Early mortality and safety after transcatheter aortic valve replacement using the SAPIEN 3 in nonagenarians.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has been performed for many elderly patients with severe aortic stenosis (AS). The SAPIEN 3 is one of the latest balloon-expandable prosthesis. This study aimed to investigate the early clinical outcomes after TAVR using the SAPIEN 3 in nonagenarians. METHODS: A total of 97 consecutive patients underwent TAVR for severe AS between December 2015 and December 2016. Of these, 85 consecutive patients who underwent TAVR using the SAPIEN 3 were included. According to the age, patients were classified into age ≥ 90 years group (17 patients) or age < 90 years group (68 patients). The clinical outcomes including all-cause mortality and composite endpoint of early safety at 30 days were evaluated. RESULTS: The Society of Thoracic Surgeons score in age ≥ 90 years group was higher than age < 90 years group (12.3 ± 6.1% vs. 8.5 ± 5.1%, P < 0.01). There was no significant difference in 30-day mortality between the two groups. However, the life-threatening bleeding and major vascular complications in age ≥ 90 years group were greater than age < 90 years group (11.8% vs. 1.5%, P = 0.04 and 11.8% vs. 1.5%, P = 0.04, respectively). The composite endpoint of early safety at 30 days was similar between the two groups. Multivariate logistic regression analysis showed that prior myocardial infarction was an independent predictor of the composite endpoint of early safety (odds ratio: 4.76, 95% confidence interval: 1.02-22.21, P = 0.047). CONCLUSIONS: The early mortality and safety after TAVR using the SAPIEN 3 in nonagenarians were similar and acceptable despite of higher operative risk.

Long-Term Clinical Outcomes after Treatment with Excimer Laser Coronary Atherectomy for In-Stent Restenosis of Drug-Eluting Stent.

Excimer laser coronary atherectomy (ELCA) has been used for the treatment of complex percutaneous coronary intervention (PCI) such as in-stent restenosis (ISR). However, little information was provided about the clinical outcomes after treatment with ELCA for ISR of drug-eluting stents (DES). This study aimed to investigate the long-term clinical outcomes after PCI with ELCA for ISR of DES.A total of 81 consecutive patients with 87 lesions who underwent PCI for ISR of DES were included. Patients were classified into a PCI with ELCA group (23 patients with 24 lesions) and a PCI without ELCA group (58 patients with 63 lesions). The major adverse cardiac events (MACE) were evaluated. The mean duration of clinical follow-up was 29.8 ± 11.6 months. The incidences of diffuse restenosis and AHA/ACC type B2 or C lesion in the PCI with ELCA group were higher than in the PCI without ELCA group. Quantitative coronary angiography showed the acute luminal gain in the PCI with ELCA group was greater than in the PCI without ELCA group (1.64 ± 0.48 mm versus 1.26 ± 0.42 mm, P < 0.001). There were no significant differences in all-cause death, myocardial infarction, or target lesion revascularization between the 2 groups. Multivariate analysis due to a Cox proportional-hazards model showed that multivessel disease was an independent predictor of MACE (hazard ratio 3.05, 95% confidence interval 1.22 to 7.61, P = 0.02). ELCA was effective as an atherectomy device for lumen enlargement and optimal lesion preparation. Even though ELCA was used for ISR of DES in significantly more complex lesions, the long-term clinical outcomes were favorable and similar.

Efficacy of radiation dose reduction due to real-time monitoring and visualization of peak skin dose during coronary angiography and percutaneous coronary intervention.

OBJECTIVES: This study assessed that the use of real-time monitoring and visualization of peak skin dose could reduce radiation dose during coronary angiography (CAG) and percutaneous coronary intervention (PCI). BACKGROUND: Exposure to ionizing radiation has dose related effects including skin damage. Reducing the radiation exposure is important during CAG and PCI. The skin dose-tracking system (DTS) has a real-time monitor of radiation peak skin dose. METHODS: A total of 323 consecutive patients who underwent CAG and PCI between September 2014 and June 2015 were enrolled. Patients were classified into with DTS group (CAG alone in 104 and PCI in 57 patients) or without DTS group (CAG alone in 106 and PCI in 56 patients). RESULTS: There was no significant difference in reference air kerma between CAG alone with and without DTS groups. Reference air kerma with DTS group during PCI was lower than without DTS group (204.6 ± 141.1 mGy vs. 294.2 ± 237.4 mGy, P = 0.016). Moreover, kerma area product (17.8 ± 13.0 Gycm2 vs. 25.2 ± 19.3 Gycm2 , P = 0.019) and number of cine runs (12.8 ± 5.0 vs. 15.5 ± 6.5, P = 0.013) with DTS group were lower than without DTS group. Multiple regression analysis showed increased reference air kerma was associated with male gender, body mass index and type B2/C lesion. Conversely, DTS correlated with decreased reference air kerma. CONCLUSIONS: The use of DTS could reduce radiation dose during PCI. Real-time radiation monitoring and visualization of peak skin dose was effective for the patients with PCI.

Successful deployment of polytetrafluoroethylene-covered stent to seal left internal mammary artery graft perforation due to guide catheter extension system.

Coronary artery bypass graft perforation during percutaneous coronary intervention is a rare complication. Perforation of a left internal mammary artery (LIMA) graft due to a guide catheter extension system has not been described. We report the successful deployment of a polytetrafluoroethylene (PTFE)-covered stent to seal the LIMA graft perforation due to the guide catheter extension system. Percutaneous coronary intervention was performed for a culprit lesion of the distal left circumflex via the LIMA graft. A balloon catheter failed to be delivered because the LIMA graft was very long and tortuous. The guide catheter extension system was introduced, and the balloon was delivered and inflated. However, the LIMA graft perforation with continuous extravasation was caused by the edge of deeper intubated guide extension catheter when a coronary stent was attempted to be delivered to the culprit lesion. A long balloon inflation was performed, but the perforation was not completely sealed. The PTFE-covered stent was successfully deployed and sealed the LIMA graft perforation. This case describes that the rapid deployment of PTFE-covered stent is effective to treat severe coronary artery bypass graft perforation due to the guide catheter extension system.

Mechanism of edge restenosis after sirolimus-eluting stent implantation.

OBJECTIVES: The present study evaluated the mechanism of edge restenosis after sirolimus-eluting stent (SES) implantation using serial (post-intervention and follow-up) intravascular ultrasound (IVUS) analysis. BACKGROUND: There is little information about the mechanism of edge restenosis after SES implantation. METHODS: Serial IVUS analysis was performed at 5 mm reference segments immediately proximal and distal to the SES in 25 lesions with edge restenosis. Proximal and distal reference segments were divided into 1 mm subsegments. RESULTS: Between post-intervention and follow-up IVUS studies, a decrease in external elastic membrane area was observed at the proximal edge. There was a significant increase in plaque & media area in the subsegment closest to the proximal edge. On the other hand, there was an increase in plaque & media area at the distal edge, with no change in external elastic membrane area. CONCLUSIONS: There may be different mechanisms between proximal and distal edge restenosis after SES implantation. Negative remodeling plays a major role in proximal edge restenosis. On the other hand, intimal hyperplasia may mainly contribute to distal edge restenosis.

Long-term clinical outcomes after sirolimus-eluting stent implantation in dialysis patients.

There is little information about long-term (> 1 year) outcomes after sirolimus-eluting stent (SES) implantation in dialysis patients. Percutaneous coronary intervention (PCI) using SES was performed in 63 dialysis patients with 77 lesions. A control group for comparison was composed of 45 consecutive dialysis patients with 62 lesions who received PCI using bare metal stents (BMS). Clinical follow-up duration was 21.7 +/- 8.4 months in the SES group and 32.1 +/- 9.2 months in the BMS group (P < 0.01). There was no significant difference in the in-segment restenosis rate (30% versus 40%, P = 0.20) between the 2 groups. The 3-year mortality (22.5% versus 22.2%, P = 0.75), myocardial infarction (3.8% versus 4.9%, P = 0.93), target lesion revascularization (24.7% versus 31.0%, P = 0.61), and stent thrombosis rates (3.8% versus 2.4%, P = 0.73) were not significantly different between the SES and BMS groups. Compared to BMS, SES do not improve long-term clinical outcomes in dialysis patients.

Prognostic significance of cystatin C in patients with ST-elevation myocardial infarction.

BACKGROUND: Cystatin C is reportedly a better endogenous marker of glomerular filtration rate than serum creatinine, so the prognostic value of cystatin C in patients with ST-elevation myocardial infarction (MI) was evaluated in the present study. METHODS AND RESULTS: A total of 71 patients who underwent percutaneous coronary intervention for ST-segment elevation MI <24 h from symptom onset were included. According to cystatin C level, patients were classified into 2 groups: (1) higher cystatin C group (n=33) and (2) lower cystatin C group (n=38). There was a trend toward more in-hospital deaths in patients with the higher cystatin C level compared with the lower cystatin C level group (15.2% vs 2.6%, P=0.06). Mean duration of clinical follow-up was 5.6 +/-2.8 months. There was no significant difference in death, reinfarction, disabling stroke or target lesion revascularization between the 2 groups. However, a higher incidence of rehospitalization for congestive heart failure was observed in patients with the higher cystatin C level than in those with the lower cystatin C level (15.2% vs 0%, P=0.01). CONCLUSIONS: Cystatin C may be associated with more cardiovascular events, mainly rehospitalization for congestive heart failure, after percutaneous coronary intervention in patients with ST-elevation MI.

Appearance of noncompaction-like remodeling of the anatomical right ventricle in a middle-aged subject with modified transposition of the great arteries who did not undergo surgery.

We describe noncompaction-like remodeling of the anatomical right ventricle (ARV) in a middle-aged subject with modified transposition of the great arteries (TGA). A 54 year-old male had been diagnosed with modified TGA at age 40, but no surgery was performed. Enhanced multislice CT revealed the ascending aorta coursing left of the anterior pulmonary trunk. Furthermore, the myocardium of the ARV appeared thickened, but contrast material could be observed in the ARV myocardium, which resembled noncompaction of the left ventricle (LV). We speculated trabecular development of the ARV, such as a Chiari network, and with TGA, the ARV provided systemic circulation through the aorta. The ARV wall may have thickened due to systemic pressure load, resulting in reduction of wall motion of the ARV on transthoracic echocardiogram. Recent advances in multislice CT imaging have revolutionized the exploration of RV anatomy, especially for depicting the three-dimensional appearance of noncompaction-like remodeling of the ARV in modified TGA in addition to transposition of the great arteries.