Importance of left ventricular contraction for left atrial reservoir function.

BACKGROUND: The determinants of left atrial (LA) reservoir function have not been clarified. METHODS: To elucidate the effect of left ventricular (LV) contraction on LA reservoir volume (ΔVLA), volume change due to mitral annular downward motion and aortic root anterior motion, which are related to LV contraction during systole, was calculated in 72 consecutive subjects [42 patients without any cardiac disease (control group), 13 patients with heart failure with reduced ejection fraction (HFrEF group) and 17 with preserved ejection fraction (HFpEF group)]. LA volume was calculated using the modified Simpson's method of bi-plane 2-D echocardiograms. ΔVLA was the difference between the maximum and minimum LA volumes. LA volume change according to mitral annular motion (ΔVMA) and aortic root motion (ΔVAR) were calculated by assuming an oval frustum and dented wedge, respectively. RESULTS: In the normal control group, ΔVAR + ΔVMA was 11.7 ml on average, correlating to ΔVLA (r = 0.55, p < 0.01), and the contribution rate to LA reservoir volume ((ΔVAR + ΔVMA)/ΔVLA) was 56% on average. In both, the HFrEF and HFpEF groups, ΔVAR, ΔVMA, and the contribution rate were significantly smaller than those in normal control group. Stroke volume correlated to ΔVAR and ΔVMA. The larger the maximum LA volume was, the smaller the contribution rate was. The smaller the rate was, the higher the systolic pulmonary artery pressure was. CONCLUSIONS: Both mitral annular motion and aortic root anterior motion, which are related to ventricular contraction, are important for the LA reservoir volume recruitment.

Different serial changes in the neointimal condition of sirolimus-eluting stents and paclitaxel-eluting stents: an optical coherence tomographic study.

AIMS: Detailed long-term changes of the neointima in sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) are still unclear. METHODS AND RESULTS: We consecutively enrolled 14 patients (18 SES) and 12 patients (13 PES) who underwent optical coherence tomography (OCT) serially at eight months and 18 months after stent implantation. For 18 SES and 13 PES, OCT was used to visualise 2,486 and 1,361 stent struts at the eight-month and 2,199 and 1,309 stent struts at the 18-month follow-up, respectively. The OCT parameters, including incidence of uncovered and malapposed struts (uncovered and malapposed percentage), average neointimal hyperplasia thickness (NIH thickness) and %NIH volume obstruction, which was defined as ([mean NIH area*stent length]/[mean stent area*stent length])100, and qualitative analysis of the neointima were compared between SES and PES and also compared between the eight- and 18-month follow-up for SES and PES, respectively. The uncovered and malapposed percentage was significantly higher in SES than PES at the eight- and 18-month follow-up, and the NIH thickness and %NIH volume obstruction were lower in SES than PES at both follow-ups. The uncovered and malapposed percentage decreased in both SES and PES between the eight- and 18-month follow-up. Percent NIH volume obstruction and NIH thickness in SES significantly increased from the eight- to 18-month follow-up; however, those parameters significantly decreased in PES. The incidence of high signal with peri-strut low-intensity areas increased in SES but decreased in PES from the eight- to 18-month follow-up. CONCLUSIONS: Uncovered and malapposed struts were reduced in both SES and PES, while the neointimal hyperplasia and qualitative changes showed different patterns.

Higher serum uric acid and lipoprotein(a) are correlated with coronary spasm.

It has been reported that a major cause of coronary vasospastic angina (VSA) is endothelial dysfunction of the coronary artery. On the other hand, some studies showed that serum uric acid and lipoprotein(a) are correlated with endothelial dysfunction. Thus, we examined whether uric acid and lipoprotein(a), are correlated with VSA. Four hundred forty-one patients with suspected VSA who underwent a coronary angiogram with acetylcholine provocation (ACh test) during an 8-year period were enrolled. We divided them into a VSA group, who showed coronary spasm by the ACh test, and an atypical chest pain (ACP) group, who showed negative ACh test. We compared serum markers between the two groups, including low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, high-sensitivity C-reactive protein (hs-CRP), lipoprotein(a), fibrinogen, total plasminogen activator inhibitor-1, and uric acid. Uric acid, hs-CRP, and lipoprotein(a) were significantly higher in the VSA group than in the ACP group (all P < 0.05) while there were no significant differences in the other parameters. Multivariate analyses identified uric acid and lipoprotein(a) as significant independent markers for VSA. Uric acid and lipoprotein(a) are correlated with VSA, and medical intervention to decrease uric acid and lipoprotein(a) might be effective in controlling VSA.

New approach for rotational dyssynchrony using three-dimensional speckle tracking echocardiography.

Left ventricular (LV) twist can be evaluated using two-dimensional speckle tracking echocardiography (2DSTE) by analyzing difference between apical and basal rotation. However, it is unable to evaluate global rotational dyssynchrony because it cannot assess mid-wall rotation. Recently developed three-dimensional STE (3DSTE) can investigate LV global rotational dyssynchrony. In this study, we investigated the role of torsion on the long-term effects of cardiac resynchronization therapy (CRT) using 3DSTE. We evaluated 43 patients by 3DSTE: 12 CRT responders, 14 CRT nonresponders, and 17 healthy normal controls. Regional torsion and rotation were assessed using 3DSTE across 16 segments during CRT-off (native conduction) and CRT-on. The following parameters were calculated: global peak twist, Δ global peak twist (difference between CRT-on and CRT-off), and torsion delay index. The torsion delay index was considered to be the rotational energy lost by rotational dyssynchrony. Global peak twist did not show significant differences between the responders and nonresponders during CRT-off (4.0 ± 3.4° vs. 2.8 ± 2.3°, P = 0.295), but it significantly improved in responders compared to nonresponders after CRT-on (5.4 ± 3.5° vs. 2.6 ± 2.6°, P = 0.029). The torsion delay index during CRT-off was significantly higher in responders compared to nonresponders and normal controls (18.5 ± 11.3 vs. 8.6 ± 3.8 and 7.8 ± 5.5, P = 0.010 and P = 0.004, respectively). The torsion delay index during CRT-off significantly correlated with the Δ global peak twist (r = 0.503, P = 0.009). Improvement in LV global peak twist, which is one of the mechanisms for the long-term effects of CRT correlated with the torsion delay index during native conduction that can only be calculated by 3DSTE.

Correlation between inflammation state and successful medical cardioversion using bepridil for refractory atrial fibrillation.

BACKGROUND: It has been reported that inflammation is associated with long-term maintenance of sinus rhythm after electrical cardioversion for non-valvular atrial fibrillation (AF). However, the relation between high-sensitive C-reactive protein (hs-CRP) and the recurrence of AF after medical cardioversion is unknown. On the other hand, bepridil is very effective in restoring sinus rhythm for patients with refractory AF. METHODS AND RESULTS: In 119 patients with non-valvular AF lasting >6 months who failed to maintain sinus rhythm after medical cardioversion without bepridil or electrical cardioversion, we prescribed bepridil. We divided our patients into success group who maintained sinus rhythm for at least 6 months using bepridil and failure group, and compared the following parameters, which were measured just before prescription of bepridil, between the two groups: hs-CRP as a marker of inflammation, left ventricular end-diastolic dimension, ejection fraction, and left atrial dimension as echocardiographic markers, and the incidence of dyslipidemia, hypertension, and diabetes mellitus. After the treatment with bepridil, 57 patients converted to sinus rhythm; however, 12 patients among these 57 patients could not maintain sinus rhythm. Therefore, the success group consisted of 45 patients (38%). Univariate analysis revealed that left atrial dimension and the value of hs-CRP were significantly lower and ejection fraction was significantly higher in the success group than the failure group. Multivariate analysis showed that hs-CRP and left atrial dimension were independent factors for AF recurrence. CONCLUSIONS: Bepridil is effective in restoring sinus rhythm for refractory AF patients. Inflammation, in addition to left atrial dimension, may be associated with successful cardioversion using bepridil.

Initial findings of impact of strut width on stent coverage and apposition of sirolimus-eluting stents assessed by optical coherence tomography.

OBJECTIVES: We investigate the influence of stent design on stent coverage at 6-9 months after sirolimus eluting stent (SES) implantation using optical coherence tomography (OCT). BACKGROUND: Although some reports suggest that stent design may correlate with stent coverage of stent struts, there were few detailed data whether stent design impact on stent coverage in the same drug-eluting stent. METHODS: A total of 21 SESs (15 patients), who had implanted 2.5, 2.75, and 3.0 mm stents, underwent OCT at 6-9 months after stent implantation. SES is constructed by two different strut width-components; narrow strut width parts (59 µm) and wide strut width parts (115 µm). Thus, we divided stent struts of SESs into two groups: narrow strut width parts (narrow group) and wide ones (wide group). We compared the incidence of incomplete apposed struts, uncovered struts, and neointimal hyperplasia (NIH) thickness between the two groups. RESULTS: We could detect 2,948 struts (narrow group consisted of 1,132 struts and wide group consisted of 1,816 struts). Incidence of uncovered struts in the narrow group was significantly lower than in the wide group (30.2% vs. 40.8%, P < 0.001), and NIH thickness in the narrow group was significantly greater than in the wide group (127.5 ± 93.4 µm vs. 118.6 ± 81.4 µm, P = 0.03). CONCLUSIONS: Stent design, especially strut width, affects stent coverage of SES. The narrow strut may avoid the absence of stent coverage in SES, which correlates with stent thrombosis.

Ovarian vein thrombosis following total laparoscopic hysterectomy.

Ovarian vein thrombosis usually occurs in pregnant patients, especially during the postpartum period. However, it is a rare complication following laparoscopic surgery in gynecology. The risk of a thromboembolic event is not well defined, and evidence-based guidelines regarding deep vein thrombosis prophylaxis in gynecological laparoscopic surgery are still lacking. Herein we report a rare case of ovarian vein thrombosis following total laparoscopic hysterectomy in a 35-year-old woman who developed a fever of unknown origin on postoperative day 3. A complete fever work-up was done. Her urine, vaginal stump and blood culture were all negative, and her white blood cell count was normal. CT revealed left ovarian vein thrombosis. The patient responded well to anticoagulation in conjunction with antibiotic therapy.

Differences in optical coherence tomographic findings and clinical outcomes between excimer laser and cutting balloon angioplasty for focal in-stent restenosis lesions.

AIM: In-stent restenosis (ISR), especially focal ISR, after percutaneous coronary intervention (PCI) remains one of the major clinical problems in the drug-eluting stent (DES) era. Several reports have revealed that excimer laser coronary angioplasty (ELCA) is useful for ISR; however, detailed findings after ELCA are unknown. Therefore, we investigated the condition of the neointima after ELCA for ISR with optical coherence tomography (OCT) and compared the OCT findings and clinical outcome between ELCA and cutting-balloon angioplasty (CBA). METHODS: Twenty-one consecutive patients with focal ISR who underwent ELCA or CBA were enrolled. All patients underwent 12- to 15-month follow-up coronary angiography. OCT was performed immediately after successful PCI to evaluate the neointimal condition in the ISR lesion. We compared the following OCT parameters between ELCA and CBA groups: maximal thickness of remaining in-stent neointima (MTN), number of tears, minimum lumen dimension (MLD), and minimum lumen area (MLA). We also evaluated clinical outcomes, including target vessel revascularization, acute myocardial infarction, death, and stent thrombosis. RESULTS: MLA in the ELCA group (n = 10) was significantly larger than in the CBA group, and number of tears in the ELCA group was significantly lower than in the CBA group. A trend was shown toward lower TLR with ELCA versus CBA (10.0% vs 45.5%). CONCLUSIONS: OCT immediately after ELCA for ISR lesions revealed larger lumen area and smaller number of tears compared with CBA, which may support favorable effects of ELCA for focal ISR.

Bidirectional endovascular treatment for chronic total occlusive lesions of the femoropopliteal arterial segment using a hand-carried ultrasound device and a retrograde microcatheter.

BACKGROUND: Although endovascular therapy for complex lesions in the lower limbs has frequently achieved successful recanalization by improvement of techniques and devices, chronic total occlusion in the femoropopliteal arterial segment still remains a challenge for treatment by endovascular therapy. We investigated the efficacy and safety of endovascular therapy for chronic total occlusion in the femoropopliteal arterial segment guided by a hand-carried ultrasound (HCUS) device and supported by a retrograde microcatheter. METHODS: We attempted endovascular therapy for chronic total occlusion lesions in the femoropopliteal arterial segment using a protocol involving a dual-access procedure using the HCUS device and a retrograde 2.7F microcatheter from January 2008 to June 2010. We evaluated the success rate, complications, and clinical outcomes, including the ankle-brachial index (ABI) and primary and secondary patency. RESULTS: Success was achieved in 18 of 19 patients (95%), without major complications (only two small hematomas). The HCUS device was useful in reducing the personnel and space requirements, radiation exposure, and the required amount of contrast agent. The retrograde flexible 2.7F microcatheter was also useful in achieving successful recanalization and contributed to reducing puncture-related complications. The ABI was significantly improved, from 0.56 ± 0.12 to 0.81 ± 0.11 at 1 year (P < .01) and this effect remained stable. Primary and secondary patency was 63% and 89%, respectively, at 3 years. CONCLUSIONS: HCUS-guided and retrograde 2.7F microcatheter-supported endovascular therapy for chronic total occlusion lesions of the femoropopliteal arterial segment can achieve a favorable clinical outcome without major complications.

Valsalva aneurysm filled with thrombi mimicking a cardiac tumor.

A Valsalva aneurysm filled with thrombi can be difficult to diagnose, because it mimics a cardiac tumor. Both cardiac magnetic resonance imaging (MRI) and transesophageal echocardiogram (TEE) were performed on a patient who showed a low-echoic mass located between the atrial septum and the non-coronary sinus. Based on MRI findings allowing tissue characterization and the accurate location of the mass and the TEE findings of an irregular surface of the mass and a partial defect in the edge of the non-coronary sinus, we diagnosed the mass as a thrombosed Valsalva aneurysm that had perforated the inter-atrial septum. The operative findings coincided with the preoperative diagnosis. Both MRI and TEE are useful for diagnosing this condition.

Long-term follow-up of a rare calcified cardiac tumor: a case report.

We describe a case of cardiac masses (high- and iso-echoic mass) which were detected by echocardiography in a 57-year-old man with cerebral infarction. Because he refused both biopsy and surgery, the patient was treated with an anticoagulant and antibiotic in our outpatient clinic. During 3-year follow-up, the iso-echoic mass disappeared and the high-echoic mass did not change. Thus, we considered the iso-echoic mass a thrombus and the high-echoic mass a benign tumor. Cardiac computed tomography revealed that the high-echoic mass had extensive calcifications like phleboliths, and magnetic resonance imaging pattern coincided with that of hemangiomas. We conclude that the benign tumor/high-echoic mass might be a vascular malformation.

Impact of 64 multi-detector computed tomography for the evaluation of aortic paraprosthetic regurgitation.

BACKGROUND: Multi-detector computed tomography (MDCT) has been used to provide diagnostic information after heart valve replacements such as prosthetic valve dysfunction. However, only few data are available about aortic paraprosthetic regurgitation (APR). The aim of this study is to assess the feasibility, accuracy, and reproducibility of the existence of APR using contrast-enhanced 64-row MDCT. METHODS: We retrospectively evaluated 20 consecutive patients who underwent both 64-row MDCT and two-dimensional transthoracic echocardiography (2D-TTE) after aortic valve replacement. The presence of APR was evaluated with 64-row MDCT, and validated with 2D-TTE, two-dimensional transesophageal echocardiography (2D-TEE), or intraoperative findings if available. If APR was present, we also evaluated paraprosthetic anatomical regurgitation orifice (PARO) area to quantify the prognostic impact of APR or for surgical planning such as closure device sizing. RESULTS: Overall, 12 of 20 valves showed beam-hardening artifact (BHA) which made the reliable evaluation of APR difficult. The presence of artifact seemed to depend on valve types. Among 8 patients who did not show BHA, there were perfect agreements between MDCT and 2D-TTE, 2D-TEE, or intra-operative findings about APR. There were excellent inter-observer agreements in the evaluation of APR and PARO area. PARO area was consistent with the echocardiographic severity of APR in this study. CONCLUSIONS: Our retrospective data suggest that MDCT could be a reliable technique for the evaluation of APR after On-X standard or SJM standard valve replacement. MDCT can become a novel quantitative tool for the evaluation of PARO area.

Comparison of angioscopic findings and three-year cardiac events between sirolimus-eluting stent and bare-metal stent in acute myocardial infarction.

The safety of sirolimus-eluting stents (SESs) in acute myocardial infarction (AMI) remains controversial. We compared long-term neointimal coverage after stent implantation for AMI evaluated by coronary angioscopy and 3-year clinical events between SESs and bare-metal stents (BMSs). Eighty-seven consecutive patients who received SESs or BMSs for AMI were enrolled. At 8 months after AMI coronary angiography with angioscopy was performed. Using angioscopy we evaluated maximum and minimum grades of neointimal coverage using an angioscopic score (0 to 3). We calculated the heterogeneity score as the maximum grade minus the minimum grade. We compared angioscopic parameters including minimum grade and heterogeneity score of neointimal coverage, thrombi and plaque color, serum parameters, and major adverse cardiac events for 3 years between the 2 groups. The restenosis rate of the SES group (n = 56) was significantly lower than that of the BMS group (n = 31, 9% vs 31%, p = 0.015). The SES group had a lower minimum grade of neointimal coverage and higher heterogeneity score and prevalence of thrombi than the BMS group, but from 8 months to 3 years after stent implantation there were no significant differences in major adverse cardiac events between the 2 groups. In conclusion, a lower minimum grade and greater heterogeneity of neointimal coverage and thrombi were shown for SESs compared to BMSs at 8 months after AMI. However, these findings did not correlate with cardiac events over a period of 3 years in our patients.

Serial angioscopic evaluation of neointimal coverage and incidence of thrombus formation after Paclitaxel-eluting stent implantation: comparison between 6- and 18-month follow-up.

BACKGROUND: Long-term serial angioscopic follow-up data after paclitaxel-eluting stent (PES) implantation has not previously been published. The aim of this study is to compare the angioscopic parameters such as neointimal coverage grade and prevalence of red mural thrombus at 6- and 18-month follow-up after PES implantation. HYPOTHESIS: Neointimal formation continues to grow and prevalence of angioscopic thrombus formation becomes low over time after PES implantation. METHODS: We retrospectively enrolled 17 patients with 19 stents who underwent both 6- and 18-month follow-up coronary angioscopy after PES implantation. We evaluated the minimum and maximum neointimal coverage grade within 1 stent using coronary angioscopy by classifying neointimal coverage grade into 4 categories. Neointimal coverage grade and incidence of angioscopic red mural thrombus were compared between 6- and 18-month follow-up groups. RESULTS: Minimum neointimal coverage grade at 18 months become lower than that at the 6-month follow-up (0.95 ± 0.62 at 6 mo vs 0.58 ± 0.51 at 18 mo, P = 0.035), whereas maximum grade was not significantly different (2.16 ± 0.83 at 6 mo vs 2.37 ± 0.76 at 18 mo, P = 0.248). High incidence of angioscopic red mural thrombus at 6 months was maintained even at 18-month follow-up (68% at 6 mo vs 84% at 18 mo, P = 0.224). CONCLUSIONS: Long-term serial angioscopic follow-up demonstrated persistent high incidence of red mural thrombus formation at 18 months after PES implantation.

Chronic effect of right ventricular pacing on left ventricular rotational synchrony in patients with complete atrioventricular block.

BACKGROUND: Chronic effect of right ventricular (RV) pacing on left ventricular (LV) rotational synchrony is unknown. The aim of this study is to assess chronic effect of RV pacing on LV rotational synchrony using two-dimensional ultrasound speckle tracking imaging. METHODS AND RESULTS: Thirty-one patients who underwent dual-chamber pacemaker implantation for complete atrioventricular block, and age- and sex-matched 10 healthy controls were assessed. We divided our patients into RV apical (RVA, n = 16) and RV outflow tract (RVOT, n = 15) pacing groups. We compared echocardiographic parameters such as LV rotational synchrony between pacing groups and healthy control. We defined Q to peak rotation interval as the interval from the beginning of the Q-wave to the peak apical counter-clockwise or peak basal clockwise rotation. We calculated apical-basal rotation delay by subtracting basal Q to peak rotation interval from apical one as the representative of rotational synchronization. Apical-basal rotation delay of RVA pacing was significantly longer than that of healthy control (100 ± 110 vs. -6 ± 15 ms, P = 0.002), while there was no statistically significant difference between RVOT pacing and healthy control (-3 ± 99 vs. -6 ± 15 ms, P = 0.919). CONCLUSIONS: LV rotation during RVOT pacing is synchronous at 15 months after pacemaker implantation, while RVA pacing provokes LV rotational dyssynchrony by inducing delayed apical rotation at 7 years after pacemaker implantation in patients with complete atrioventricular block.

Vulnerable disease may induce neointimal coverage after sirolimus-eluting stent implantation.

BACKGROUND: Neointimal formation can protect against thrombosis after sirolimus-eluting stent (SES) implantation; however, promoters of neointimal formation are unknown. METHODS: Six-month follow-up angioscopy was performed in 141 consecutive patients with SES implantation. All patients received aspirin (100 mg) and ticlopidine (200 mg) daily until angioscopy. We defined 2 grades of neointimal coverage as follows: insufficient coverage including no or partial neointimal coverage of stent struts, and sufficient coverage. The possible promoters of neointimal formation that were evaluated in this study were the condition of coronary artery disease (stable angina or acute coronary syndrome); angioscopic markers, including visible thrombus and plaque color (white or yellow); serum markers, including low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, fasting blood glucose, hemoglobin A(1c), high-sensitive C-reactive protein, and fibrinogen; blood pressure and smoking; intervention markers, including stent size and length and intravascular ultrasound measurements; and medication, including statins, anticoagulants, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, calcium antagonists, and ß-blockers. RESULTS: Univariate analysis revealed that high-sensitive C-reactive protein, plaque color, and the condition of coronary artery disease were significantly correlated with the grade of neointimal coverage. Multivariate analysis using these 3 parameters revealed that only acute coronary syndrome (vulnerable disease) significantly promoted neointimal coverage. CONCLUSION: Vulnerable disease may promote neointimal coverage after SES implantation.

Renin-angiotensin system blockade is associated with the long-term protection against cardiac remodeling after cardioversion in hypertensive patients with atrial fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia, and renin-angiotensin system blockade (RAS-B) may be favorable for AF because of its effect on cardiac remodeling. However, effects of RAS-B on AF in hypertensive patients are controversial. Thus, in this study, we investigated the long-term effects of RAS-B on cardiac remodeling and rhythm control after electrical cardioversion for hypertensive patients with persistent AF. We studied 27 consecutive hypertensive patients with persistent AF (duration > one week) who received electrical cardioversion and once recovered to sinus rhythm. Blood pressure of the patients was controlled by medication including RAS-B. The patients were divided into those who were pre-treated with RAS-B (n = 10) for at least two months before electrical cardioversion and those without RAS-B (n = 17). We performed echocardiography before electrical cardioversion and 3 years after electrical cardioversion in all patients and compared the differences in echocardiographic cardiac remodeling parameters, including left atrial dimension, left ventricular end-diastolic dimension and left ventricular ejection fraction. The AF recurrence-free ratio during the follow-up period was significantly higher in the RAS-B group than in the non-RAS-B group, judged by Kaplan-Meier analysis (60 vs. 24%, P = 0.01). All cardiac remodeling parameters in the RAS-B group showed better values than those in non-RAS-B group (each parameter, P < 0.05), supporting the beneficial effects of RAS-B on AF in hypertensive patients. In hypertensive patients with AF, pre-treatment with RAS-B before electrical cardioversion can prevent cardiac remodeling for 3 years and maintain sinus rhythm.

High incidence of thrombus formation at 18 months after paclitaxel-eluting stent implantation: angioscopic comparison with sirolimus-eluting stent.

BACKGROUND: Difference of neointimal formational pattern and incidence of thrombus formation between sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES) at 18 months after stent implantation has not previously been reported. METHODS: We retrospectively enrolled 35 event-free patients who received SES (15 patients, 18 stents) or PES (20 patients, 23 stents) implantation with 18-month follow-up coronary angioscopy. We divided our patients into SES or PES groups and compared neointimal coverage pattern and incidence of red mural thrombus formation between the 2 groups. Neointimal coverage grades were classified into 4 categories. Minimum neointimal coverage grade, maximum grade, and heterogeneity score were assessed in each stent. Heterogeneity score was calculated by subtracting minimum from maximum grade within one stent. RESULTS: Minimum neointimal coverage grade of PES was significantly lower than that of SES (0.70 +/- 0.64 vs 1.33 +/- 0.69, P = .005), whereas maximum grade was not significantly different (2.48 +/- 0.73 vs 2.22 +/- 0.73, P = .218). Heterogeneity score and incidence of red mural thrombus of PES were higher than those of SES (1.78 +/- 0.80 vs 0.89 +/- 0.76, P = .002 and 70% vs 11%, P < .001). CONCLUSIONS: The present study revealed that PES shows more heterogeneous neointimal coverage and higher incidence of thrombus formation as compared with SES at 18 months after stent implantation.

Difference of neointimal formational pattern and incidence of thrombus formation among 3 kinds of stents: an angioscopic study.

OBJECTIVES: The purpose of this study is to compare the neointimal formational pattern and incidence of thrombus formation among sirolimus-eluting (SES), paclitaxel-eluting (PES), and bare-metal stents (BMS) with coronary angioscopy. BACKGROUND: Neointimal formation and incidence of mural thrombus are different with the type of stent. METHODS: One hundred successive patients who received 43 SES, 40 PES, or 32 BMS implantation underwent 6-month follow-up coronary angioscopy. We evaluated angioscopic parameters, including minimum and maximum neointimal grade; presence and number of red mural thrombus; neointimal grade around thrombus; and heterogeneity score, which is defined by subtracting minimum from maximum grade within 1 stent by classifying angioscopic neointimal coverage grades into 4 categories. We compared these parameters among 3 kinds of stent groups. RESULTS: Heterogeneity scores of SES, PES, and BMS were 0.79 +/- 0.60, 1.27 +/- 0.75, and 1.03 +/- 0.82, respectively (p = 0.011). The PES showed the highest incidence of angioscopic red mural thrombus (50% in PES, 12% in SES, and 3% in BMS, p < 0.001), and the number of thrombus observed within 1 stent in the PES group tended to be larger than those in the SES and BMS groups. CONCLUSIONS: At 6 months after stent implantation, PES showed the most heterogeneous neointimal formation and the highest incidence of thrombus formation compared with SES and BMS.

Two cases of quadricuspid aortic valve.

Quadricuspid aortic valve (QAV) is a rare congenital aortic valve anomaly. We present two cases of QAV diagnosed by using echocardiography including transesophageal echocardiography (TEE) and cardiac computed tomography (CT). The first case, QAV with four equal-sized cusps, was identified in a 58-year-old man. The second case, QAV with a small accessory cusp between the right coronary and non-coronary cusp, was identified in a 42-year-old man. TEE and cardiac CT could lead to accurate diagnosis of QAV. QAV in these two patients could be diagnosed before indication for surgery but it is necessary to continue careful follow-up.