Target Lesion Revascularization After Intravascular Ultrasound-Guided Percutaneous Coronary Intervention.

BACKGROUND: Several stent expansion criteria derived from the intravascular ultrasound (IVUS) evaluation have been proposed to predict future clinical outcomes, but optimal stent expansion criteria as a guide during percutaneous coronary intervention (PCI) are still controversial. There are no studies evaluating the utility of stent expansion criteria along with the clinical and procedural factors in predicting target lesion revascularization (TLR) after contemporary IVUS-guided PCI. METHODS: OPTIVUS-Complex PCI study (Optimal Intravascular Ultrasound Guided Complex Percutaneous Coronary Intervention) multivessel cohort was a prospective multicenter study enrolling 961 patients undergoing multivessel PCI including left anterior descending coronary artery using IVUS with an intention to meet the prespecified criteria for optimal stent expansion. We compared several stent expansion criteria (minimum stent area [MSA], MSA/distal or average reference lumen area, MSA/distal or average reference vessel area, OPTIVUS criteria, IVUS-XPL [Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions] criteria, ULTIMATE [Intravascular Ultrasound Guided Drug Eluting Stents Implantation in "All-Comers" Coronary Lesions] criteria, and modified MUSIC [Multicenter Ultrasound Stenting in Coronaries Study] criteria) as well as clinical, angiographic, and procedural characteristics between lesions with and without TLR. RESULTS: Among 1957 lesions, the cumulative 1-year incidence of lesion-based TLR was 1.6% (30 lesions). Hemodialysis, treatment of proximal left anterior descending coronary artery lesions, calcified lesions, small proximal reference lumen area, and small MSA had univariate associations with TLR, while all of the stent expansion criteria except for MSA were not associated with TLR. The independent risk factors of TLR were calcified lesions (hazard ratio, 2.34 [95% CI, 1.03-5.32]; P=0.04) and small proximal reference lumen area (Tertile 1: hazard ratio, 7.01 [95% CI, 1.45-33.93]; P=0.02; and Tertile 2: hazard ratio, 5.40 [95% CI, 1.17-24.90]; P=0.03). CONCLUSIONS: In contemporary IVUS-guided PCI practice, the 1-year incidence of TLR was very low. MSA, but not other stent expansion criteria, had univariate association with TLR. Independent risk factors of TLR were calcified lesions and small proximal reference lumen area, although the findings should be interpreted with caution due to small number of TLR events, limited lesion complexity, and short duration of follow-up.

Inappropriate subcutaneous implantable cardioverter defibrillator shock due to incomplete sealing of the seal plug: a case report.

Background: A subcutaneous implantable cardioverter defibrillator (S-ICD) has several advantages over the transvenous ICD, including a reduced risk of lead-related mechanical complications and infection. However, inappropriate shock therapy is one of the most common adverse events associated with S-ICDs. We herein report a case of inappropriate shock therapy of S-ICD due to incomplete sealing of the seal plug. Case summary: A 60-year-old man, who had been on haemodialysis with a history of myocardial infarction, was transferred to the hospital after successfully being resuscitated from ventricular fibrillation (VF). An S-ICD was implanted for secondary prevention. On the third and the seventh post-operative days, S-ICD shock therapy was delivered without any tachyarrhythmias. As device interrogation revealed reproducible noises in both the secondary and alternate vectors by tapping at the generator, the sensing vector was fixed to the primary vector. Two months after discharge, the patient died of VF after receiving appropriate S-ICD shock delivery seven times. The S-ICD was retrieved from the body, and it was revealed that the seal plug had incompletely sealed and returned to its normal closed position after reinsertion of a torque wrench. Discussion: Seal plug damage is a rare complication but should be considered if noise oversensing is provoked only at the secondary and/or alternate vectors. In the present case, the inappropriate shock therapy might have been prevented if we had checked the seal plug carefully. Therefore, we advocate confirming the seal plug routinely after the removal of the torque wrench.

Acute Mitral Regurgitation of Unknown Etiology Associated with Disseminated Intravascular Coagulation Eventually Diagnosed as Enterococcus Faecalis Infective Endocarditis by Mitral Valve Surgery.

BACKGROUND Infective endocarditis is prevalent worldwide and the modified Duke criteria have been used universally to diagnose this condition. However, making the correct diagnosis is rather difficult because the clinical presentation and findings of blood tests are non-specific. CASE REPORT A 70-year-old female complaining of dyspnea for 5 days with acute mitral regurgitation was transferred to our hospital. She had acute heart and respiratory failure and disseminated intravascular coagulation. Although infective endocarditis was suspected, repeated blood cultures and transesophageal echocardiography could not reveal any findings of infective endocarditis. Because the etiology of her condition was not determined by various examinations, mitral annuloplasty was required to treat her mitral regurgitation, and was performed for definitive diagnosis and treatment revealing the presence of vegetation on the mitral valve. Enterococcus faecalis was detected by cultures of the mitral valve and blood after the surgery. CONCLUSIONS It can be very difficult to diagnose infective endocarditis correctly, especially when a case fails to fulfill the modified Duke criteria. In such a case, only cardiac surgery might enable us to make an accurate diagnosis and save a patient's life.