Spontaneous Remission Without Steroid Therapy in Isolated Cardiac Sarcoidosis with Severe Left Ventricular Systolic Dysfunction.

Spontaneous remission is often observed in extracardiac cases of sarcoidosis, such as skin sarcoidosis. However, for cardiac sarcoidosis (CS), the prognosis is unfavorable. Although corticosteroids are the first-line treatment for CS, data regarding the natural history of isolated CS are limited. We describe a rare case of isolated CS with severe left ventricular systolic dysfunction that improved without steroid therapy.

Safety and potential usefulness of sequential intracoronary acetylcholine and ergonovine administration for spasm provocation testing.

BACKGROUND: Although guidelines recommend intracoronary acetylcholine (ACh) and ergonovine (ER) provocation testing for diagnosis of vasospastic angina, the feasibility and safety of sequential (combined) use of both pharmacological agents during the same catheterization session remain unclear. OBJECTIVES: In this study, we investigated the feasibility and safety of sequential intracoronary ACh and ER administration for coronary spasm provocation testing. METHODS: The study included 235 patients who showed positive results on ACh and ER provocation testing. Initial intracoronary ACh administration was followed by ER administration for left coronary artery (LCA) spasm provocation testing. Subsequently, the right coronary artery (RCA) was subjected to sequential ACh and ER administration for provocation testing. The primary outcome of the study was the safety of sequential intracoronary ACh and ER provocation testing, which was assessed based on a composite of all-cause death, sustained ventricular tachycardia and fibrillation, and cardiogenic shock. RESULTS: Even in patients with negative results on sequential intracoronary ACh and ER provocation testing in the LCA and only ACh administration into the RCA, additional administration of ER into the RCA showed a positive provocation test result in 33 of 235 (14.0%) patients; three (1.3%) patients developed adverse effects (cardiogenic shock occurred in all cases) during LCA provocation testing. We observed no deaths attributable to spasm provocation testing. CONCLUSION: Sequential administration of intracoronary ACh and ER was associated with a relatively low major complication rate and may be safe and potentially useful for diagnosis of vasospastic angina.

Safety and potential usefulness of novel coronary spasm provocation testing protocolCoronary spasm represents a subtype of ischemic heart disease, potentially leading to heart attack. Although guidelines recommend intracoronary administration of different pharmacological agents, acetylcholine (ACh) and ergonovine (ER), for coronary spasm provocation testing, the feasibility and safety of sequential (combined) use of both drugs are unclear. In the present study, we showed that sequential administration of intracoronary ACh and ER was associated with a relatively low major complication rate and may be safe and potentially useful for diagnosis of coronary vasospasm.

Right versus left coronary artery involvement in patients with type A acute aortic dissection.

BACKGROUND: Type A acute aortic dissection (AAD) complicated by coronary malperfusion is a life-threatening disease. In the present study, we compared the clinical characteristics and prognostic impact of treatment strategies including surgical treatment and percutaneous coronary intervention (PCI) in type A AAD patients with RCA and LCA involvement. METHODS: This multicenter registry included 220 patients with type A AAD and either RCA or LCA involvement. Treatment strategies were left to treating physicians. The primary endpoint was in-hospital death. RESULTS: Of 220 patients, 115 (52.3%) and 105 (47.7%) had RCA and LCA involvement. Patients with LCA involvement were more1 likely to present with Killip class IV on admission than those with RCA involvement. Coronary angiography was performed in 52 of 220 (23.6%) patients, among whom 39 (75.0%) underwent subsequent PCI. During the hospitalization, 93 (42.3%) patients died. Patients with LCA involvement had an increased risk of in-hospital mortality compared to those with RCA involvement (54.3% vs. 31.3%, p < 0.001). In patients with RCA involvement, multivariable analysis identified Killip class IV and no surgical treatment as predictors of in-hospital death, while PCI and surgical treatment were indicated as factors associated with lower in-hospital mortality in patients with LCA involvement. CONCLUSIONS: The rates of RCA and LCA involvement were similar in type A AAD. Immediate PCI as a bridge to subsequent surgical treatment might improve survival in patients with type A AAD complicated by coronary malperfusion, especially in those with LCA involvement.

Coexistence of Spontaneous Coronary Artery Dissection, Takotsubo Cardiomyopathy, and Myocardial Bridge.

We report a case of spontaneous coronary artery dissection located next to a myocardial bridge in a patient with concomitant takotsubo cardiomyopathy. A fusion image with multidetector-row computed tomography and single-photon emission computed tomography played an important role in the diagnosis of these lesions. (Level of Difficulty: Advanced.).

The Role of Saline and Sodium Bicarbonate Preprocedural Hydration to Prevent Mid-term Renal Insufficiency in Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention.

Objective Persistent renal damage (RD) three months after exposure to contrast media is associated with contrast-induced acute kidney injury (CI-AKI) and poor clinical outcomes. Little is known about the role of preprocedural hydration on persistent RD in patients with chronic kidney disease [CKD; estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2] undergoing percutaneous coronary intervention (PCI). We therefore examined the use of preprocedural hydration to decrease the incidence of persistent RD. Methods Between 2012 and 2015, 1,230 consecutive patients undergoing PCI, except for patients with an eGFR ≥60 mL/min/1.73 m2, on dialysis, having acute myocardial infarction, or recently having started renin-angiotensin inhibitors, were screened (n=333). Before their index PCI, the 12-h saline group (n=103) received 1 mL/kg/h 0.9% sodium chloride for 12 hours, and the 1-h bicarbonate group (n=63) received 3 mL/kg 154 mEq/L sodium bicarbonate for 1 hour. The control group (n=167) received no pre-procedural hydration. The study outcome of kidney function decline was investigated using the percent-change (%-change) of the calculated creatinine clearance between the baseline value and the lowest value recorded three to six months after index PCI. Results There was less renal function deterioration in the saline group than in the control group, and the bicarbonate group showed deterioration similar to the other groups (%-change; 12-h saline 2.0±11.3% vs. control -5.6±12.6%, p<0.001; vs. 1-h bicarbonate -1.8±14.1%, p=0.18; 1-h bicarbonate vs. control, p=0.14 ANOVA). A multiple regression analysis adjusted for risk factors for persistent RD showed that saline hydration correlated independently with a higher %-change (r=0.262, p<0.001). Conclusion Preprocedural 12-h saline may be better than no preprocedural hydration in preventing mid-term renal insufficiency in CKD patients undergoing PCI.

Pre-Angioplasty Instantaneous Wave-Free Ratio Pullback Predicts Hemodynamic Outcome In Humans With Coronary Artery Disease: Primary Results of the International Multicenter iFR GRADIENT Registry.

OBJECTIVES: The authors sought to evaluate the accuracy of instantaneous wave-Free Ratio (iFR) pullback measurements to predict post-percutaneous coronary intervention (PCI) physiological outcomes, and to quantify how often iFR pullback alters PCI strategy in real-world clinical settings. BACKGROUND: In tandem and diffuse disease, offline analysis of continuous iFR pullback measurement has previously been demonstrated to accurately predict the physiological outcome of revascularization. However, the accuracy of the online analysis approach (iFR pullback) remains untested. METHODS: Angiographically intermediate tandem and/or diffuse lesions were entered into the international, multicenter iFR GRADIENT (Single instantaneous wave-Free Ratio Pullback Pre-Angioplasty Predicts Hemodynamic Outcome Without Wedge Pressure in Human Coronary Artery Disease) registry. Operators were asked to submit their procedural strategy after angiography alone and then after iFR-pullback measurement incorporating virtual PCI and post-PCI iFR prediction. PCI was performed according to standard clinical practice. Following PCI, repeat iFR assessment was performed and the actual versus predicted post-PCI iFR values compared. RESULTS: Mean age was 67 ± 12 years (81% male). Paired pre- and post-PCI iFR were measured in 128 patients (134 vessels). The predicted post-PCI iFR calculated online was 0.93 ± 0.05; observed actual iFR was 0.92 ± 0.06. iFR pullback predicted the post-PCI iFR outcome with 1.4 ± 0.5% error. In comparison to angiography-based decision making, after iFR pullback, decision making was changed in 52 (31%) of vessels; with a reduction in lesion number (-0.18 ± 0.05 lesion/vessel; p = 0.0001) and length (-4.4 ± 1.0 mm/vessel; p < 0.0001). CONCLUSIONS: In tandem and diffuse coronary disease, iFR pullback predicted the physiological outcome of PCI with a high degree of accuracy. Compared with angiography alone, availability of iFR pullback altered revascularization procedural planning in nearly one-third of patients.

Impact of target vessel on long-term cardiac mortality after successful chronic total occlusion percutaneous coronary intervention: Insights from a Japanese multicenter registry.

BACKGROUND: The impact of successful chronic total occlusion (S-CTO) percutaneous coronary intervention (PCI) on cardiac mortality may differ depending on target CTO vessel; however, to date this has not yet been adequately evaluated. The aim of this study was to investigate the impact of target vessel on cardiac mortality after S-CTO PCI. METHODS: From January 2004 to December 2011, 1517 CTO PCIs were performed in 4 Japanese centers and enrolled in a multicenter registry. Cases were retrospectively analyzed and divided per target vessel treated. The primary endpoint was cardiac mortality during the follow-up period. RESULTS: During the study period, 1424 CTOs with 1 main vessel CTO per patient were analyzed (left anterior descending artery [LAD]: 487, right coronary artery [RCA]: 599, left circumflex [LCx]: 338). 92.3% (n=1314) of cases were S-CTO PCIs. The median follow-up period was 1677 (interquartile range; 811-2463) days. In LAD and RCA CTOs, S-CTO PCI was associated with a lower cardiac mortality rate at 5-year follow-up when compared with unsuccessful CTO (U-CTO) (2.6% vs 9.7%, p=0.01, 2.6% vs 27.3%, p<0.01, respectively). This finding was not present with LCx CTO PCI (2.2% vs 0.0%, p=0.53). Cox regression analysis demonstrated that LAD and RCA S-CTO PCI were independent predictors of a lower cardiac mortality rate (LAD; HR: 0.18, 95% CI: 0.06-0.56; p<0.01; RCA; HR: 0.24, 95% CI: 0.09-0.65; p<0.01). CONCLUSIONS: S-CTO LAD and RCA PCI were associated with a lower long-term cardiac mortality after CTO PCI. This finding was not observed with LCx CTO PCI.

The role of integrated backscatter intravascular ultrasound in characterizing bare metal and drug-eluting stent restenotic neointima as compared to optical coherence tomography.

BACKGROUND: To evaluate the role of integrated backscatter intravascular ultrasound (IB-IVUS) in assessing the morphology of neointima in bare-metal stent (BMS) and drug-eluting stent (DES) restenosis as compared to the gold-standard, optical coherence tomography (OCT). METHODS: A total of 120 cross-sections were evaluated by IB-IVUS and OCT at five cross-sections from 24 patients (24 lesions): at the minimal lumen area (MLA) and at 1 and 2mm proximal and distal to the MLA site in 24 lesions (9 treated with DES and 15 treated with BMS). IB-IVUS and OCT findings were analyzed according to the time at which restenosis was identified (early <12 months and late ≥12 months) and the stent type. RESULTS: IB-IVUS was found to correctly characterize the neointima of both BMS and DES in-stent restenosis (ISR) as compared to OCT. The overall agreement between the pattern of ISR neointima by IB-IVUS and that by OCT was excellent (kappa=0.85, 95% CI 0.76-0.94). Late DES ISR was characterized by more non-homogeneous, low backscatter and lipid-laden neointima, as compared to the BMS equivalent (BMS vs. DES, 45.0% vs. 80.0%, p<0.01; 51.7% vs. 85.0%, p=0.008; 33.3% vs. 65.0%, p<0.01, respectively). CONCLUSIONS: IB-IVUS assessment of the ISR neointima pattern appears to provide similar information as the gold-standard OCT in patients with stable angina. Both modalities suggested that late DES restenosis is characterized by a non-homogeneous lipid-laden neointima.

Impact of combined supine and prone myocardial perfusion imaging using an ultrafast cardiac gamma camera for detection of inferolateral coronary artery disease.

BACKGROUND: Although combined supine and prone acquisitions improve the detection of inferolateral obstructive coronary artery disease (CAD), the predictors of inaccurate detection of inferolateral ischemia have not been reported by using cadmium zinc telluride (CZT) myocardial perfusion imaging (MPI). METHODS AND RESULTS: Vasodilator stress (99m)Tc tetrofosmin MPI using CZT camera and coronary angiography was performed in 322 patients within an interval of 2 months. Prone MPI was performed immediately after supine MPI. Narrowing of the luminal diameter ≥ 75% was considered significant. The presence of an abnormality on both supine and prone images was considered significant. Combined supine and prone imaging, compared with supine-only quantification, was more specific (93% vs. 72%, respectively, p<0.0001) and accurate (88% vs. 74%, p<0.0001) without compromising sensitivity (82% vs. 68%, p=0.10). The area under the curve for detecting inferolateral ischemia was 0.769 (95% CI 0.705-0.833) for supine imaging and 0.802 (95% CI 0.730-0.875) for combined supine and prone imaging (p<0.05). Multivariable analysis revealed that previous inferolateral myocardial infarction was an independent predictor of a false diagnosis (odds ratio=3.45, 95% confidence interval [CI] 1.62-7.37, p<0.001). CONCLUSIONS: Combined supine and prone quantitative CZT MPI enhances the detection of inferolateral CAD without adversely affecting its sensitivity. However, we recommend inferolateral ischemia be monitored in patients with a history of previous inferolateral MI because previous inferolateral MI is a predictor of inaccurate diagnosis.

Calcification analysis by intravascular ultrasound to define a predictor of left circumflex narrowing after cross-over stenting for unprotected left main bifurcation lesions.

OBJECTIVES: The aim of this study was to identify predictors of significant LCx-ostium compromise after distal unprotected left main coronary artery (ULMCA) stenting on the basis of baseline intravascular ultrasound (IVUS). BACKGROUND: Provisional single-stenting is considered as the default strategy for non-true bifurcation lesions in ULMCA. However, in certain cases, left circumflex artery (LCx)-ostium stenting is necessary. METHODS: A total of 77 patients underwent percutaneous coronary intervention with drug-eluting stents for non-true bifurcation lesions in ULMCA and had IVUS evaluation. Pre-procedural IVUS was performed to measure cross-sectional areas at the following segments: left main trunk, left anterior descending artery (LAD)-ostium. Post-stenting-narrowing at the circumflex ostium (PSN-LCx) was defined as the presence of more than 50% diameter stenosis at the LCx-ostium as determined by quantitative coronary angiography analysis. RESULTS: PSN-LCx occurred in 27 (35%) patients. The presence of calcified plaque at the culprit lesion as identified by IVUS was more frequently observed in the PSN-LCx group as compared to the non-PSN-LCx group (81.5% vs. 22.0%, p<0.001). Calcium arc in the PSN-LCx group was significantly greater than that in the non-PSN-LCx group (118.1°±69.9° vs. 36.9°±63.0°, p<0.001). On multivariable analysis, a calcium arc>60° was an independent predictor of PSN-LCx (odds ratio: 5.12, 95% confidence interval: 1.21-25.01, p=0.03). CONCLUSIONS: The presence of calcified plaque at the culprit lesion appears to be one of the factors involved in LCx-ostial compromise in non-true bifurcation ULMCA lesions, especially when the calcium arc is >60°.

Appearance of neointima according to stent type and restenotic phase: analysis by optical coherence tomography.

AIMS: The features of neointima after bare metal stent (BMS) or drug-eluting stent (DES) implantation have not yet been fully characterised. The aim of this study was to investigate in-stent neointima characteristics according to stent type and restenotic phase. METHODS AND RESULTS: The study included 59 consecutive patients undergoing target lesion revascularisation for in-stent restenosis (ISR) evaluated by optical coherence tomography (OCT) during the early phase (≤1 year, n=30) and late phase (>1 year, n=29) after either BMS (n=37) or DES (n=22) implantation. The OCT signal patterns of tissues at the minimal lumen area were categorised into three patterns: (1) homogeneous high-signal band, (2) heterogeneous mixed-signal band, and (3) lipid-laden intima. The predominant OCT pattern was homogeneous high-signal band in the BMS early phase (19/21 [91%]), lipid-laden intima in the BMS late phase (12/16 [76%]), and heterogeneous mixed-signal band in the DES late phase (9/13 [69%]). Heterogeneous mixed-signal band was seen more frequently in the DES early phase compared with BMS early phase (44% vs. 9%, p<0.05). CONCLUSIONS: There were differences of neointima according to stent type and restenotic phase, and this may lead to a better understanding of the different mechanisms of ISR.

Re-restenosis and target lesion revascularization after treatment of sirolimus-eluting stent restenosis: retrospective analysis of 4 Japanese hospitals.

BACKGROUND: There is limited information about optimal management of drug-eluting stent (DES) restenosis. This study evaluated the incidences of re-restenosis and re-target lesion revascularization (TLR) after the treatment of sirolimus-eluting stent (SES) restenosis. METHODS AND RESULTS: A total of 102 lesions in 101 patients who underwent TLR for SES restenosis were classified according to: (1) focal (lesion length < or = 10 mm) or non-focal restenosis (>10 mm); and (2) use of DES for TLR: (1) focal restenosis treated with DES (focal-DES, n=40); (2) focal restenosis treated by balloon angioplasty (focal-balloon, n=31); (3) non-focal restenosis with DES (non-focal-DES, n=17); and (4) non-focal restenosis by balloon angioplasty (non-focal-balloon, n=14). Re-restenosis and re-TLR were observed in 6 (19.4%) and 5 lesions (12.5%) of the focal-DES group, in 13 (65.0%) and 11 (35.5%) of the focal-balloon group, in 7 (50.0%) and 6 (35.3%) of the non-focal-DES group, and in 8 (61.5%) and 7 (50.0%) of the non-focal-balloon group, respectively (P<0.05 for restenosis and TLR between the focal-DES group and other groups). CONCLUSIONS: Re-DES implantation for focal DES restenosis results in lower re-restenosis and re-TLR rates compared to re-DES implantation for non-focal DES restenosis or conventional balloon angioplasty either for focal or non-focal DES restenosis.

Angiographic patterns of restenosis after sirolimus-eluting stent implantation.

BACKGROUND: Large-scale randomized trials demonstrate a high proportion of focal restenosis after drug-eluting stent (DES) implantation. On the other hand, recent reports have shown that in real-world practice a significant proportion of the restenosis is non-focal when DESs are used in unselected lesions. The present study evaluated angiographic patterns of restenosis after sirolimus-eluting stent (SES) implantation in Japan. METHODS AND RESULTS: Angiographic restenosis patterns of all consecutive restenotic lesions (n=124) after SES implantation were evaluated and classified according to the following scheme: focal (10 mm within the stent), proliferative (restenosis >10 mm in length extending outside the stent), and occlusive. There were 98 focal (79.0%), 15 diffuse (12.1%), and 5 proliferative restenoses (4.0%) and 6 total occlusions (4.8%). Focal intrastent restenosis was most dominant (42.7%). Proximal edge restenosis occurred in 22 lesions (17.7%). Multivariate analysis demonstrated diabetes mellitus (P<0.01) as an independent predictor of non-focal restenosis. CONCLUSIONS: Focal restenosis is predominant after SES implantation in real-world practice in Japan.

Impact of drug-eluting stents on clinical and angiographic outcomes in dialysis patients.

BACKGROUND: It remains unclear whether sirolimus-eluting stents (SES) have an advantage over bare metal stents (BMS) in patients on dialysis. METHODS AND RESULTS: Percutaneous coronary intervention (PCI) using SES was performed in 54 dialysis patients with 69 lesions. A control group for comparison comprised 54 consecutive dialysis patients with 58 lesions who underwent PCI using BMS. Angiographic and clinical follow-ups were scheduled at 9 months. After the procedure, minimum lumen diameter (MLD) was similar between the 2 groups. At follow-up, the SES group had a higher MLD than the BMS group (1.98+/-0.83 mm vs 1.50+/-0.78 mm, p<0.01). In-stent restenosis rate was lower in lesions treated with SES than in those with BMS (22% vs 40%, p=0.048). However, there was no significant difference between the 2 groups for in-segment restenosis (31% vs 43%, p=0.3). During follow-up, there was no significant difference in the incidence of death, myocardial infarction or target lesion revascularization (TLR) (14% vs 21%, p=0.4) between the SES and BMS groups. CONCLUSIONS: In this retrospective study, SES, in comparison with BMS, reduced in-stent restenosis in patients on dialysis. However, in-segment restenosis and TLR were not statistically different between lesions treated with SES and those with BMS.

Volumetric intravascular ultrasound assessment of neointimal hyperplasia and nonuniform stent strut distribution in sirolimus-eluting stent restenosis.

The neointimal hyperplasia (IH) distribution pattern of in-stent restenotic lesions after sirolimus-eluting stent (SES) implantation has not been well described. We identified 48 in-stent restenotic lesions (41 patients) after SES implantation and performed volumetric intravascular ultrasound analyses. Lumen area, stent area, and IH area at the minimal lumen area site were 2.7 +/- 1.0, 5.4 +/- 1.9, and 2.7 +/- 1.4 mm(2), respectively. IH area at the minimal lumen site was larger in the group with a stent area > or =5.0 mm(2) than the group with a stent area <5.0 mm(2) (3.7 +/- 1.3 vs 1.9 +/- 0.8 mm(2), p <0.001). There were fewer visualized stent struts in lesions with a minimum stent area > or =5.0 mm(2) at the minimum lumen site compared with those with a stent area <5.0 mm(2) (0.69 +/- 0.25 vs 0.83 +/- 0.16, p = 0.04). When we compared lesions in patients with diabetes mellitus with patients without diabetes, minimum lumen areas, percent IH at minimal lumen area, percent IH, and neointima-free stent length were identical. In conclusion, (1) lesions without SES underexpansion at the minimum lumen site had more IH and greater nonuniform stent strut distribution compared with restenotic SESs that were underexpanded, and (2) the IH response did not appear to be more aggressive in patients with diabetes mellitus than in those without diabetes mellitus.

Outcome after acute incomplete sirolimus-eluting stent apposition as assessed by serial intravascular ultrasound.

We investigated the fate of postprocedural incomplete stent apposition (ISA) after sirolimus-eluting stent (SES) implantation by evaluating long-term intravascular ultrasound findings in 168 consecutive patients (182 de novo lesions). Postprocedural ISA was defined as > or = 1 stent strut that was clearly separated from the vessel wall with evidence of blood speckle behind the strut without overlapping a side branch. After SES implantation, there were 61 ISA sites in 46 stents in 31 patients (23 at the proximal edge, 7 at the distal edge, and 31 within the stent body). There were no clinical, procedural, or intravascular ultrasound measurement differences between patients and lesions with versus without ISA. At follow-up, 15 acute ISA sites (25%) in 11 patients completely resolved and 40 sites (75%) in 20 patients persisted, although 32 of 46 persisting ISA sites (70%) decreased. There was a greater decrease in effective lumen area and a greater increase in peristent plaque area in the complete-resolution group than in the persistent-ISA group. No lesion developed stent thrombosis or in-stent restenosis (angiographic diameter stenosis > 50%). Six acute ISA sites were also associated with new, late acquired ISA, only 1 of which resulted in aneurysm formation. Although most ISAs after SES implantation do not resolve completely, the incidence of restenosis or thrombosis is not affected.