Risk Stratification by SYNTAX Score Systems in Current Percutaneous Revascularization Era

No abstract available.

Aortic Stenosis and Transcatheter Aortic Valve Implantation: Current Status and Future Directions in Korea

Transcatheter aortic valve implantation (TAVI) has been accepted as one of primary options for treatment of symptomatic severe aortic stenosis. Although TAVI has been predominantly used for patients at high risk or with old age who were not considered optimal candidates for surgical aortic valve replacement (SAVR), its indication is now expanding toward low risk profile and younger age. Many clinical trials are now ongoing to test the possibility of TAVI for use in patients even with uncharted indications who are not eligible for SAVR in current guidelines but may benefit from valve replacement. Current issues including periprocedural safety, long-term adverse events, hemodynamics and durability associated with TAVI should be also solved for expanding use of TAVI. The review presents current status and future directions of TAVI and discusses perspectives in Korea.

Open Reduction and Internal Fixation in Comminuted Radial Head Fracture

PURPOSE: Radial head fractures, which account for 33% of all fractures, are treated depending on the Mason classification. In comminuted type 3 fractures, open reduction internal fixation (ORIF), and radial head arthroplasty are the treatment options. This study examined the clinical outcome of modified Mason type 3 radial head fractures using ORIF with a plate. MATERIALS AND METHODS: The medical records and image of 33 patients, who underwent ORIF for modified Mason type 3 radial head fractures, were reviewed retrospectively. The preoperative plain radiographs and computed tomography images were used to examine the location of the fracture of the radial head, the number of fragments, union, joint alignment, and traumatic arthritis at the final follow-up. The range of motion (ROM) of the elbow at the last follow-up, pain score (visual analogue scale), modified Mayo elbow score (MMES), and complications were analyzed for the clinical outcome. RESULTS: Of the 33 cases, 14 were men and 19 were women. The mean age was 41.8 years and the average follow-up period was 19 months. The functional ROM was divided into three groups according to the number of bone fragments: 141.2°±9.3° of 3 (n=20), 123.8°±18.5° of 4 (n=7), 100.7°±24.4° of more than 4 (n=6). Furthermore, the MMES were 88.2±2.9, 83.7±4.3, and 77.3±8.4, respectively (p=0.027). Depending on the radial head fracture location, the ROM and MMES were 130.7°±7.5° and 82.1±4.7, respectively, with poor outcomes on the ulnar aspect compared to 143.1°±3.8° and 89.9±3.2 on the radial aspect. CONCLUSION: Various factors, such as the degree of crushing and location involved in the clinical outcome. In particular, the result was poor in the case of more than four comminuted fragments or chief position located in the ulnar aspect. In this case, radial head arthroplasty may be considered in the early stages.

Aortic Stenosis and Transcatheter Aortic Valve Implantation: Current Status and Future Directions in Korea

Transcatheter aortic valve implantation (TAVI) has been accepted as one of primary options for treatment of symptomatic severe aortic stenosis. Although TAVI has been predominantly used for patients at high risk or with old age who were not considered optimal candidates for surgical aortic valve replacement (SAVR), its indication is now expanding toward low risk profile and younger age. Many clinical trials are now ongoing to test the possibility of TAVI for use in patients even with uncharted indications who are not eligible for SAVR in current guidelines but may benefit from valve replacement. Current issues including periprocedural safety, long-term adverse events, hemodynamics and durability associated with TAVI should be also solved for expanding use of TAVI. The review presents current status and future directions of TAVI and discusses perspectives in Korea.

Good Patients Make Favorable Clinical Outcome: K-TAVI Registry Reports

No abstract available.

Clinical Implications of Moderate Coronary Stenosis on Coronary Computed Tomography Angiography in Patients with Stable Angina

PURPOSE: The present study investigated the diagnostic accuracy and clinical implications of moderate stenosis (50–69%, Coronary Artery Disease Reporting and Data System, grade 3) on coronary computed tomography angiography (CCTA), compared with invasive coronary angiography (ICA). MATERIALS AND METHODS: Two hundred and seventy-six patients who underwent ICA due to moderate stenosis alone on CCTA were selected from our prospective registry cohort. RESULTS: Diagnostic concordance between CCTA and ICA was found in only 50 (18%) patients. Among the 396 vessels and 508 segments with moderate stenosis, diagnostic concordance was found in 132 vessels (33%) and 127 segments (25%). Segments with calcified plaque had lower diagnostic concordance than those with mixed or non-calcified plaque (22% vs. 28% vs. 27%, respectively, p=0.001). While calcified plaque burden did not have an influence on severe stenosis (≥70%) on ICA, higher burden of non-calcified plaque was correlated with a greater incidence of ICA-based severe stenosis, which was more frequent in patients with ≥3 segments of non-calcified plaque (75%) than those without non-calcified plaque (22%, p < 0.001). Typical angina and mixed or non-calcified plaque were correlated with a higher incidence of under-diagnosis, while the use of next-generation computed tomography scanners reduced the incidence of under-diagnosis. Increased body weight, left circumflex artery involvement, and calcified plaque were independent factors that increased the risk of over-diagnosis of CCTA. CONCLUSION: The diagnosis of moderate stenosis by CCTA may be limited in estimating the exact degree of ICA-based anatomical stenosis. Unlike calcific burden, non-calcific burden was positively correlated with the presence of severe stenosis on ICA.

Randomized Comparison of Strut Coverage between Ticagrelor and Clopidogrel in Acute Myocardial Infarction at 3-Month Optical Coherence Tomography

PURPOSE: This study aimed to compare the effects of ticagrelor and clopidogrel on early neointimal healing assessed with optical coherence tomography (OCT) after drug-eluting stent (DES) implantation in patients with acute myocardial infarction (AMI). MATERIALS AND METHODS: AMI patients were randomly assigned to either the ticagrelor or clopidogrel arm. After DES implantation, OCT was performed to assess the percentages of uncovered struts immediately after procedure and 3 months later. RESULTS: Due to early termination, 83 patients out of 106 initially enrolled patients (24% of planned participants) underwent 3-month OCT. Differences in vascular healing patterns between the two groups, including percentage of uncovered struts on 3-month OCT (9.6% vs. 11.7% in ticagrelor vs. clopidogrel, respectively; p=0.867), neointimal thickness, percentage of malapposed struts, and healing scores did not reach statistical significance. The predictors of uncovered strut on 3-month OCT included greater reference vessel diameter [odds ratio (OR)=1.96, p < 0.001] and more malapposed struts (OR=1.12, p=0.003). CONCLUSION: The current study did not explore favorable effect of ticagrelor on 3-month vascular healing after DES implantation. Our findings should only be considered for generating hypothesis, due to insufficient power.

Effects of Coronary Artery Revascularization with a Polymer-Free Biolimus A9–Coated BioFreedom Stent Versus Bypass Surgery before Noncardiac Surgery

PURPOSE: The present study aimed to evaluate the efficacy and safety of polymer-free drug-coated BioFreedom stent implantation in comparison to coronary artery bypass graft (CABG) before major noncardiac surgery. MATERIALS AND METHODS: In a multicenter registry, 55 patients required revascularization before major noncardiac surgery that should not be delayed >6 months. Of them, 27 underwent BioFreedom stent implantation and 28 underwent CABG. Primary outcomes included rate of noncardiac surgery, time from revascularization to noncardiac surgery, and occurrence of composite outcomes (all-cause death, myocardial infarction, stent thrombosis, stroke, repeat revascularization, or major bleeding). RESULTS: The rate of major noncardiac surgery was significantly higher in the BioFreedom group (92.6%) than in the CABG group (64.3%; p=0.027). Time from revascularization to noncardiac surgery was significantly shorter in the BioFreedom group (38.0 days) than in the CABG group (73.0 days; p=0.042). During the hospitalization for revascularization period, the occurrence of primary outcomes did not differ between the groups. However, the BioFreedom group showed a shorter hospitalization period and lower total treatment cost than the CABG group. During the hospital stay for noncardiac surgery, the occurrence of composite outcome was not significantly different between groups (4% vs. 0%; p>0.999): stroke occurred in only 1 case, and there were no cases of death or stent thrombosis in the BioFreedom group. CONCLUSION: This study demonstrated that BioFreedom stenting as a revascularization strategy before major noncardiac surgery might be feasible and safe in selected patients with less severe coronary artery diseases.

The Use Pattern and Clinical Impact of New Antiplatelet Agents Including Prasugrel and Ticagrelor on 30-day Outcomes after Acute Myocardial Infarction in Korea: Korean Health Insurance Review and Assessment Data

BACKGROUND AND OBJECTIVES: Despite the favorable efficacy of new antiplatelet agents demonstrated in randomized controlled trials, their clinical implications in Korea are unclear. The purpose of this study was to investigate trends in antiplatelet agent use for acute myocardial infarction (AMI) and their impact on 30-day clinical outcomes. METHODS: AMI patients undergoing percutaneous coronary intervention between 2010 and 2015 were assessed using claim data from the Health Insurance Review and Assessment Service. RESULTS: The use of new antiplatelet agents has rapidly increased since 2013 and has been preferred over clopidogrel (Plavix; Bristol-Myers Squibb/Sanofi Pharmaceuticals) since 2015. Both prasugrel (Effient; Eli Lilly and Company) (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.31–0.67; p < 0.001) and ticagrelor (Brilinta; AstraZeneca Pharmaceuticals LP) (OR, 0.84; 95% CI, 0.71–0.98; p=0.032) had an independent effect on lowering 30-day mortality in a weighted multivariable logistic regression model. However, new antiplatelet agents had no significant effect on other clinical outcomes including myocardial infarction, stroke, bleeding, and readmission within 30 days. CONCLUSION: The use of new antiplatelet agents is rapidly increasing, and they have been used more commonly than clopidogrel since 2015. We demonstrated that new antiplatelet agents have a favorable effect on reducing 30-day mortality in AMI patients in Korea.

Impact of family history on the presentation and clinical outcomes of coronary heart disease: data from the Korea Acute Myocardial Infarction Registry

BACKGROUND/AIMS: Family history (FHx) of coronary heart disease (CHD) is a well-known risk factor for CHD. However, the prognostic implication of FHx has not been established clearly in patients with acute myocardial infarction (AMI). METHODS: In total, 11,612 patients (8,132 males [70%], age 63 +/- 13 years) with first-onset AMI between November 2005 and June 2008 in a nationwide, prospective, multicenter, online registry (the Korea AMI Registry) were analyzed. Clinical characteristics and outcomes (cardiac death and major adverse cardiac events [MACEs]) were assessed according to the presence of FHx. RESULTS: The patients with FHx were younger and included more males. Male patients with FHx included more current smokers and individuals with poor lipid profiles. In all patients, after adjustment using the Cox proportional hazard model, FHx was related to the risk of MACEs (hazard ratio [HR], 1.41; p = 0.009) and cardiac death (HR, 1.56; p = 0.080). The poor prognostic implication of FHx was further augmented in females and a low risk subset of patients. A significant interaction was only found between male and female patients for composite MACEs (p for interaction = 0.057), and between patients with more risk factors (> or = 2 risk factors) and fewer risk factors for cardiac deaths (p for interaction = 0.008). CONCLUSIONS: FHx may be an independent prognostic predictor, especially in female patients and patients with low-risk profile.

Successful Management of a Rare Case of Stent Fracture and Subsequent Migration of the Fractured Stent Segment Into the Ascending Aorta in In-Stent Restenotic Lesions of a Saphenous Vein Graft

Stent fracture is a complication following implantation of drug eluting stents and is recognized as one of the risk factors for in-stent restenosis. We present the first case of successfully managing a stent fracture and subsequent migration of the fractured stent into the ascending aorta that occurred during repeat revascularization for in-stent restenosis of an ostium of saphenous vein graft after implantation of a zotarolimus-eluting stent. Although the fractured stent segment had migrated into the ascending aorta with a pulled balloon catheter, it was successfully repositioned in the saphenous vein graft using an inflated balloon catheter. Then, the fractured stent segment was successfully connected to the residual segment of the zotarolimus-eluting stent by covering it with an additional sirolimuseluting stent.

Late Stent Thrombosis After Drug-Eluting Stent Implantation: A Rare Case of Accelerated Neo-Atherosclerosis and Early Manifestation of Neointimal Rupture

An 80-year old woman suffered from sudden onset of chest pain and dyspnea, and visited the emergency room. She received stent implantation with a biolimus A9-eluting stent (Nobori(R) 3.0x24 mm) at a the mid-portion of the left anterior descending artery 5 months prior to admission. The emergency 5-month follow-up angiogram was performed under the impression of late stent thrombosis. The follow-up angiogram showed subtotal occlusion at the mid-portion of the left anterior descending artery, which was the same segment of previous stent implantation 5 months ago. Immediately after thrombus aspiration with the thrombus aspiration catheter, the optical coherence tomography showed layered appearance of neointimal hyperplasia and neointimal rupture within the previously stented segment. Thus, neointimal rupture within accelerated growth of neointimal tissue was observed within a relatively shorter period (i.e., about 5 months) after stent implantation.