Bailout subintimal trans-catheter withdrawal (STRAW) technique for a distally extended coronary hematoma.

A coronary hematoma, which can sometimes obstruct coronary flow, may be left behind after tip-detection antegrade dissection and reentry. We present a novel bailout technique utilizing subintimal trans-catheter withdrawal technique with the assistance of a stent and a balloon. This technique can be used before performing bailout long stenting or a fenestration procedure with a cutting balloon, which are standard treatments for hematoma, to improve impaired coronary flow caused by a distally extended hematoma.

Outcomes of non-flow-limiting spiral dissection after drug-coated balloon angioplasty for de novo femoropopliteal lesions.

BACKGROUND: Whether drug-coated balloon (DCB) angioplasty would be effective in spiral dissection (SD) lesions with no flow impairment has been thoroughly investigated. AIMS: The present study sought to assess the clinical outcomes of non-flow-limiting SD after DCB angioplasty for de novo femoropopliteal lesions in patients with symptomatic lower extremity artery disease. METHOD: This single-center retrospective study enrolled 497 patients with non-flow-limiting SD (n = 92) or non-SD (n = 405) without bailout stenting. The primary endpoint was 1-year primary patency, with the secondary endpoints including freedom from target lesion revascularization (TLR), major adverse limb event (MALE), all-cause death, and 30-day restenosis. RESULTS: The 1-year primary patency and freedom from TLR were significantly lower in the SD group than in the non-SD group (69.8% vs. 83.3%, p = 0.004; 78.7% vs. 93.0%, p = 0.007, respectively). The SD group had a higher incidence of MALE and 30-day restenosis than the non-SD group (24.6% vs. 11.9%, p = 0.001; 4.3% vs. 0.5%, p = 0.002, respectively). All-cause death was comparable. One-year restenosis after SD was associated with chronic limb-threatening ischemia (CLTI) (hazard ratio, 3.36 [95% confidence interval, 1.21-9.36]; p = 0.020), TASC Ⅱ D (hazard ratio, 3.97 [95% confidence interval, 1.02-15.52]; p = 0.047), and residual stenosis ≥50% (hazard ratio, 4.92 [95% confidence interval, 1.01-23.94]; p = 0.048). The incidence of restenosis after SD increased with the number of these risk factors. CONCLUSIONS: Despite normal antegrade flow, the 1-year primary patency rate after DCB angioplasty for de novo femoropopliteal lesions was significantly lower in lesions with SD than those without SD. CLTI, TASC II D, and residual stenosis ≥50% were risk factors associated with 1-year restenosis after DCB angioplasty for non-flow-limiting SD lesions.

Real-time Ripple technique: A case report on Ripple map for real-time identification of conduction gaps without first-pass pulmonary vein isolation.

This paper presents a novel approach to gap mapping in pulmonary vein isolation (PVI) for atrial fibrillation (AF) treatment, utilizing the real-time Ripple (RR) technique. Radiofrequency (RF) catheter ablation, particularly encircling PVI, is a common intervention for AF. Identifying left atrium-pulmonary vein conduction gaps is crucial for achieving PVI with minimal additional ablation if first-pass PVI is unsuccessful. However, identifying conduction gaps can be relatively challenging, often necessitating manual electrocardiogram reannotation due to the limitations of local activation time (LAT) maps. In the case of a 63-year-old patient with drug-resistant symptomatic persistent AF, the RR technique was utilized to identify conduction gaps during RF ablation. The technique involved pausing fast anatomical mapping (FAM), activating Ripple map (RM) feature on the CARTO 3 system and acquiring points with an ultrahigh-resolution mapping catheter. This approach revealed that the actual site of earliest activation differs from the LAT map indication, enabling successful PVI. The RM feature's capability to reflect actual excitation propagation without reliance on map annotations was crucial for precise conduction gap identification, overcoming inter-operator variability and inaccuracies of conventional methods. The RR technique not only facilitated real-time analysis during gap mapping but also significantly reduced the procedure time, minimizing potential complications. This case report highlights the efficacy of the RR technique in real-time gap mapping, demonstrating its value in cases where first-pass PVI is unsuccessful. The integration of this technique into PVI procedures can enhance both the accuracy and efficiency of catheter ablation for AF.

Wire ThRoUgh Snare Twice (Wire TRUST) technique: A novel method to grasp a lead with inaccessible ends as a supportive femoral approach for transvenous lead extraction.

INTRODUCTION: Transvenous lead extraction (TLE) is a crucial procedure for managing cardiac implantable electronic devices. The use of a combined superior and femoral approach has been found to enhance the success rate of TLE. This report introduces a novel technique, named "Wire ThRoUgh Snare Twice" (Wire TRUST), for effectively grasping a lead without a free end during TLE. METHOD: The Wire TRUST technique was applied in a case involving a 49-year-old male patient requiring TLE due to electrical artifact on the right ventricular (RV) lead, replacement of the RV lead, and pacemaker generator exchange. The Wire TRUST technique involved the insertion of a 4-Fr pigtail catheter and a 6-Fr snare catheter through the 14-Fr sheath inserted from the right common femoral vein. The 4-Fr pigtail catheter was hooked to the RV lead under multidirectional fluoroscopic guidance in the right atrium. The 0.014-in. guidewire was advanced through the pigtail catheter, crossing the RV lead until reaching the inferior vena cava. Subsequently, the distal end of the 0.014-in. guidewire was captured using a snare and pulled, facilitating externalization of the guidewire. After externalization, both ends of the 0.014-in. guidewire were passed through the snare outside the body and reinserted into the 14-Fr sheath. By simultaneously advancing and closing the snare while applying tension to the 0.014-in. guidewire, a secure grip on the lead without free ends was achieved. RESULTS: The Wire TRUST technique enabled successful lead extraction and replacement without any complications. The technique facilitated the co-axial alignment of the powered sheath with the RV lead, ensuring safe and efficient extraction. CONCLUSION: The Wire TRUST technique presents a novel and effective approach for grasping leads with inaccessible ends during TLE.

Modified leopard-crawl technique using intravascular lithotripsy balloon in calcified coronary lesions.

Intravascular lithotripsy (IVL) has emerged as a novel therapy for the treatment of coronary calcification. Numerous studies have reported the safety and efficacy of IVL in calcified coronary lesions, while IVL balloon-uncrossable calcified coronary lesions are sometimes encountered in clinical practice. This case report represents a novel technique called "modified leopard-crawl" to advance the IVL balloon antegradely by creating significant calcium cracking forward when the enhanced stent visualization system reveals that the distal emitter seems adjacent to calcification. This technique might be a valuable alternative when conventional procedures fail and has the potential to enhance the clinical applicability of IVL in daily practice.

Dual Antiplatelet Therapy Duration After Multivessel Optimal Intravascular Ultrasound-Guided Percutaneous Coronary Intervention.

BACKGROUND: There is a scarcity of data evaluating contemporary real-world dual antiplatelet therapy (DAPT) strategies after percutaneous coronary intervention (PCI).Methods and Results: In the OPTIVUS-Complex PCI study multivessel cohort enrolling 982 patients undergoing multivessel PCI, including left anterior descending coronary artery using intravascular ultrasound (IVUS), we conducted 90-day landmark analyses to compare shorter and longer DAPT. DAPT discontinuation was defined as withdrawal of P2Y12inhibitors or aspirin for at least 2 months. The prevalence of acute coronary syndrome and high bleeding risk by the Bleeding Academic Research Consortium were 14.2% and 52.5%, respectively. The cumulative incidence of DAPT discontinuation was 22.6% at 90 days, and 68.8% at 1 year. In the 90-day landmark analyses, there were no differences in the incidences of a composite of death, myocardial infarction, stroke, or any coronary revascularization (5.9% vs. 9.2%, log-rank P=0.12; adjusted hazard ratio, 0.59; 95% confidence interval, 0.32-1.08; P=0.09) and BARC type 3 or 5 bleeding (1.4% vs. 1.9%, log-rank P=0.62) between the off- and on-DAPT groups at 90 days. CONCLUSIONS: The adoption of short DAPT duration was still low in this trial conducted after the release of the STOPDAPT-2 trial results. The 1-year incidence of cardiovascular events was not different between the shorter and longer DAPT groups, suggesting no apparent benefit of prolonged DAPT in reducing cardiovascular events even in patients who undergo multivessel PCI.

Impact of postprocedural minimum lumen area on clinical outcome after femoropopliteal drug-eluting stent implantation.

INTRODUCTION: Although favorable results of fluoropolymer-based drug-eluting stent (FP-DES) treatment for femoropopliteal lesions have been reported, it is unclear whether minimal lumen area (MLA) after FP-DES implantation affects clinical outcomes. This study aimed to reveal the association between intravascular ultrasound (IVUS)-evaluated MLA and the 1-year risk of restenosis and aneurysmal degeneration after FP-DES implantation for femoropopliteal lesions. METHODS: A subanalysis of the CAPSICUM (Contemporary outcomes After Paclitaxel-eluting peripheral Stent implantation for symptomatic lower limb IsChemia with sUperficial feMoral or proximal popliteal lesion) study analyzed 718 limbs in 686 patients with available IVUS-evaluated MLA data. The association of MLA with the 1-year risk of restenosis and aneurysmal degeneration was analyzed using the generalized propensity score method. RESULTS: The 1-year incidence rate of restenosis was estimated to be 8.8% (95% CI, 6.1% to 12.5%) for the upper quartile of MLA (21.1 mm2) versus 14.3% (95% CI, 10.7% to 18.7%) for the lower quartile of MLA (15.2 mm2), with an odds ratio of 0.58 (95% CI, 0.36 to 0.93; p = 0.024), whereas the 1-year incidence rate of aneurysmal degeneration was 23.8% (95% CI, 19.5% to 28.8%) for the upper quartile versus 16.8% (95% CI, 12.6% to 22.0%) for the lower quartile, with an odds ratio of 1.55 (95% CI, 1.04 to 2.32; p = 0.031). CONCLUSION: A large MLA after FP-DES implantation for femoropopliteal lesions was associated with decreased restenosis risk but increased aneurysmal degeneration risk. These findings suggest that MLA is a valuable predictor of clinical outcomes.

Predictors of Pacing Capture Threshold Exacerbation After Leadless Pacemaker Implantation.

The predictors of pacing capture threshold (PCT) exacerbation after leadless pacemaker implantation remain unknown. We analyzed the predictors of poor PCT by identifying risk factors using multivariate logistic regression analysis for 211 patients with leadless pacemaker implantation. Twenty patients met the criteria for elevated PCT levels and were categorized in the poor PCT group. Multivariate analyses revealed that PCT (P < 0.0001) and pacing impedance (P = 0.03) were independent predictors of PCT exacerbation. Elevated PCT levels and low pacing impedance during leadless pacemaker implantation were potential risk factors for the replacement of leadless pacemakers after the procedure.

[The Role of a Nurse Practitioner in Cardiovascular Surgery at a Japanese Private Hospital].

Since 2020, our hospital has introduced nurse practitioners( NP) into cardiovascular surgery with the aim to improve labor efficiency. A cardiovascular surgery NP has both pre- and postoperative roles. An NP is not only involved in a necessary intervention but also in an intervention as the first assistant regardless of regular or emergency surgery. By having an NP perform the work normally performed by doctors, a labor burden on doctors is reduced and care administered by the medical team is smoothened. This study reports the role of NPs in the field of cardiovascular surgery in private hospitals.

Analysis of factors influencing patient satisfaction after total hip arthroplasty in a Japanese cohort: the significant effect of postoperative physical activity.

[Purpose] To determine patient satisfaction after total hip arthroplasty in a Japanese cohort and to identify factors that significantly influence patient satisfaction. [Participants and Methods] This study included 285 patients who underwent primary total hip arthroplasty for osteoarthritis. Postoperative satisfaction, Oxford hip score, short form-12 mental component summary score, and University of California Los Angeles activity score were investigated. Muscle strength and daily step counts were determined using a hand-held dynamometer (µ-Tas F1) and activity monitor (ActivPAL) in 89 and 26 patients, respectively. Factors associated with postoperative satisfaction, Oxford hip score-activities of daily living, and University of California Los Angeles activity score were identified. The relationship between the Oxford hip score-activities of daily living and daily step counts was examined. [Results] Overall, 94.7% of the patients reported satisfaction with total hip arthroplasty. The Oxford hip score-activities of daily living and University of California Los Angeles activity score were significantly associated with patient satisfaction. Younger age and hip abductor strength were significantly associated with a higher Oxford hip score-activities of daily living and University of California Los Angeles activity score. The average daily step count was significantly correlated with the Oxford hip score-activities of daily living. [Conclusion] Self-reported physical activity levels significantly influenced patient satisfaction and were correlated with objective muscle strength and daily step count measurements. These findings can guide total hip arthroplasty patient counseling on the importance of muscle strength and activity levels.

Coil Embolization for Coronary Artery Perforation: A Retrospective Analysis of 110 Patients.

OBJECTIVE: Coil embolization (CE) for coronary artery perforation (CAP) has not been thoroughly evaluated. This study aimed to evaluate the extent of myocardial damage and impact on cardiac function after CE for CAP. METHODS: A total of 110 consecutive patients treated with CE for CAP were retrospectively identified. The degree of myocardial damage and impact on cardiac function were evaluated. RESULTS: Forty-nine (44.5%) cases involved chronic total occlusions. A guidewire was the cause of perforation in 97 (88.2%) patients. The success rate of CE was 98.2%. Almost all patients were prescribed either antiplatelet drugs or anticoagulant medication or both. Patients with perforation types III and IV were found to be prone to creatinine kinase (CK) elevation and epicardial main vessel perforation, thereby causing myocardial damage. No changes were noted in the ejection fraction (EF) in patients with type V distal perforation and collateral channel perforation, while patients with perforation of the epicardial main vessel may show impaired cardiac function afterward. CONCLUSIONS: CE is safe and effective for treating CAP, especially when collateral channels and distal vessels are involved. Meanwhile, efforts should be taken to prevent CAP in epicardial main vessels since it may be difficult to treat with CS and cause myocardial damage when bailed out with CE leading to vessel sacrifice. We found that it was not necessary to change the anticoagulant regimen after CE owing to its ability to achieve robust hemostasis.

Anticoagulation Protocol for Secondary Prevention of Acute Ischemic Stroke Associated with Nonvalvular Atrial Fibrillation.

OBJECTIVES: There is no clear evidence regarding when to initiate oral anticoagulants (OACs) for secondary prevention of recurrent stroke in patients with atrial fibrillation (AF). Therefore, this study aimed to evaluate the safety and efficacy of a novel OAC initiation protocol for secondary prevention of acute ischemic stroke associated with AF. MATERIALS AND METHODS: In this multicenter prospective study 597 consecutive Japanese patients with acute ischemic stroke associated with nonvalvular AF received post-stroke OACs according to a protocol based on severity (clinical (NIHSS) and radiological (ASPECTS + W)), rt-PA use, reperfusion, and hemorrhagic transformation (HT). Primary outcomes of safety and efficacy, including symptomatic hemorrhage, cerebral stroke, and disability were evaluated at 14 and 90 days. RESULTS: Mean OAC initiation time was 2.60±2.14 days from onset. The shortest and longest mean initiation times were 0.47±0.50 and 6.16±0.72 days, respectively. Following OAC administration, no ICH was observed within 90 days. A significantly higher incidence of acute recurrent ischemic events occurred 14 days prior to OAC (4.7%) compared with chronic recurrence within 90 days (0.8%) (P = 0.00013, McNemar's test) . Recurrence prior to OAC use was significantly correlated with days to treatment (P = 0.00224), severity (NIHSS, ASPECTS+W: P = 0.0223, P = 0.0393, respectively), and HAS-BLED (P = 0.0395) and there were no correlations with CHADS2 (P = 0.277) or CHA2DS2-VASc (P = 0.246) (Wilcoxon rank sum-test). CONCLUSIONS: This comprehensive OAC initiation protocol was relatively safe and effective for secondary prevention of stroke in patients with AF. Risk of acute recurrence was high, indicating that OACs should be started as early as possible. (clinical trial registration number: 15B 128).

Comparison of Drug-Eluting Stent and Plain Old Balloon Angioplasty After Rotational Atherectomy in Severe Calcified and Large Coronary.

Drug-eluting stent (DES) is well known to be effective in severely calcified lesion after rotational atherectomy (ROTA). However, there are still some situations when stents should be avoided and plain old balloon angioplasty (POBA) should be the preferred option. The present study aims to explore whether POBA is comparably effective to DES in large and calcified coronary pretreated by ROTA in clinical outcomes.Consecutive patients treated for severely calcified lesions in the large (≥ 3 mm) coronary using ROTA + DES or ROTA + POBA were retrospectively analyzed. The major adverse cardiac events (MACE), including all-cause/cardiac death and target lesion revascularization (TLR) at 1 year and 2 years posttreatment, were compared between groups using the Cox regression analysis to identify independent predictors of TLR and MACE.The analysis included 285 cases in the ROTA + DES group and 47 cases in the ROTA + POBA group, without relevant differences in clinical baseline characteristics. Of note, lesion length was greater in the ROTA + DES group (37.2 versus 19.3 mm, P < 0.001); the ROTA + DES group had a higher rate of chronic total occlusion (CTO) lesions, with 8.4%, and the ROTA + POBA group had none. The inhospital/30-day mortality rate (5.3%, ROTA + DES; 6.4%, ROTA + POBA) and the 12- and 24-month all-cause/cardiac mortality rate (9.3%, ROTA + DES; 7.7%, ROTA + POBA) were not significantly different between the two groups. TLR rates were not significantly different between the two groups at 12 (4.6%, ROTA + DES; 4.3%, ROTA + POBA) and 24 (5.3%, ROTA + DES; 6.4%, ROTA + POBA) months.Outcomes were comparable for ROTA + DES and ROTA + POBA in severely calcified large coronary artery intervention with respect to midterm death or TLR rate, especially for short lesion of < 20 mm.

Reappraisal Value of a Modified Rotational Atherectomy Technique in Contemporary Coronary Angioplasty Era.

OBJECTIVES: To introduce a modified rotational atherectomy (RA) procedure and investigate the early and midterm outcomes of the RA-facilitating diversified percutaneous coronary intervention (PCI) in a large group of aged patients with higher cardiovascular risk. BACKGROUND: Previous studies about the outcomes of RA were limited with small sample size and low-risk population. METHODS: Between January 2013 and November 2015, 1169 consecutive patients treated with modified RA-facilitated PCI were retrospectively enrolled, including de novo calcified lesions and in-stent restenosis. Patients were regularly followed up for at least 1 year. Major adverse cardiac events (MACE) were analyzed for all participants by different strategies. Cox regression analysis was performed to identify risk factors for the events. RESULTS: The median age of patients was 75 years, with 11.7% of patients on maintenance hemodialysis. Most lesions (99.9%) were complex (American Heart Association type B2/C), and 68.3% were treated with RA + drug-eluting-stent (DES). Successful angiography was achieved in 97.8% cases, with 1.7% (20/1169) experiencing coronary perforation (including guidewire perforation). The incidence of MACE was 20.5% and 26.8% at 1-year and 2-year follow-up and were mainly driven by target lesion revascularization (TLR) (10.3% and 12.5%, respectively). The strategy of RA + DES had the lowest 2-year MACE, compared with the RA + drug-coated balloon and RA + plain old balloon angioplasty (14.5%, 30.5%, and 26.0%, respectively). CONCLUSIONS: The modified RA technique is a safe and effective tool in the contemporary PCI era, even in high-risk patients. The TLR rate was relatively high but acceptable in such complex lesions.

Evolut Self-Expanding Transcatheter Aortic Valve Replacement in Patients with Extremely Horizontal Aorta (Aortic Root Angle ≥ 70°).

Because of its rigidity and non-steerability, the presence of a horizontal aortic root poses a major anatomical issue during transcatheter aortic valve replacement (TAVR) with Evolut self-expanding valve. Previous studies have elucidated the difficulties of coaxial implantation of the self-expanding valve in patients with horizontal aorta, often resulting in increased complications and a lower device success rate. To date, most patients with extremely horizontal aorta (aortic root angle ≥ 70°) have been excluded from major TAVR clinical trials. Therefore, available data on TAVR with Evolut in this challenging anatomy are limited, and standardized treatment strategies and clinical results remain unknown. Herein, we report a clinical case series of TAVR with Evolut in extremely horizontal aorta. Among seven patients (aged 80-92 years; STS score, 12.6% ± 7.9%) who underwent TAVR with Evolut system, aortic root angle ranged from 71° to 83° (mean, 75.1°± 4.5°). All patients achieved device success with dedicated strategies and were clinically stable at 3-month follow-up. None of the patients had more than mild paravalvular leakage (PVL) at any point during follow-up.Complications in three patients included complete atrioventricular block requiring a permanent pacemaker implantation, cerebral infarction because of atrial fibrillation 3 days after TAVR, and cardiac tamponade requiring pericardiocentesis. In this case series, Evolut self-expanding TAVR in extremely horizontal aorta was effective and feasible with a high device success rate. Based on anatomical features, some dedicated strategies majorly contribute to the success of this procedure. Large-scale multicenter studies are required to confirm our findings.

Assessment of reattempted percutaneous coronary intervention strategy for chronic total occlusion after prior failed procedures: Analysis of the Japanese CTO-PCI Expert Registry.

OBJECTIVES: We aimed to investigate strategies for reattempted percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs) by highly skilled operators after a failed attempt. BACKGROUND: Development of complex techniques and algorithms has been standardized for CTO-PCI. However, there is no appropriate strategy for CTO-PCI after a failed procedure. METHOD: From 2014 to 2016, the Japanese CTO-PCI Expert Registry included 4,053 consecutive CTO-PCIs (mean age: 66.8 ± 10.9 years; male: 85.6%; Japanese CTO [J-CTO] score: 1.92 ± 1.15). Initial outcomes and strategies for reattempted CTO-PCIs were evaluated and compared with first-attempt CTO-PCIs. RESULTS: Reattempt CTO-PCIs were performed in 820 (20.2%) lesions. The mean J-CTO score of reattempt CTO-PCIs was higher than that of first-attempt CTO-PCIs (2.86 ± 1.03 vs. 1.68 ± 1.05, p < .001). The technical success rate of reattempt CTO-PCIs was lower than that of first-attempt CTO-PCIs (86.7% vs. 90.8%, p < .001). Regarding successful CTO-PCIs, the strategies comprised antegrade alone (reattempt: 36.1%, first attempt: 63.8%), bidirectional approach (reattempt: 54.4%, first attempt: 30.3%), and antegrade approach following a failed bidirectional approach (reattempt: 9.4%, first attempt: 5.4%). Parallel wire technique, intravascular ultrasound guide crossing, and bidirectional approach technique were frequently performed in reattempt CTO-PCIs. Reattempt CTO-PCIs showed higher rates of myocardial infarction (2.1% vs. 0.9%, p < .001) and coronary perforation (6.9% vs. 4.2%, p = .002) than first-attempt CTO-PCIs. CONCLUSIONS: The technical success rate of reattempt CTO-PCIs is lower than that of first-attempt CTO-PCIs. However, using more complex strategies, the success rate of reattempt CTO-PCI can be improved by highly skilled operators.

Predictors of clinical outcomes after coronary implantation of bioresorbable polymer sirolimus-eluting Ultimaster stents in all-comers: A report of 1,727 cases.

BACKGROUND: Although bioresorbable polymer sirolimus-eluting Ultimaster stents (BP-SESs) are likely useful for percutaneous coronary interventions (PCIs), the clinical data from real-world cases are insufficient. Furthermore, the predictors of adverse clinical outcomes after BP-SES implantation have not been fully investigated. OBJECTIVES: This study evaluated the 1-year clinical outcomes after BP-SES implantation in real-world PCI cases and identified the predictors of adverse outcomes. METHODS: In this single-center, all-comers study, we consecutively implanted BP-SESs in all patients who required coronary stents between October 2015 and August 2016. We conducted a clinical follow-up assessment of these patients. RESULTS: The sample comprised 1,727 patients; 67% were men, the mean age was 72 years, and 37% had diabetes. Of the 2,085 lesions detected, 88% were type B2/C lesions, 4% were chronic total occlusions (CTOs), and 23% were bifurcations. The cumulative incidences of target lesion revascularization (TLR) and target lesion failure (TLF) at 1-year were 2.4% and 5.2%, respectively. A multivariate analysis revealed that hemodialysis (HD) (hazard ratio [HR] 8.40) and CTO (HR 4.21) were independent predictors of TLR. Stent sizes ≤2.5 mm were not associated with either TLR or TLF. CONCLUSIONS: The current study indicates that patients on HD and those with CTO were more likely to experience adverse clinical outcomes after BP-SES implantation. In contrast, small vessel diameter was not significantly related to adverse outcomes. The 1-year clinical outcomes after BP-SES implantation were found to be favorable among all-comer PCI cases, including patients receiving HD and those with in-stent restenosis.

Rotational atherectomy and new-generation drug-eluting stent implantation.

OBJECTIVES: The aim of this study was to evaluate the clinical outcomes of rotational atherectomy (RA) followed by new-generation drug-eluting stent (DES) implantation in patients with an extensive amount of calcified and fibrotic plaque. BACKGROUND: RA followed by new-generation DES implantation for complex lesions has not been thoroughly evaluated. METHODS: A total of 744 consecutive patients (770 lesions) treated with new-generation DES implantation following RA for de novo lesions between January 2013 and November 2015 were retrospectively identified using our institutional database. Clinical outcomes at 12 months were evaluated and the independent predictors of all-cause death and target vessel failure (TVF) were assessed using Cox regression models. RESULTS: Target lesion revascularization occurred in 22 lesions (2.9%) and TVF occurred in 51 lesions (6.6%). In a multivariate analysis, hemodialysis, non-ST-segment elevation acute coronary syndrome, low ejection fraction, and HbA1c ≧ 7% were associated with 12-month mortality. Hemodialysis and right coronary artery were identified as independent predictors of TVF (hazard ratio (HR) 4.107, 95% confidence interval (CI) 2.194-7.685, P < .001; HR 2.491, 95% CI 1.023-6.062, P = .044, respectively). CONCLUSIONS: A good debulking with RA followed by new-generation DES implantation is recommended for patients with an excessive amount of calcified and fibrotic plaque, as this will likely improve the clinical outcomes.

Initial results of a first-in-human study on the PlasmaWire™ System, a new radiofrequency wire for recanalization of chronic total occlusions.

OBJECTIVES: To examine the safety, efficacy, and efficiency of the PlasmaWireTM System to recanalize coronary chronic total occlusions (CTO) using controlled ablation inside the CTO. BACKGROUND: The PlasmaWireTM System is a new bipolar radiofrequency (RF) wire system utilizing plasma-mediated ablation to facilitate wire crossing in CTOs. Two independent PlasmaWireTM wires are used in tandem for channel creation by applying RF energy between the tips so as to localize the ablation. METHODS: Prospective, nonrandomized, single-arm, multicenter study in seven patients with CTOs indicated for percutaneous coronary intervention (PCI). RESULTS: In this study, both wires were antegradely delivered to the distal end of CTO for antegrade re-entry in two cases and bidirectionally (antegrade and retrograde) delivered to the CTO for retrograde re-entry in five cases. In all cases, channel creation was achieved within a few seconds and was confirmed on angiogram or intravascular ultrasound (IVUS) and CTO recanalization was successfully achieved without any major adverse cardiac and cerebrovascular events (MACCE) or other minor complications. The clinical follow-up showed no clinical event at 1 month. CONCLUSIONS: The PlasmaWireTM System was shown to be safe and effective in obtaining CTO recanalization through a re-entry channel utilizing plasma-mediated ablation while reducing procedure time. The PlasmaWire™ System is a new bi-polar RF wire system utilizing plasma-mediated ablation for channel creation to facilitate CTO recanalization. This first-in-human study in which seven patients were enrolled was conducted to demonstrate the safety, efficacy, and efficiency of this system for CTO recanalization. Channels through the CTOs were successfully created within a few seconds by applying RF energy between the tips of two independent PlasmaWireTM wires and recanalization was achieved in all cases without any complication. The PlasmaWireTM System may safely facilitate CTO recanalization with less vessel injury and improve initial results of CTO PCI while reducing procedure time.