Shorter door-to-balloon time, better long-term clinical outcomes in ST-segment elevation myocardial infarction patients: J-MINUET substudy.

BACKGROUND: The impact of shorter door-to-balloon (DTB time on long-term outcomes in ST-segment elevation myocardial infarction (STEMI treated with primary percutaneous coronary intervention (PPCI has not been fully elucidated. METHODS: We investigated 3283 consecutive patients with acute myocardial infarction selected from a prospective, nationwide, multicenter registry (J-MINUET database comprising 28 institutions in Japan between July 2012 and March 2014. Among the study population, we analyzed 1639 STEMI patients who had PPCI within 12 h of onset. Patients were stratified into four groups (DTB time < 45 min, 45-60 min, 61-90 min, >90 min. The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. We performed landmark analysis for incidence of the primary endpoint from 31 days to 3 years among the four groups. RESULTS: The primary endpoint rate from 31 days to 3 years increased significantly and time-dependently with DTB time (10.2 % vs. 15.3 % vs. 16.2 % vs. 19.3 %, respectively; log-rank p = 0.0129. Higher logarithm-transformed DTB time was associated with greater risk of a primary endpoint from 31 days to 3 years, and the increased number of adverse long-term clinical outcomes persisted even after adjusting for other independent variables. CONCLUSION: Shorter DTB time was associated with better long-term clinical outcomes in STEMI patients treated with PPCI in contemporary clinical practice. Further efforts to shorten DTB time are recommended to improve long-term clinical outcomes in STEMI patients. TRIAL REGISTRATION: UMIN Unique trial Number: UMIN000010037.

Prospective multi-center registry to evaluate efficacy and safety of the newly developed diamond-like carbon-coated cobalt-chromium coronary stent system.

The purpose of this multi-center, non-randomized, and open-label clinical trial was to determine the non-inferiority of diamond-like carbon (DLC)-coated cobalt-chromium coronary stent, the MOMO DLC coronary stent, relative to commercially available bare-metal stents (MULTI-LINK VISION®). Nineteen centers in Japan participated. The study cohort consisted of 99 patients from 19 Japanese centers with single or double native coronary vessel disease with de novo and restenosis lesions who met the study eligibility criteria. This cohort formed the safety analysis set. The efficacy analysis set consisted of 98 patients (one case was excluded for violating the eligibility criteria). The primary endpoint was target vessel failure (TVF) rate at 9 months after stent placement. Of the 98 efficacy analysis set patients, TVF occurred in 11 patients (11.2 %, 95 % confidence interval 5.7-19.2 %) at 9 months after the index stent implantation. The upper 95 % confidence interval for TVF of the study stent was lower than that previously reported for the commercially available MULTI-LINK VISION® (19.6 %), demonstrating non-inferiority of the study stent to MULTI-LINK VISION®. All the TVF cases were related to target vascular revascularization. None of the cases developed in-stent thrombosis or myocardial infarction. The average in-stent late loss and binary restenosis rate at the 6-month follow-up angiography were 0.69 mm and 10.5 %, respectively, which are lower than the reported values for commercially available bare-metal stents. In conclusion, the current pivotal clinical study evaluating the new MOMO DLC-coated coronary stent suggested its low rates of TVF and angiographic binary restenosis, and small in-stent late loss, although the data were considered preliminary considering the small sample size and single arm study design.

Resolution of spontaneous coronary artery dissection within 3 weeks detected by computed tomography angiography and intravascular ultrasound.

A 62-year-old woman was admitted with chest pain lasting about 3 h. Spontaneous coronary artery dissection (SCAD) was detected in the left anterior descending artery (LAD) by intravascular ultrasound (IVUS). Sixteen days after onset, follow-up computed tomography angiography was performed and revealed shrinkage of the false lumen of the SCAD. On hospital day 22, IVUS image confirmed that the SCAD in the LAD was completely healed. This case shows the possibility of rapid healing of SCAD.

Application of the real-time Retinex image enhancement for endoscopic images.

This paper presents a real-time image enhancement technique for gastric endoscopy, which is based on the variational approach of the Retinex theory. In order to efficiently reduce the computational cost required for image enhancement, processing layers and repeat counts of iterations are determined in accordance with software evaluation result, and as for processing architecture, the pipelining architecture can handle high resolution pictures in real-time. To show its potential, performance comparison between with and without the proposed image enhancement technique is shown using several video images obtained by endoscopy for different parts of digestive organ.

Early intervention with rosuvastatin decreases the lipid components of the plaque in acute coronary syndrome: analysis using integrated backscatter IVUS (ELAN study).

BACKGROUND: It has recently become possible to analyze coronary plaque characteristics by using integrated backscatter intravascular ultrasound (IB-IVUS). The aim of this study was to use this modality to evaluate the impact of early intervention with rosuvastatin on both the volume and tissue characteristics of non-culprit plaques in acute coronary syndrome (ACS). METHODS AND RESULTS: Patients with ACS underwent IB-IVUS after percutaneous coronary intervention procedure and were administered rosuvastatin. Follow-up IB-IVUS was recorded 6 months later. We analyzed the changes in plaque burden and tissue characteristics in these patients. Plaque components were classified as calcified, fibrous, and lipid according IB-IVUS. We comprehensively analyzed 20 ACS patients. The low-density lipoprotein-cholesterol levels decreased significantly from 117 ± 34 mg/dl to 73 ± 19 mg/dl (P<0.001) after statin therapy. Comparing the baseline images with the follow-up ones revealed a significant reduction in the plaque burden from 98.4 ± 42.1mm(3)/10mm to 80.2 ± 35.8 mm(3)/10mm (P<0.001) and in the lipid volume from 44.1 ± 29.6 mm(3)/10mm to 28.6 ± 17.8 mm(3)/10mm (P<0.001). With respect to the % lipid volume, the reduction rate at follow-up showed a significant correlation with its baseline value (r=-0.498, P=0.024). CONCLUSIONS: Early intervention with rosuvastatin in ACS patients enabled significant reduction of the non-culprit plaque during 6 months. This regression was mainly due to the decrease in the lipid component of the plaque.

Influence of circumferential pulmonary vein isolation for atrial fibrillation on ST elevation in patient with Brugada syndrome.

We present a patient with Brugada syndrome and paroxysmal atrial fibrillation who underwent circumferential pulmonary vein isolation. His electrocardiogram showed normal sinus rhythm and first-degree AV block (P-R 280 ms) with coved-type ST elevation in V1-2 (+2.0 mm) before ablation. During ablation around the left pulmonary vein ostium, atrial fibrillation, progression of ST elevation (+4.5 mm), and T wave alternans occurred. After right pulmonary vein encirclement was complete, ST elevation improved to +1.0 mm. The following day, the ST segments remained lower than baseline levels.

Rationale and design of assessment of lipophilic vs. hydrophilic statin therapy in acute myocardial infarction (the ALPS-AMI) study.

BACKGROUND: Statins reduce the incidence of cardiovascular events in patients with acute myocardial infarction (AMI). Although all statins are equally effective in secondary prevention, there might be certain differences in the effects of lipophilic and hydrophilic statins. Therefore, our aim is to compare the effectiveness of lipophilic atorvastatin and hydrophilic pravastatin in secondary prevention after AMI. METHODS AND RESULTS: This study is a prospective, randomized, open-label, multicenter study of 500 patients with AMI. Patients that have undergone successful percutaneous coronary intervention will be randomly allocated to receive either atorvastatin or pravastatin with the treatment goal of lowering their low-density lipoprotein-cholesterol level below 100 mg/dl for 2 years. The primary endpoint will be death due to any cause, nonfatal MI, nonfatal stroke, unstable angina, or congestive heart failure requiring hospital admission, or any type of coronary revascularization. CONCLUSION: This is the first multicenter trial to compare the effects and safety of lipophilic and hydrophilic statin therapy in Japanese patients with AMI. It addresses an important issue and could influence the use of statin treatment in the secondary prevention of coronary artery disease.

Noninvasive evaluation of coronary endothelial function following sirolimus-eluting stent implantation by using positron emission tomography.

OBJECTIVE: Several invasive studies have reported delayed reendothelialization and endothelial dysfunction following sirolimus-eluting stent (SES) implantation. We evaluated the changes in coronary endothelial function following SES implantation by using a noninvasive method that involved positron emission tomography and cold pressor testing (CPT). METHODS: The study was conducted on 14 lesions on which percutaneous coronary intervention (PCI) was successively performed. The lesions were classified into 2 groups depending on the PCI performed: the conventional PCI group, in which 7 conventional PCIs (plain old balloon angioplasty or bare-metal stents) were performed, and the SES group, in which 7 SESs were implanted. Coronary endothelial function was defined as the percent increase in the myocardial blood flow (MBF) during CPT. RESULTS: The resting MBF in the segments distal to the PCI sites did not differ between the conventional PCI and SES groups; however, the MBF significantly decreased in the SES group during CPT. CONCLUSIONS: These data suggest that SES implantation induces coronary endothelial dysfunction in the segments distal to the PCI sites.

Coagulation activity is increased in the left atria of patients with paroxysmal atrial fibrillation during the non-paroxysmal period. Comparison with chronic atrial fibrillation.

BACKGROUND: Evaluation of plasma markers of thrombin activity (thrombin-antithrombin III complex: TAT), active fibrinolysis (plasmin-alpha 2-plasmin inhibitor complex: PIC), and platelet activity (platelet factor 4: PF4) is useful for identifying patients with various cardiovascular disorders who are at high risk of thromboembolism. In this study, these markers were investigated in the left atria (LA) of patients with paroxysmal atrial fibrillation (pAF) in the non-paroxysmal period. METHODS AND RESULTS: Patients with pAF (n=10) and chronic AF (cAF) (n=10) were enrolled. TAT, PIC, and PF4 levels were determined in blood samples obtained from the LA of AF patients before radiofrequency catheter ablation. TAT levels were high in both pAF and cAF patients. PF4 levels were slightly elevated in both groups, but there was no significant difference between the groups. On the other hand, PIC levels in both groups were almost within normal limits, again with no significant difference between groups. CONCLUSIONS: Coagulation activity is elevated in the LA of patients with pAF, even in the non-paroxysmal period, so these patients are at high risk of thromboembolism and anticoagulant therapy is indicated.

Impact of accelerator-based boron neutron capture therapy (AB-BNCT) on the treatment of multiple liver tumors and malignant pleural mesothelioma.

BACKGROUND AND PURPOSE: To confirm the feasibility of accelerator-based BNCT (AB-BNCT) for treatment of multiple liver tumors and malignant pleural mesothelioma (MPM), we compared dose distribution and irradiation time between AB-BNCT and reactor-based BNCT (RB-BNCT). MATERIAL AND METHODS: We constructed treatment plans for AB-BNCT and RB-BNCT of four multiple liver tumors and six MPM. The neutron beam data on RB-BNCT were those from the research reactor at Kyoto University Research Reactor Institute (KURRI). The irradiation time and dose-volume histogram data were assessed for each BNCT system. RESULTS: In BNCT for multiple liver tumors, when the 5 Gy-Eq dose was delivered as the mean dose to the healthy liver tissues, the mean dose delivered to the liver tumors by AB-BNCT and RB-BNCT was 68.1 and 65.1 Gy-Eq, respectively. In BNCT for MPM, when the mean lung dose to the normal ipsilateral lung was 5 Gy-Eq, the mean dose delivered to the MPM tumor by AB-BNCT and RB-BNCT was 20.2 and 19.9 Gy-Eq, respectively. Dose distribution analysis revealed that AB-BNCT is superior to RB-BNCT for treatment of deep-seated tumors. CONCLUSIONS: The feasibility of the AB-BNCT system constructed at our institute was confirmed from a clinical viewpoint in BNCT for multiple liver tumors and MPM.

Elevated osteopontin levels in patients with peripheral arterial disease.

This study was carried out to compare concentrations of osteopontin (OPN) and osteoprotegerin (OPG) in peripheral arterial disease (PAD). The study population consisted of 200 consecutive subjects in whom both OPN/OPG and ankle-brachial index were measured. It was found that OPN levels, but not OPG levels, were significantly more increased in patients with PAD than those without PAD. Serum OPN levels were significantly lower in subjects with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers than those without these agents. In this study, it has been demonstrated for the first time that serum OPN levels are related to PAD. Inhibition of renin- angiotensin system could decrease OPN levels and prevent the progression of PAD.

Gigantic bronchial artery aneurysm treated with transcatheter arterial embolization: a case report.

Bronchial artery aneurysm (BAA) is a rare condition. Rupture of BAA can cause critical hemorrhage, and intervention for BAA is thus recommended. A 69-year-old woman presented with BAA 70 mm in diameter in the right hilum of the lung. Transcatheter arterial embolization for afferent arteries of the BAA was performed and the BAA has subsequently been shrinking as observed by radiography. We present this case and a brief review of management of BAA based on the literature.

Successful treatment of primary cardiac angiosarcoma with docetaxel and radiotherapy.

A 49-year-old man was admitted for primary cardiac angiosarcoma with a cardiac tamponade. Transthoracic echocardiography and contrast-enhanced computed tomography scan demonstrated a large mass in the right atrium and thickening of the right ventricular wall. 18F-labeled deoxyglucose (FDG) positron emission tomography (PET) scan showed increased FDG uptake in the mediastinum and over the heart. The patient responded to combination therapy with docetaxel and radiotherapy and tolerated the treatment well, except for radiation esophagitis, which required a soft diet and resolved 1 month after treatment. This combination therapy resulted in a minimal response with slight regression in the tumor size, but FDG-PET initially showed an increase in FDG uptake by the tumor that was no longer seen after combination therapy. There is no evidence of progression or metastasis even at 12 months after diagnosis.

Fluvastatin improves arterial stiffness in patients with coronary artery disease and hyperlipidemia: a 5-year follow-up study.

BACKGROUND: The present study was designed to test the hypothesis that fluvastatin might improve arterial stiffness, as assessed with pulse wave velocity (PWV), in patients with coronary artery disease (CAD) and hyperlipidemia over the long term. METHODS AND RESULTS: Ninety-three patients were randomly assigned to either fluvastatin (group A, n=50) or bezafibrate (group B, n=43) and followed for 5 years. There was no difference in the clinical findings between the 2 groups. In group A, there was a progressive reduction in the brachial-ankle PWV along with a decrease in serum low-density lipoprotein-cholesterol (LDL-C) and C-reactive protein (CRP) by 12 months after fluvastatin, and the improvement was maintained until 5 years after treatment. In group B, despite identical lowering of the serum lipid, PWV was progressively increased. In group A, the percentage change in PWV correlated significantly with that of the serum CRP (r=0.49, p<0.001), but not with that of the serum LDL-C after treatment. CONCLUSIONS: The beneficial vascular effects of fluvastatin persisted for a long period in patients with CAD and hyperlipidemia. Its anti-inflammatory action might contribute to the favorable effects on arterial stiffness.

Relationship of plasma brain-type natriuretic peptide levels to left ventricular longitudinal function in patients with congestive heart failure assessed by strain Doppler imaging.

BACKGROUND: Plasma brain-type natriuretic peptide (BNP) levels have been used to diagnose congestive heart failure (CHF), but significant heterogeneity in BNP levels is not explained by standard echocardiographic indexes of cardiac function. Recent data indicate that longitudinal left ventricular (LV) dysfunction exists in the presence of normal standard echocardiographic indexes and BNP was predicted well by LV longitudinal systolic velocity. We examined whether longitudinal LV function assessed by strain or strain rate (SR) tissue Doppler imaging could be determinants of plasma BNP levels in patients with CHF. METHODS: We examined 137 consecutive patients with suspected CHF. Standard echocardiography and Doppler flow records were obtained. Strain, and SR at the basal and mid parts of the ventricle were investigated in 2 apical views. Tissue velocities of mitral annulus were also obtained. Plasma BNP levels were measured on the day of echocardiography. RESULTS: Multivariate analysis showed the mean longitudinal LV strain (r=0.75, P<0.0001) to be an independent powerful predictor of plasma log BNP levels. Subgroup analysis (ejection fraction <50%, n=30; ejection fraction >50%, n=107) also showed that the mean longitudinal LV strain (r=0.89, P<0.0001; r=0.68, P<0.0001, respectively) was only an independent predictor of log BNP levels. CONCLUSION: Longitudinal LV strain is closely related to log BNP levels in patients with CHF, both in patients with systolic and diastolic heart failure.

Temporary inferior vena cava filter for deep vein thrombosis and acute pulmonary thromboembolism: effectiveness and indication.

Although the temporary inferior vena cava filter (IVC-F) is being used increasingly for protection against pulmonary thromboembolism (PTE), indications for its use are not established. Our strategy for the prevention of PTE is: (1) contraindication or failure of anticoagulation: permanent IVC-F; (2) for patients with residual proximal deep vein thrombosis (a) who have permanent risk factor: permanent IVC-F; (b) who have transient risk factor: temporary IVC-F; (3) others: no IVC-F. Temporary IVC-F was also implanted in deep vein thrombosis (DVT) patients without PTE who were preoperation or had floating thrombus. We investigated the outcome of patients given a temporary IVC-F versus those given a permanent IVC-F to clarify the efficacy and our strategy for implantation of a temporary IVC-F. Subjects were 12 men and 38 women with acute PTE and/or floating DVT admitted to our hospital between April 1999 and April 2002. Patient age was 25-91 years (mean 63 years). Eighteen patients were given a permanent IVC-F (group A) and 32 patients were given a temporary IVC-F (group B) as primary treatment, according to our criteria. There were no major complications in either group. Mortality after implantation of the IVC-F was 35% (6/17) in group A and 16% (4/25) in group B, with no significant difference (P = 0.14). Pulmonary thromboembolism recurred in 18% (3/17) of group A patients but in no group B patients (P = 0.10). All recurrences resulted in death. The 14 patients in group B who were not given a permanent IVC-F after removal of the temporary IVC-F survived. The temporary IVC-F can be used safely in patients with venous thromboembolism and is efficacious in preventing recurrence of PTE. Prognosis after removal of the temporary IVC-F is excellent.

Long-term vardenafil therapy improves hemodynamics in patients with pulmonary hypertension.

The phosphodiesterase-5 (PDE-5) inhibitor, sildenafil, has been reported to produce sustained pulmonary vasodilatation in patients with pulmonary hypertension (PH). Recently, vardenafil, a more potent and selective PDE-5 inhibitor than sildenafil, has been approved for the treatment of erectile dysfunction. However, the long-term effects of oral vardenafil in patients with PH are unknown. We studied five consecutive patients with PH; one with primary pulmonary hypertension, two with chronic pulmonary thromboembolism, one with Eisenmenger syndrome (ventricular septal defect) and one with secondary pulmonary hypertension after a ventricular septal defect closure operation. In an acute hemodynamic trial, vardenafil (5 mg) significantly decreased both the pulmonary vascular resistance (PVR) and systemic vascular resistance (SVR) with an increase in cardiac output. In a chronic hemodynamic trial, the maintenance dose of vardenafil (10 to 15 mg) for 3 months significantly decreased the PVR, but not the SVR, with a 20.7% reduction of the PVR/ SVR ratio. Plasma brain natriuretic peptide (BNP) levels were also significantly decreased after 3 months. This pilot study demonstrates that long-term oral vardenafil therapy may be a safe and effective treatment for patients with PH.

Diurnal variation in QT dispersion in patients with chronic heart failure.

QT dispersion is defined as the difference in QT interval among the different leads of the standard 12-lead electrocardiogram and reflects inhomogeneity of myocardial repolarization. Dispersion of repolarization is an important electrophysiologic feature that is considered fundamental for the initiation of ventricular fibrillation. However, no data exist regarding the diurnal variation of QT dispersion measured from simultaneous 12-lead recording in chronic heart failure patients. The aim of this study was to identify diurnal variation in QT dispersion in patients with chronic heart failure. QT dispersion was measured in the 12-lead standard electrocardiogram in 11 patients with chronic heart failure. QT dispersion in these patients was increased in the afternoon compared to the morning. It is concluded that QT dispersion has a clear diurnal variation in patients with chronic heart failure. These findings have potentially significant implications for therapy and prevention of sudden cardiac death in patients with chronic heart failure.

Radiofrequency catheter ablation of accessory pathway in a patient with Ebstein's anomaly and atrial septal defect--a case report.

The authors report the case of a 57-year-old woman with Ebstein's anomaly and atrial septal defect. She was referred to their hospital for treatment of refractory paroxysmal wide QRS tachycardia. Her 12-leads ECG in sinus rhythm showed ventricular preexcitation of type B Wolff-Parkinson-White syndrome. In a baseline electrophysiological study, a wide QRS tachycardia with right bundle branch block configurations was induced. This tachycardia was orthodromic atrioventricular reciprocating tachycardia with a right inferior accessory pathway. Radiofrequency current was successfully delivered at the inferior site of the atrialized right ventricle. Radiofrequency catheter ablation seems to be useful for supraventricular tachycardia in patients with Ebstein's anomaly and atrial septal defect.

Large saccular aneurysm in a coronary arterial fistula--a case report.

The authors present a case of a large saccular aneurysm in a coronary artery fistula originating from the proximal left anterior descending coronary artery, draining into the main trunk of the pulmonary artery. The diagnosis was made by 3-dimensional computed tomography and coronary arteriography. Congenital coronary artery fistula is not uncommon. With a saccular aneurysm, however, it is very rare. A ruptured aneurysm will induce sudden death if surgical repair is not done.