Balloon-expandable covered stent to superficial femoral artery.

A 57-year-old woman with critical limb-threatening ischemia (CLTI) of the left lower leg underwent endovascular therapy. She had undergone a femoropopliteal (F-P) bypass for treatment of chronic total occlusion (CTO) of the superficial femoral artery (SFA) four years prior.

Rescue balloon pulmonary angioplasty for worsening chronic thromboembolic pulmonary hypertension with essential thrombocythaemia and the JAK2-V617F mutation: a case report.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare thromboembolic disease, with occasional critical consequences. Essential thrombocythaemia (ET) is associated with an increased incidence of venous and arterial thrombotic events. In addition, the JAK2-V617F mutation increases the risk of thrombosis. Few reports have evaluated the utility of balloon pulmonary angioplasty (BPA) for worsening CTEPH with ET and the JAK2-V617F mutation. Case Summary: A 76-year-old woman, diagnosed with ET and the JAK2-V617F mutation, presented with dyspnoea. Echocardiography showed severe tricuspid regurgitation with a flattened interventricular septum. Contrast-enhanced computed tomography showed an eccentric thrombus in the right main pulmonary artery (PA) and thrombi in bilateral peripheral PAs. Acute pulmonary embolism (PE) was initially diagnosed, and heparinization was initiated; however, her oxygen saturation gradually worsened despite continued anticoagulation therapy. Her oxygen saturation level decreased to 90% (under a reservoir mask of 10 L). Her haemodynamics suggested CTEPH comorbidity. We decided to perform emergency right heart catheterization (RHC) and pulmonary angiography (PAG). RHC showed severe pulmonary hypertension. PAG showed fresh and organized thrombi and web regions in several segmental PAs. These findings indicated a combination of acute PE and CTEPH. Rescue BPA was performed on the right A1, A3, A8, and A9 segments. After BPA, the patient's oxygen saturation showed marked improvement. The patient was discharged 18 days after hospitalization without complications. Discussion: Rescue BPA could be an effective treatment for worsening CTEPH in severely impaired conditions, even with ET and the JAK2-V617F mutation.

Emergent balloon pulmonary angioplasty in a patient with central-type chronic thromboembolic pulmonary hypertension with cardiac shock.

The standard treatment of chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA); however, it may be unsuitable in the presence of comorbidities such as cardiac shock and severe hypoxia. We describe a successful case of emergent balloon pulmonary angioplasty performed before PEA in a patient with deteriorating central-type CTEPH.

Characteristics, Antithrombotic Patterns, and Prognostic Outcomes in Claudication and Critical Limb-Threatening Ischemia Undergoing Endovascular Therapy.

PURPOSE: The underlying difference between intermittent claudication (IC) and critical limb-threatening ischemia (CLTI) still remains unclear. This prospective multicenter observational study aimed to clarify differences in clinical features and prognostic outcomes between IC and CLTI, and prognostic factors in patients undergoing endovascular therapy (EVT). MATERIALS AND METHODS: A total of 692 patients with 808 limbs were enrolled from 20 institutions in Japan. The primary measurements were the 3-year rates of major adverse cardiovascular event (MACE) and reintervention. RESULTS: Among patients, 79.0% had IC and 21.0% had CLTI. Patients with CLTI were more frequently women and more likely to have impaired functional status, undernutrition, comorbidities, hypercoagulation, hyperinflammation, distal artery disease, short single antiplatelet and long anticoagulation therapies, and late cilostazol than patients with IC. Aortoiliac and femoropopliteal diseases were dominant in patients with IC and infrapopliteal disease was dominant in patients with CLTI. Patients with CLTI underwent less frequently aortoiliac intervention and more frequently infrapopliteal intervention than patients with IC. Longitudinal change of ankle-brachial index (ABI) exhibited different patterns between IC and CLTI (pinteraction=0.002), but ABI improved after EVT both in IC and in CLTI (p<0.001), which was sustained over time. Dorsal and plantar skin perfusion pressure in CLTI showed a similar improvement pattern (pinteraction=0.181). Distribution of Rutherford category improved both in IC and in CLTI (each p<0.001). Three-year MACE rates were 20.4% and 42.3% and 3-year reintervention rates were 22.1% and 46.8% for patients with IC and CLTI, respectively (log-rank p<0.001). Elevated D-dimer (p=0.001), age (p=0.043), impaired functional status (p=0.018), and end-stage renal disease (p=0.019) were independently associated with MACE. After considering competing risks of death and major amputation for reintervention, elevated erythrocyte sedimentation rate (p=0.003) and infrainguinal intervention (p=0.002) were independently associated with reintervention. Patients with CLTI merely showed borderline significance for MACE (adjusted hazard ratio 1.700, 95% confidence interval 0.950-3.042, p=0.074) and reintervention (adjusted hazard ratio 1.976, 95% confidence interval 0.999-3.909, p=0.05). CONCLUSIONS: The CLTI is characterized not only by more systemic comorbidities and distal disease but also by more inflammatory coagulation disorder compared with IC. Also, CLTI has approximately twice MACE and reintervention rates than IC, and the underlying inflammatory coagulation disorder per se is associated with these outcomes. CLINICAL IMPACT: The underlying difference between intermittent claudication (IC) and critical limb-threatening ischemia (CLTI) still remains unclear. This prospective multicenter observational study, JPASSION study found that CLTI was characterized not only by more systemic comorbidities and distal disease but also by more inflammatory coagulation disorder compared to IC. Also, CLTI had approximately twice major adverse cardiovascular event (MACE) and reintervention rates than IC. Intriguingly, the underlying inflammatory coagulation disorder per se was independently associated with MACE and reintervention. Further studies to clarify the role of anticoagulation and anti-inflammatory therapies will contribute to the development of post-interventional therapeutics in the context of peripheral artery disease.

Twelve-month safety and effectiveness of TCD-17187 drug-coated balloon for the treatment of atherosclerotic lesions in the superficial femoral and proximal popliteal artery.

PURPOSE: The aim of this preapproval trial was to evaluate the 12-month safety and effectiveness of the TCD-17187 drug-coated balloon (DCB) for the treatment of atherosclerotic lesions in the superficial femoral artery (SFA) and/or proximal popliteal artery (PA). METHODS: This was a prospective, multicenter, core laboratory adjudicated, single-arm trial. From October 2019 to November 2020, a total of 121 symptomatic peripheral artery disease patients with SFA and/or proximal PA lesions were enrolled. The primary effectiveness endpoint was 12-month primary patency defined as freedom from restenosis as determined by duplex ultrasonography in the absence of clinically driven target lesion revascularization (CD-TLR). The safety endpoint was the major adverse event (MAE) rate defined as freedom from a composite of device- and procedure-related death within 30 days, and index limb major amputation and/or CD-TLR through follow-up. RESULTS: Average age was 74.5 ± 7.3 years and the frequency of diabetes mellitus was 67.5%. Average lesion length and vessel diameter were 106.0 ± 52.6 and 5.2 ± 0.8 mm, respectively. The frequency of chronic total occlusion and bilateral calcification was 17.5% and 50.8% of patients, respectively. The 12-month primary patency rate calculated by Kaplan-Meier analysis was 81.1%, while 12-month freedom from CD-TLR was 95.8%. The MAE rate at 30 days was 1.7% and all events comprised CD-TLR. There were no instances of device- or procedure-related deaths, major amputations, or thrombosis throughout the 12-month evaluation period. CONCLUSION: This preapproval trial confirmed the safety and effectiveness of TCD-17187 DCB in the treatment of atherosclerotic lesions in the SFA and/or proximal PA.

Cardiac function response to stenting in atherosclerotic renal artery disease with and without heart failure: results from the Carmel study.

AIMS: Consensus-derived guidelines recommend renal stenting for patients with atherosclerotic renal artery disease (ARAD) and heart failure (HF). The aim of this prospective multi-centre observational study was to verify our hypothesis that changes in E/e', an echocardiographic correlate of left ventricular (LV) filling pressure, following renal stenting may differ between ARAD patients with and without HF. METHODS AND RESULTS: This study enrolled de novo ARAD patients undergoing renal stenting at 14 institutions. The primary endpoint was the difference in E/e' change between ARAD patients with and without HF. Clinical and echocardiographic data were prospectively collected at baseline, the day following renal stenting, and 1 month and 6 months afterwards. ARAD patients with HF were defined as patients with New York Heart Association (NYHA) Class 2 and more, or a history of HF hospitalization. A total of 76 patients were included, and 39% were ARAD patients with HF. ARAD patients with HF had significantly lower estimated glomerular filtration rate (P = 0.028) and higher NYHA functional class (P < 0.001) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score (P = 0.001) than ARAD patients without HF. Also, ARAD patients with HF had significantly lower LV ejection fraction (P = 0.003) and e'-velocity (P = 0.003) and higher E/e' ratio (P = 0.001), left atrial volume index (LAVI) (P = 0.046), LV end-diastolic volume (LVEDV) (P = 0.001), LV end-systolic volume (LVESV) (P = 0.001), and LV mass index (P = 0.009) than ARAD patients without HF. All procedures were successful. In contrast to blood pressure and renal function, there was a significant interaction in E/e' (Pinteraction  < 0.001) between time and HF, and ARAD patients with HF showed a significant (P < 0.001) decrease in E/e' albeit those without HF. By the same token, there was a significant interaction in NYHA class (Pinteraction  < 0.001), MLHFQ score (Pinteraction  = 0.018), E-velocity (Pinteraction  = 0.002), LAVI (Pinteraction  = 0.001), LVEDV (Pinteraction  = 0.003), and LVESV (Pinteraction  = 0.001) between time and HF with a significant improvement in all these variables in ARAD patients with HF (NYHA class, P = 0.001; MLHFQ score, P = 0.002; E-velocity, P = 0.005; LAVI, P = 0.001; LVEDV, P = 0.017; and LVESV, P = 0.011). CONCLUSIONS: Change in LV filling pressure after renal stenting differed between ARAD patients with and without HF, with a significant improvement in LV filling pressure in patients with HF-ARAD. These unique findings might support clinical cardiac benefits of renal stenting in ARAD patients with HF.

In vivo optical coherence tomography of very late drug-eluting stent thrombosis compared with late in-stent restenosis.

BACKGROUND: Autopsy findings have suggested delayed arterial healing as a primary cause of very late stent thrombosis (VLST) after drug-eluting stent (DES) implantation. METHODS AND RESULTS: Optical coherence tomography of DES-treated lesions that developed VLST (n = 6) was compared with that of DES-treated lesions that developed late in-stent restenosis (L-ISR: n = 32) among patients with recurrent ischemia >1 year after DES implantation (mean, 37 ± 17 months), and with the stented segment without any evidence of VLST or L-ISR (no-event: n = 20; mean, 38 ± 19 months). The proportion of uncovered and malapposed struts in each stented segment was evaluated. A total of 961 frames, 9,763 struts were analyzed. The proportion of uncovered struts was higher in the VLST group than in the L-ISR group and the no-event group (29.2 ± 22.8%, 7.9 ± 9.7%, and 7.6 ± 8.0%, respectively; P = 0.0002). The proportion of malapposed struts was higher in the VLST group than in the no-event group (7.3 ± 8.7% vs 1.1 ± 2.4%, P = 0.01). Two patients in the VLST group had lower rates of uncovered and malapposed struts, but this involved lipid-laden-like neointima with disruptions. CONCLUSIONS: Delayed neointimal coverage and incomplete stent apposition were frequently observed in the DES-treated lesions that developed very late thrombosis. Lipid-laden-like neointima with disruption within the DES may be another possible mechanism for very late thrombosis.

The potential benefits and risks of the use of dual antiplatelet therapy beyond 6 months following sirolimus-eluting stent implantation for low-risk patients.

BACKGROUND: The optimal duration of dual antiplatelet therapy (DAT) in patients undergoing intracoronary sirolimus-eluting stent implantation remains controversial. OBJECTIVE: To evaluate the clinical effects of long duration DAT in patients undergoing intracoronary sirolimus-eluting stent implantation in daily practice. In addition, to attempt to identify the optimal duration of DAT after implantation of a sirolimus-eluting stent. METHODS: We retrospectively report on 1293 consecutive patients who underwent successful intracoronary sirolimus-eluting stent implantation. We analyzed the cumulative incidence of stent thrombosis, non-fatal myocardial infarction (MI), death from cardiac causes, and the cumulative incidence of bleeding complications. RESULTS: We compared the study end point in patients who received DAT for <6 months (n=1136) with that for patients who received DAT for >6 months (n=157). The median follow-up period was 1260 ± 462 days. Major bleeding occurred in 35 patients and intracranial hemorrhage in 8. In patients on DAT for >6 months, the incidence of any bleedings, major bleedings, and intracranial hemorrhage was significantly increased. On the other hand, there was no significant difference between the two groups in the risk of the primary end points (stent thrombosis, non-fatal MI, death from cardiac causes, death or MI). CONCLUSIONS: Prolonged DAT for more than 6 months was not significantly more beneficial than aspirin monotherapy in reducing the risk of the occurrence of acute MI, stent thrombosis, and death, although it was associated with an increase in bleeding complications for low-risk patients.

The impact of gender difference on the effects of preinfarction angina on microvascular damage with reperfused myocardial infarction.

BACKGROUND: Few studies have addressed gender differences in evoking preconditioning. In an experimental study, it was reported that the preconditioning effect disappeared after gonadectomy. OBJECTIVES: We sought to determine the effects of preinfarction angina (PA) on myocardial damage using intravenous contrast echocardiography. METHODS: We studied 334 consecutive patients with anterior myocardial infarction (AMI) who underwent successful angioplasty. All patients underwent myocardial contrast echocardiography (MCE) 14 days after percutaneous coronary intervention (PCI). Contrast defect was calculated as contrast defect area/myocardial area. Typical angina occurring in the 24-hour period preceding myocardial infarction was present in 133 patients (29 women) (group PA) and absent in 201 patients (43 women) (group non-PA). All women were postmenopausal. RESULTS: The contrast defect size and peak creatinine phosphokinase (max CPK) level in women were both significantly higher than that of men in group PA (18.3% +/- 6.3% vs 11.9% +/- 9.0%; P < 0.01 and 5000 +/- 599 IU/L vs 2672 +/- 221 IU/L; P < 0.005). The functional status of the myocardium among group PA, as expressed by risk area wall motion score index, was better in men than in women at 14 days (1.1 +/- 0.8 vs 1.7 +/- 0.8; P < 0.01) and at 6 months (0.7 +/- 0.4 vs 1.6 +/- 0.6; P < 0.01). However there were no significant gender differences in group non-PA. Multivariate regression analysis showed that the female gender (P < 0.05) was a significant independent predictor for microvascular damage. CONCLUSIONS: These findings suggest that preconditioning effects were attenuated in women with reperfused AMI.

Waist circumference reduction is more strongly correlated with the improvement in endothelial function after acute coronary syndrome than body mass index reduction.

BACKGROUND: Endothelial function predicts recurrence of adverse cardiac events in patients with acute coronary syndromes (ACS). Moreover, the recovery of endothelial function correlates with cardiac event-free survival. OBJECTIVES: The aim of this study was to determine which clinical factors correlate with the improvement in endothelial function after ACS. METHODS: Vascular endothelial function was assessed in 98 patients with ACS by flow-mediated dilation (FMD) of the brachial artery using high-resolution ultrasound at 2 weeks and 6 months after ACS. We measured several risk parameters including plasma markers of glucose homeostasis, lipids, and blood pressure at baseline and at 6 months after ACS. Body mass index (BMI) and waist circumference (WC) were also measured as anthropometric assessments. RESULTS: At baseline, FMD was significantly correlated with BMI, WC, high-density lipoprotein cholesterol, the homeostasis model assessment of insulin resistance, and brachial artery diameter (r=-0.32, p=0.001; r=-0.44, p<0.0001; r=0.34, p=0.0006; r=-0.21, p=0.04; r=-0.47, p<0.0001, respectively). In a stepwise multivariate regression analysis at baseline, larger WC and brachial artery diameter were independently correlated with lower brachial artery FMD (R(2)=0.319, p<0.0001). At 6 months, the change in FMD was significantly correlated with the change in WC and BMI (r=-0.59, p<0.0001; r=-0.33, p=0.001, respectively). In a stepwise multivariate regression analysis, WC reduction was independently correlated with improved FMD (R(2)=0.349, p<0.0001). CONCLUSIONS: WC reduction is more strongly correlated with the improvement of endothelial function after ACS than BMI reduction.

Effects of smoking cessation on coronary endothelial function in patients with recent myocardial infarction.

BACKGROUND: Smoking is associated with an increased risk and extent of advanced atherosclerotic vascular disease, but few studies have examined the clinical effect of smoking cessation on human coronary endothelial function. OBJECTIVES: We sought to determine the effects of smoking cessation on endothelial function in patients with recent myocardial infarction. METHODS: Infarcted-not-related coronary arteries of 53 patients with acute myocardial infarction undergoing successful angioplasty were examined in two groups: smoking cessation group (n=35, 28 males, mean age 56 years) and non-smoking group (n=18, 10 males, mean age 65 years). We infused acetylcholine into the coronary artery and the diameter was assessed by quantitative angiography at baseline and 6 months after PTCA. RESULTS: The mean % diameter change from baseline was significantly more constricted in the smoking cessation group than in the non-smoking group (38%+/-5 vs. 19%+/-5, p<0.05). However, the response after six months was significantly decreased after smoking cessation (from 38%+/-5 to 28%+/-4, p<0.01). Multiple regression analysis showed smoking cessation (p=0.03) was a significant determinant factor for improvement of endothelial function. CONCLUSIONS: These findings suggest that just 6 months of smoking cessation improves coronary endothelial function in patients with recent myocardial infarction.

Usefulness of coronary flow reserve immediately after primary coronary angioplasty for acute myocardial infarction in predicting long-term adverse cardiac events.

Coronary flow reserve (CFR) evaluated immediately after reperfusion is thought to reflect the degree of microvascular injury and predict left ventricular (LV) functional recovery after acute myocardial infarction. It was hypothesized that CFR immediately after reperfusion would be predictive of the occurrence of long-term adverse cardiac events. Using a Doppler guidewire, CFR was evaluated immediately after primary coronary angioplasty in 118 consecutive patients with first anterior acute myocardial infarctions. Adverse cardiac events combining cardiac death, recurrent myocardial infarction, and congestive heart failure were recorded during an average follow-up period of 62 +/- 32 months. Using receiver-operating characteristic analysis, CFR 1.3 (n = 68). Patients with CFR 1.3. CFR was significantly correlated with the LV ejection fraction at 4 weeks (r = 0.50, p <0.0001) and LV end-diastolic volume at 4 weeks (r = -0.43, p <0.0001). Kaplan-Meier survival analysis showed a higher incidence of adverse cardiac events in patients with CFR

Relation between neutrophil counts on admission, microvascular injury, and left ventricular functional recovery in patients with an anterior wall first acute myocardial infarction treated with primary coronary angioplasty.

Increased neutrophil counts have been associated with an increased risk of adverse clinical events after acute myocardial infarction (AMI). We examined the association of neutrophil counts on admission with degree of microvascular injury and left ventricular functional recovery after primary coronary angioplasty in AMI. We studied 116 patients with a first anterior wall AMI who underwent primary coronary angioplasty within 12 hours of onset. Patients were categorized into 3 groups based on initial neutrophil count: low (<5,000/mm(3)), intermediate (5,000 to 10,000/mm(3)), and high (>10,000/mm(3)). Coronary flow velocity parameters were assessed immediately after reperfusion using a Doppler guidewire. We defined severe microvascular injury as the presence of systolic flow reversal and a diastolic deceleration time <600 ms. Echocardiographic wall motion was analyzed before revascularization and 4 weeks after revascularization. In patients with a high neutrophil count, systolic flow reversal was more frequently observed, diastolic deceleration time was shorter, and coronary flow reserve was lower. By regression analysis, neutrophil count significantly correlated with diastolic deceleration time (r = -0.38, p <0.0001), coronary flow reserve (r = -0.33, p = 0.0004), and score for change in wall motion (r = -0.36, p = 0.0004). Multivariate analysis showed that neutrophil count on admission was an independent predictor of severe microvascular injury (odds ratio 2.94, p = 0.02). In conclusion, neutrophilia on admission is associated with impaired microvascular reperfusion and poor functional recovery after primary coronary angioplasty.

Early prediction of myocardial salvage after primary coronary angioplasty: comparative study of coronary flow velocity pattern immediately after primary coronary angioplasty and perfusion-metabolism mismatch.

OBJECTIVES: Perfusion-metabolism mismatch in the subacute phase using thallium-201/radio iodinated beta-methyl-p-iodophenyl pentadecanoic acid (T1/BMIPP) dual scintigraphy is an indicator of viable myocardium in acute myocardial infarction. This study investigated early prediction of myocardial salvage from the T1/BMIPP mismatch and coronary flow velocity (CFV) patterns in patients with acute myocardial infarction. METHODS: Thirty three patients with first anterior wall myocardial infarction underwent primary coronary angioplasty and achieved reflow within 8 hr of onset. By using a Doppler guide wire, CFV patterns were assessed immediately after primary coronary angioplasty. T1/BMIPP dual scintigraphy was performed within 3 days after reperfusion. The extent of discordance in severity score was defined as the T1/BMIPP mismatch score. RESULTS: Regression analysis showed dual scintigraphy mismatch score correlated well with deceleration time of diastolic flow velocity (r = 0.54, p < 0.01). Mismatch score was greater in the non-early systolic reversal flow group than in the early systolic reversal flow group (5.5 +/- 3.3 vs 1.9 +/- 2.1, respectively, p < 0.01). CONCLUSIONS: Changes in CFV patterns correlated well with T1/BMIPP mismatch score. CFV pattern immediately after reperfusion is useful for early prediction of myocardial salvage.

Usefulness of ultrasonic strain measurements to predict regional wall motion recovery in patients with acute myocardial infarction after percutaneous coronary intervention.

Strain Doppler echocardiography can detect systolic regional myocardial dysfunction. This study assessed whether strain could predict recovery of regional left ventricular function in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention. Forty-three patients with anterior AMI undergoing successful percutaneous coronary intervention of the left anterior descending coronary artery were studied. Longitudinal myocardial strain was measured at the left anterior descending coronary artery territory in the apical long-axis view within 24 hours after percutaneous coronary intervention. Regional wall motion was analyzed by the anterior wall motion score index (A-WMSI). Viable myocardium was defined as a decrease < or = 2.0 in A-WMSI. Patients were categorized as A-WMSI at 4 weeks into a viable group (n = 24) and a nonviable group (n = 19). End-systolic strain and peak strain were significantly lower in the nonviable group than in the viable group (-4.8 +/- 4.8% vs -9.9 +/- 4.7 %, p <0.005; -9.9 +/- 4.6 vs -13.5 +/- 4.1 %, p <0.05). Moreover, corrected time to peak strain (cTPS; time delay from end-systolic to peak strain/RR interval) was significantly longer in the nonviable group than in the viable group (0.19 +/- 0.04 vs 0.13 +/- 0.03, p <0.0001). For prediction of viable myocardium, cTPS <0.15 had a sensitivity of 95% and a specificity of 85%. In conclusion, strain, especially cTPS, is useful for predicting recovery of regional left ventricular function in patients with AMI after percutaneous coronary intervention.

The effects of atorvastatin on coronary endothelial function in patients with recent myocardial infarction.

BACKGROUND: Endothelial dysfunction is a key early event in atherosclerosis that occurs in acute coronary syndrome. It was reported that atorvastatin improves the endothelial function of skeletal muscle vessels, but the effect on the coronary artery is unknown. HYPOTHESIS: The purpose of this study is to determine the effects of atorvastatin on coronary endothelial function in humans. METHODS: Non-infarct-related coronary arteries of 48 patients with acute myocardial infarction who had undergone successful percutaneous transluminal coronary angioplasty were examined. Three groups were studied: hyperlipidemia with use of atorvastatin (Group 1, n=17), hyperlipidemia without statin use (Group 2, n=18), and normal cholesterol level controls (Group 3, n=13). Statin treatment was started at discharge. Acetylcholine (Ach) was infused into the coronary artery and the diameter was assessed by quantitative angiography at baseline and after 6 months. RESULTS: Acetylcholine given in doses of 1, 3, 10, and 30 mg/min increased the coronary artery diameter change in a dose-dependent manner. In the initial study, patients in the three groups had similar responses to Ach. The mean diameter change after 6 months was significantly improved in Group 1 compared with Groups 2 and 3 (-11 +/- 3% vs. -20 +/- 7% and -21 +/- 6%, respectively; p < 0.01 in each case). Multivariate regression analysis showed that atorvastatin (p < 0.01) was the significant determinant for improvement of endothelial function. CONCLUSIONS: These findings suggest that atorvastatin improves endothelial function of the coronary artery in patients with myocardial infarction.

Acute myocardial infarction caused by simultaneous occlusion of the right coronary artery and the left anterior descending coronary artery probably due to coronary spasm: a case report.

A 56-year-old man had an attack of chest pain associated with ST-segment elevation in both the inferolateral and anteroseptal leads on electrocardiography. Emergency coronary angiography showed thrombus in the mid right coronary artery and total occlusion in the distal left anterior descending coronary artery. Intravenous heparin infusion and antiplatelet therapy were given without other coronary intervention. After 1 week, repeat coronary angiography showed neither significant stenosis nor thrombus in the coronary arteries. Severe coronary artery spasm in the left coronary artery was induced by the provocation test with intracoronary injection of 50 microg acetylcholine. He had an uneventful hospital course. This unique case demonstrated intracoronary thrombus formation in the right coronary artery and left anterior descending coronary artery simultaneously due to suspected coronary spasm.

Left ventricular free wall rupture in transient left ventricular apical ballooning.

A 79-year-old woman presented with chest pain. Her symptoms, combined with the results of an electrocardiogram, echocardiogram and laboratory investigations were compatible with an extensive acute anterior myocardial infarction. However, emergency coronary angiography showed no stenotic lesion in any coronary artery, but left ventriculography revealed apical ballooning akinesis and basal hyperkinesis and she was diagnosed as having transient left ventricular apical ballooning. After 7 days, she suddenly went into cardiopulmonary arrest because of cardiac tamponade. The autopsy revealed a free wall rupture. Generally, the prognosis in transient left ventricular apical ballooning is good; left ventricular free wall rupture is very rare.

Efficacy of stenting after rotational atherectomy for ostial LAD and ostial LCX stenosis in patients with diabetes.

OBJECTIVE: The goal of this study was to investigate the efficacy of stenting after rotational atherectomy (rotastent) for ostial LAD and ostial LCX stenosis in patients with diabetes. BACKGROUND: Previous studies have demonstrated that rotastent for non-aorto ostial stenoses can be performed safely with high clinical success rate. However, in diabetic patients, long-term results of rotastent for ostial stenoses are still unknown. METHODS: A series of 70 patients with de novo non-aorto ostial stenosis who underwent successful elective stenting after rotational atherectomy were the subject of this study. Clinical, angiographic, and procedural characteristics, as well as acute and chronic results were obtained for all patients. RESULTS: There were no significant differences between diabetic versus non-diabetic patients in terms of baseline clinical characteristics, lesion characteristics, and procedural factors. The restenosis rate of diabetic patients was significantly higher than that of non-diabetic patients as assessed by the follow-up angiogram (53% versus 28%, respectively; p < 0.05). The rate of lesion progression which meant the development of new left main or non-treated artery-ostial narrowing was significantly higher in diabetic patients at follow-up angiography (23% versus 5%; p < 0.05 compared to non-diabetic patients). By use of multiple regression analysis, diabetes mellitus was identified as an independent predictor of restenosis and lesion progression. CONCLUSIONS: These results suggest that diabetic patients are more likely to have not only higher rates of restenosis but also development of new left main narrowing or non-treated artery ostial narrowing compared to non-diabetic patients.