite was significantly associated with MACE (Hazard ratio 1.698, 95% confidence interval 1.243-2.319, p < 0.001) after controlling for multiple confounding factors. CONCLUSION: Appetite at the time of discharge was significantly associated with long-term clinical outcomes in patients with AMI. Patients with poor appetite should be carefully followed up after discharge from AMI.
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The concept of lifetime management has not been discussed in the field of percutaneous coronary intervention (PCI), because the durability of drug-eluting stent (DES) is considered to be long enough for most patients. Furthermore, even if in-stent restenosis occurs, the treatment for in-stent restenosis is simple in most cases. On the other hand, the long-term clinical outcomes after DES implantation are worse in severely calcified coronary lesions than in non-calcified lesions. Moreover, the treatment for in-stent calcified restenosis or restenosis due to stent underexpansion is not simple. The concept of lifetime management of severely calcified lesions may be necessary like that of aortic stenosis. Recently, several algorithms have been published in PCI to severely calcified lesions, partly because of the emergence of IVL. These algorithms focus on the selection of cracking and debulking devices for the preparation of stenting. However, the optimal stent expansion does not guarantee the long-term patency, when the target lesion includes calcified nodules. Stent restenosis due to calcified nodules is difficult to manage. In this review article, we propose the algorithm for severely calcified lesions focused on the shape of calcification. We do not need to hesitate stenting when multiple cracks on circumferential calcification are observed by intravascular imaging devices. However, DCB may be an option as final device in some situations, when lifetime management of severely calcified lesions is considered.
Subject(s)
Angioplasty, Balloon, Coronary , Atherectomy, Coronary , Coronary Artery Disease , Coronary Restenosis , Drug-Eluting Stents , Percutaneous Coronary Intervention , Vascular Calcification , Humans , Coronary Artery Disease/diagnosis , Coronary Artery Disease/surgery , Percutaneous Coronary Intervention/adverse effects , Angioplasty, Balloon, Coronary/methods , Drug-Eluting Stents/adverse effects , Coronary Restenosis/etiology , Coronary Angiography/methods , Treatment Outcome , Vascular Calcification/surgery , Vascular Calcification/complications , Atherectomy, Coronary/adverse effectsABSTRACT
Serious complications including vessel perforation may occur during rotational atherectomy (RA) to left circumflex (LCX) ostial lesions. In fact, if perforation occurs around LCX ostium, bailout procedures including deployment of covered stents may cause fatal ischemia in the territory of left anterior descending artery, which results in broad anterior acute myocardial infarction and subsequent death. In this review article, we described tips and tricks for RA to LCX ostial lesions. First, we should cautiously decide the indication for RA to LCX ostial lesions, because there are several reasons to avoid RA to LCX ostial lesions. Before procedures, we should estimate the difficulty of RA to LCX ostial lesions, which is mainly determined by the combination of the bifurcation angle and the severity of stenosis. Thus, the combination of the large bifurcation angle and the tight stenosis makes RA to LCX ostial lesions most difficult. Appropriate position of guide catheter and RotaWire is a key to successful RA to LCX ostial lesions. Differential cutting is an essential concept for RA to LCX ostial lesions. However, since there is no guarantee that differential cutting always works, small burr (≤ 1.5 mm) would be a safe choice as initial burr for RA to LCX ostial lesions.