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.

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.

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.

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.

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.

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.

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.

Relationship between residual atheroma burden and neointimal growth in patients undergoing stenting: analysis of the atherectomy before MULTI-LINK improves lumen gain and clinical outcomes trial intravascular ultrasound substudy.

OBJECTIVES: The objective of this study was to examine the relationship between quantitative volumetric and cross-sectional measures of residual atheroma burden and neointimal growth after coronary stenting. BACKGROUND: Previous intravascular ultrasound (IVUS) studies have demonstrated a correlation between residual atheroma burden and neointimal growth after coronary stenting. However, postmortem studies contradict this finding. METHODS: The study population included 34 patients who underwent IVUS six to eight months after stent placement, including 26 patients who underwent IVUS immediately after stent placement and at six to eight months follow-up. Using manual planimetry, the lumen cross-sectional area (LA), stent cross-sectional area (SA) and external elastic membrane cross-sectional area (EEM) were measured at 1-mm intervals after the procedure and at follow-up. Percent neointimal area (NA) and atheroma area (AA) were calculated as: percent neointimal area = ([SA - LA]/SA) x 100; percent AA = ([EEM - SA]/EEM) x 100 in the entire cross section and in individual quadrants. Postinterventional atheroma volume and neointimal volume at follow-up were calculated using Simpsons's rule. RESULTS: In pooled analyses using all cross sections and cross-sectional quadrants, there was a weak correlation between percent AA and NA (r = 0.11 and 0.12, respectively). Analysis in individual patients demonstrated no significant relationship between total or quadrant measurements of percent AA and NA (p = 0.47 and 0.4, respectively). No relationship between atheroma volume postintervention and neointimal volume at follow-up was observed (r = 0.1, p = 0.62). CONCLUSIONS: This study failed to demonstrate a clinically significant relationship between quantitative volumetric and cross-sectional measures of residual atheroma burden and subsequent neointimal growth.

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.

Impact of nonmeasurable borders and variation in cross-section counts on intravascular ultrasound measurement of atherosclerotic plaque volume.

The inability to measure borders and variation in the number of 1-mm cross sections acquired from an identical length of vessel in serial intravascular ultrasound (IVUS) pullbacks represents potential errors in calculating volumes by IVUS. In a clinical IVUS trial, the percentage of nonmeasurable lumen and external elastic membrane borders, and the percent variation in the number of 1-mm cross sections acquired from an identical vessel length at 2 separate time points, were determined. A statistical model that simulated the effect of varying the percentage of the total number of cross sections in a pullback (i.e., sample fraction) was developed using SAS software. Mean and maximum errors for calculation of atheroma volume for each sample fraction were determined. The mean percentage of nonmeasurable lumen and external elastic membrane borders in an individual patient was 8.4 +/- 8.4% and 17.4 +/- 18.4%, respectively. Mean variation in the number of 1-mm cross sections acquired in serial studies was 5.6 +/- 6.2%. A decrease in sample fraction from 95% to 50% was associated with a linear increase in the mean and maximum errors in atheroma volume, from 2.0 +/- 0.9% and 5.9 +/- 3.0%, to 7.1 +/- 2.8% and 23.4 +/- 10.3%, respectively. Thus, nonmeasurable borders and variation in the number of 1-mm cross sections acquired from an identical length of vessel in serial studies are real considerations in clinical IVUS trials. However, given the reported incidence of these considerations in this clinical trial, our statistical model suggests that the impact of each of these considerations on atheroma volume calculation is small.

Early constriction or expansion of the external elastic membrane area determines the late remodeling response and cumulative lumen loss in transplant vasculopathy: an intravascular ultrasound study with 4-year follow-up.

BACKGROUND: Early constriction of the external elastic membrane (EEM) area has been observed after cardiac transplantation. The aim of this study was to compare the late disease process of transplant vasculopathy between coronary segments with early constrictive and expansive remodeling. METHODS: Serial intravascular ultrasound data obtained annually for 4 years after transplantation in 38 transplant recipients was available. In 135 matched segments from 59 coronary arteries ultrasound images were digitized at 1-mm intervals. Mean values of the external elastic membrane (EEM), lumen and intimal areas were calculated. On the basis of a decrease or increase in EEM area within the first year after transplantation, we defined segments with early constrictive remodeling (CR, n = 71) or early expansive remodeling (ER, n = 64). RESULTS: Annual changes in intimal area were similar between segments with early CR and ER throughout the follow-up period. However, during the second and third year, annual increases in EEM area were greater in segments with early CR than in segments with early ER (second year: 1.5 +/- 2.7 vs 0.6 +/- 2.8 mm(2), p = 0.052; third year: 1.3 +/- 2.5 vs -0.03 +/- 2.6 mm(2), p = 0.003). Despite this late expansion, segments with early CR showed a cumulative decrease in the EEM area and a greater lumen loss than segments with early ER (-2.5 +/- 3.4 vs -0.6 +/- 2.6 mm(2), p < 0.001). CONCLUSIONS: In transplant vasculopathy, the late remodeling response was different between segments with early constrictive and expansive remodeling, despite similar intimal thickening. Early constriction caused an overall decrease in EEM area and greater loss of lumen during follow-up.

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.

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.

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.

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.