A novel coronary angiographic index for predicting correlation between fractional flow reserve and resting full-cycle ratio.

OBJECTIVES: The discordant results between fractional flow reserve (FFR) and resting full-cycle ratio (RFR) and the influence of angiographic characteristics on their correlation have not been sufficiently investigated. We aimed to identify angiographic characteristics that can predict FFR and RFR correlations using a novel angiographic scoring system. METHODS: This retrospective analysis included 220 patients with 252 intermediate coronary lesions assessed using FFR and RFR. Each branch distal to the target lesion was scored based on the vessel diameter (0 points: < 1.5 mm, 1 point: 1.5-2.0 mm, and 2 points: > 2.0 mm) measured using quantitative coronary angiography. The angiographic score was calculated by adding these scores. RESULTS: In a propensity score-matched cohort including 84 lesions (42 lesions in each low-and high-angiographic score group), the correlation between FFR and RFR in the high-angiographic score group (>4) was weaker than that in the low-score group (≤4) (Spearman's correlation: r = 0.44 vs. r = 0.80, P  < 0.01). Considering a threshold of functional myocardial ischemia as FFR ≤ 0.80 and RFR ≤ 0.89, the low-angiographic score group showed a significantly lower discordance rate of abnormal FFR/normal RFR than the high-angiographic score group (7.1% vs. 23.8%, P  = 0.03), whereas the discordance rates of normal FFR/abnormal RFR were similar in both groups (7.1% vs. 9.5%, P  = 0.69). CONCLUSION: This retrospective analysis highlights the influence of angiographic characteristics on the correlation between FFR and RFR. Our simple angiographic assessment method may be useful for interpreting physiological evaluations in daily clinical practice.

Leadless pacemaker implantation sites confirmed by computed tomography and their parameters and complication rates.

BACKGROUND: Implantations of leadless pacemakers in the septum lower the risk of cardiac perforation. However, the relationship between the implantation site and the success rate, complication rate, and pacemaker parameters are not well-investigated. METHODS: Patients who underwent leadless pacemaker implantation with postprocedural computed tomography (CT) between September 2017 and November 2020 were analyzed. Septum was targeted with fluoroscopic guidance with contrast injection. We divided patients into two groups based on the implantation site confirmed by CT: septal and non-septal, which included the anterior/posterior edge of the septum and free wall. We compared the complication rates and pacemaker parameters between the two groups. RESULTS: A total of 67 patients underwent CT after the procedure; among them, 28 were included in the septal group and 39 were included in the non-septal group. The non-septal group had significantly higher R wave amplitudes (6.5 ± 3.3 vs. 9.7 ± 3.9 mV, p = .001), lower pacing threshold (1.0 ± 0.94 vs. 0.63 ± 0.45 V/0.24 ms, p = .02), and higher pacing impedance (615 ± 114.1 vs. 712.8 ± 181.3 ohms, p = .014) after the procedure compared to the septal group. Cardiac injuries were observed in four patients (one cardiac tamponade, one possible apical hematoma, two asymptomatic pericardial effusion), which were only observed in the non-septal group. CONCLUSIONS: Leadless pacemaker implantation may be technically challenging with substantial number of patients with non-septal implantation when assessed by CT. Septal implantation may have a lower risk of cardiac injury but may lead to inferior pacemaker parameters than non-septal implantation.

Relationship of systemic pentraxin-3 values with coronary plaque components on optical coherence tomography and post-percutaneous coronary intervention outcomes in patients with stable angina pectoris.

BACKGROUND AND AIMS: Elevated pentraxin-3 (PTX3) values are associated with vulnerable plaque existence and poor outcomes in acute coronary syndrome patients. The clinical significance of PTX3 values in stable angina pectoris (SAP) patients is, however, undetermined. We investigated the relationship of systemic PTX3 values and coronary plaque components and post-percutaneous coronary intervention (PCI) outcomes in SAP patients. METHODS: We included 93 consecutive de-novo lesions in 93 SAP patients with a normal pre-PCI high-sensitivity cardiac troponin-T (<0.014 ng/mL), undergoing pre- and post-PCI optical coherence tomography (OCT). Systemic PTX3 values were obtained immediately pre- and post-PCI, at 24-h and 9-month post-PCI. RESULTS: Peak post-PCI PTX3 values correlated with thinnest fibrous cap thickness (r = -0.23, p = 0.03) and lipid length (r = 0.24, p = 0.03), and were higher in patients with lesions having OCT-derived thin-cap fibroatheroma (6.67 (3.19-7.33) vs. 3.13 (2.34-4.11) ng/mL, p = 0.04) and post-stenting irregular tissue protrusion (4.76 (3.31-6.80) vs. 2.98 (2.23-4.06) ng/mL, p = 0.003) than in those without. At 9-month follow-up, cardiac event-free survival was poorer in patients with a peak post-PCI PTX3 value ≥ 4.08 ng/mL (upper tertile) (log-rank test χ2 = 9.0; p = 0.003). Multivariate Cox regression analysis showed a peak post-PCI PTX3 value ≥ 4.08 ng/mL as an independent predictor of MACE (hazard ratio, 3.915; 95% CI, 1.129-13.583; p = 0.03). CONCLUSIONS: Peak post-PCI PTX3 values correlated with pre-PCI plaque characteristics and post-PCI outcomes, providing a good prognostic factor of outcomes in SAP patients undergoing elective PCI.

Aortic Plaque Distribution, and Association between Aortic Plaque and Atherosclerotic Risk Factors: An Aortic Angioscopy Study.

AIM: Knowledge of subclinical plaque morphology and plaque distribution in the aorta in vivo remains unclear. This study aimed to increase the body of knowledge in this area. METHODS: We enrolled 37 consecutive patients with stable angina pectoris patients who underwent non-obstructive angioscopy for both the coronary artery and aorta immediately after percutaneous coronary intervention. We evaluated the presence of aortic plaques and the distribution of plaque instability. Patients were allocated into two groups according to the number of vulnerable plaques in whole aorta (a low [0-11] and high [≥ 12] group). We evaluated the relationships between the two groups in terms of cardiovascular risk factors. RESULTS: Aortic plaques were identified using non-obstructive angioscopy in all patients, and the greatest number of plaques was found at the infrarenal abdominal aorta (IAA) (the aortic arch, the descending thoracic aorta, the suprarenal abdominal aorta, the IAA, and common iliac artery; 65%, 76%, 65%, 95%, and 49%, respectively; p＜0.001). The maximum yellow grade, and the number of intense yellow plaques, ruptured plaques, and thrombi were highest at the IAA (p＜0.001). The prevalence of diabetes mellitus and peripheral arterial disease was higher in the high vulnerable plaque group (83.3% vs. 40.0%, p=0.010, 50.0% vs. 8.0%, p=0.005, respectively). CONCLUSIONS: Aortic atherosclerosis was the most severe at the IAA, and aortic plaque vulnerability and distribution were associated with the prevalence of diabetes mellitus and peripheral artery disease in patients with stable angina pectoris. Non-obstructive angioscopy may identify patients at high risk of future aortic events.

Observation of an Asymptomatic Dissecting Aortic Aneurysm Using Non-Obstructive Angioscopy.

Non-obstructive angioscopy has become a novel method of evaluating atheromatous plaques of the aortic intimal wall. A 77-year-old man with coronary artery disease underwent percutaneous coronary intervention in the left descending artery. We subsequently used non-obstructive angioscopy to identify aortic atheromatous plaques and incidentally diagnosed an aortic dissecting aneurysm. Non-obstructive angioscopy demonstrated a great fissure in severe atheromatous plaques at the entry site of the aortic dissection identified by enhanced computed tomography. This is the first report to describe the aortic intimal findings of an aortic dissecting aneurysm in vivo by using trans-catheter angioscopy.

The clinical significance of echo-attenuated plaque in stable angina pectoris compared with acute coronary syndromes: A combined intravascular ultrasound and optical coherence tomography study.

BACKGROUND: Echo-attenuated plaque (EA) on intravascular ultrasound (IVUS) is related to poor outcomes after percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) patients. However, the clinical significance of EA in stable angina pectoris (SAP) patients compared with that in ACS patients remains unclear. We assessed the relationships between EA and unstable plaque characteristics in patients with ACS and SAP. METHODS: We investigated 609 coronary lesions in 609 patients (234 with ACS; 375 with SAP) undergoing pre-intervention IVUS and optical coherence tomography (OCT). The differences in plaque morphology and post-PCI outcomes were assessed according to the clinical status of ACS or SAP and the presence or absence of EA. RESULTS: EA was more frequent in patients with ACS than in those with SAP (44.0% vs. 25.1%, p < 0.001). SAP-EA lesions showed thicker fibrous cap (157 ±â€¯97 µm vs. 100 ±â€¯58 µm, p < 0.001), smaller lipid arc (208 ±â€¯76° vs. 266 ±â€¯99°, p < 0.001), smaller plaque burden (83.0 ±â€¯6.1% vs. 86.5 ±â€¯4.1%, p < 0.001), and lower frequency of transient slow-reflow phenomenon during PCI (21.3% vs. 51.5%, p < 0.001) than ACS-EA lesions, but similar plaque vulnerability compared with ACS-non-EA lesions. SAP-EA lesions had less frequent OCT-thrombus than ACS-non-EA lesions (20.2% vs. 71.2%, p < 0.001). CONCLUSIONS: SAP-EA lesions had less plaque vulnerability than ACS-EA lesions, but were comparable to ACS-non-EA lesions. Less frequent thrombus formation might differentiate SAP-EA lesions from ACS-non-EA lesions. A combined IVUS and OCT approach might be useful to assess plaque vulnerability in SAP-EA lesions compared with ACS lesions.

Intravascular Ultrasound and Angioscopy Assessment of Coronary Plaque Components in Chronic Totally Occluded Lesions.

BACKGROUND: The in vivo lesion morphologies and plaque components of coronary chronic total occlusion (CTO) lesions remain unclear.Methods and Results:We investigated 57 consecutive CTO lesions in 57 patients with stable angina pectoris undergoing elective percutaneous coronary intervention with intravascular ultrasound (IVUS) and coronary angioscopy (CAS) examination. All CTO lesions were classified according to the proximal angiographic lumen pattern; tapered-type (T-CTO) and abrupt-type (A-CTO). The differences in the intracoronary images of these lesion types were evaluated according to the location within the CTO segment. A total of 35 lesions (61.4%) were T-CTO. T-CTO lesions had higher frequencies of red thrombi (proximal 71.4%; middle 74.3%; distal 31.4%; P<0.001) and bright-yellow plaques (yellow-grade 2-3) (48.6%; 74.3%; 2.9%; P<0.001) at the proximal or middle than at the distal subsegment; A-CTO lesions showed no significant differences among the 3 sub-segments. At the middle subsegment, T-CTO lesions showed higher frequencies of positive remodeling (51.4% vs. 18.2%, P=0.01) and bright-yellow plaques (74.3% vs. 13.6%, P<0.001) compared with A-CTO lesions. Multivariate analysis identified bright-yellow plaque as an independent predictor (odds ratio, 7.25; 95% confidence interval, 1.25-42.04; P=0.03) of the occurrence of periprocedural myocardial necrosis. CONCLUSIONS: The combination of IVUS and CAS analysis may be useful for identifying lesion morphology and plaque components, which may help clarify the pathogenetic mechanism of CTO lesions.

Relationship between quantities of tissue prolapse after percutaneous coronary intervention and neointimal hyperplasia at follow-up on serial optical coherence tomography examination.

BACKGROUND: The clinical significance of the extent of tissue prolapse (TP) after percutaneous coronary intervention (PCI) for long-term outcomes remains undetermined. This study investigated the relationship between the quantities of TP immediately after PCI and neointimal hyperplasia (NIH) at follow-up on serial optical coherence tomography (OCT) examination. METHODS: We evaluated 145 native coronary lesions (89 lesions with stable angina pectoris [SAP] and 56 with acute coronary syndrome [ACS]). OCT was performed to examine pre-PCI plaque morphologies at the narrowest culprit sites, post-PCI TP area in each cross-sectional area (CSA) and TP volume throughout the stented segments, 9-month follow-up NIH area in each CSA and NIH volume throughout the stented segments. We investigated the relationships between the quantities of TP and NIH and their differences according to clinical presentation. RESULTS: ACS lesions had a larger TP area at the narrowest culprit sites (0.39 [0.14-0.85] vs. 0.11 [0.00-0.32] mm2, P<0.001) and at the most protruding sites (0.51 [0.24-1.08] vs. 0.21 [0.10-0.52] mm2, P<0.001) compared with SAP lesions. In ACS lesions, TP area was correlated with NIH area at the culprit sites (r=0.283, P=0.042) and at the most protruding sites (r=0.288, P=0.038). In SAP lesions, TP area was correlated with NIH area at the most protruding sites (r=0.244, P=0.030), but not at the culprit sites. CONCLUSIONS: The extent of TP immediately after PCI was quantitatively related to the degree of NIH at 9-month follow-up on serial OCT examination. The quantities of TP might influence long-term stent outcomes.

Impact of chronic kidney disease stages on atherosclerotic plaque components on optical coherence tomography in patients with coronary artery disease.

The progression of coronary atherosclerosis has been influenced by the presence of chronic kidney disease (CKD). This study investigated the impact of CKD stages on coronary plaque components observed on optical coherence tomography (OCT). We investigated 296 native coronary lesions with stable angina pectoris treated with stent implantation. All lesions were divided into the three groups according to the values of estimated glomerular filtration rate (eGFR, mL min-1 1.73 m-2): the non-CKD group (eGFR ≥60, n = 142), CKD group (15 ≤ eGFR < 60, n = 126), and end-stage kidney disease (ESKD) group (eGFR <15 and/or hemodialysis, n = 28). Among the groups, plaque morphologies at the narrowest culprit sites on OCT were evaluated. The CKD group had a larger lipid arc [207.5 (88.3-264.5) vs. 159.3 (73.3-227.7) degrees, P = 0.037] and longer lipid length [2.4 (0.0-5.7) vs. 0.0 (0.0-4.7) mm, P = 0.017] than the non-CKD group. The ESKD group had a thinner fibrous cap [120 (70-258) vs. 170 (100-270) µm, P = 0.044], higher prevalence of plaque rupture (28.6 vs. 12.3 %, P = 0.038), and larger calcification arc [124.8 (0.0-194.3) vs. 0.0 (0.0-125.4) degrees, P = 0.025] than the non-ESKD group (CKD + non-CKD groups). The presence of CKD was related to the growth of lipidic plaques. Furthermore, the advancement in the CKD stage to ESKD affected the occurrence of plaque rupture or progression of calcification.

Comparison of vascular responses after different types of second-generation drug-eluting stents implantation detected by optical coherence tomography.

Few studies have directly compared vascular responses to second-generation drug-eluting stents (DESs). We performed optical coherence tomography examinations in 56 consecutive patients with implanted single stent [19 cobalt-chromium everolimus-eluting stents (CoCr-EES), 22 platinum-chromium EES (PtCr-EES), and 15 resolute zotarolimus-eluting stents (R-ZES)] for de novo lesions, and who did not have restenosis at their 9-month follow-up. Neointimal thickness (NIT), stent apposition, and neointimal coverage were assessed in every strut. A neointimal unevenness score [(NUS), maximum NIT/average NIT in the same cross-section] was determined for every 1-mm cross-section (CS). A total of 8350 struts and 1159 CSs were analyzed. The CoCr- and PtCr-EES had significantly fewer malapposed struts compared to the R-ZES (CoCr-EES: 0.19 % vs. PtCr-EES: 0.19 % vs. R-ZES: 0.61 %, p = 0.007). Furthermore, the PtCr-EES had a lower frequency of uncovered struts compared to the others (CoCr-EES: 2.0 % vs. PtCr-EES: 1.4 % vs. R-ZES: 2.3 %, p = 0.047). The NUS correlated with the frequency of uncovered struts (p < 0.001, r = 0.54). The EESs demonstrated more homogenous neointimal growth, as shown in the NUS, compared to the R-ZES [CoCr-EES: 1.66 (1.38-1.97) vs. PtCr-EES: 1.67 (1.41-2.00) vs. R-ZES: 1.94 (1.56-2.28), p < 0.001]. Our results demonstrate that unevenness neointimal growth may relate with strut coverage after second-generation DES implantation. The PtCr-EES had a high frequency of strut coverage with a homogeneous neointima, suggesting fewer risks for stent thrombosis.

Impact of optical coherence tomography- and coronary angioscopy-assessed neointimal tissue characteristics on occurrence of periprocedural myonecrosis in patients with in-stent restenosis.

Several characteristics of neointimal tissues, including neoatherosclerotic progression, have been reported in lesions with in-stent restenosis (ISR). However, the effects of these characteristics on outcomes after percutaneous coronary intervention (PCI) for ISR lesions remain unclear. We assessed the relationships between neointimal tissue characteristics and the occurrence of periprocedural myonecrosis (PMN) after PCI in ISR lesions. We investigated 72 ISR lesions in 72 patients with stable angina pectoris (SAP) who underwent pre- and post-revascularization optical coherence tomography (OCT) and coronary angioscopy (CAS). All lesions were classified as with PMN, defined by an elevated peak high-sensitivity cardiac troponin-T level during the 24-h post-PCI period, and without PMN. PMN was observed in 23 (31.9 %) lesions. PMN lesions had higher frequencies of OCT-derived thin-cap fibroatheroma (26.1 vs. 6.1 %, P = 0.03), CAS-derived intensive yellow neointima (30.4 vs. 10.2 %, P = 0.04), neointima with complex surface (60.9 vs. 28.6 %, P = 0.01), and CAS-derived atheromatous appearance (CAS-AAP), defined as yellow plaque including complex thrombi underneath disrupted neointimal coverage after ballooning (47.8 vs. 16.3 %, P = 0.008) at the most stenotic sites inside stents, compared to lesions without PMN. Multivariate logistic regression analysis identified CAS-AAP (odds ratio: 3.568, 95 % confidence interval: 1.109-11.475, P = 0.033) as an independent predictor of PMN. For ISR lesions in SAP patients, an OCT- and CAS-based assessment of neointimal tissue characteristics might help to predict the occurrence of PMN.

Association of Intravascular Ultrasound- and Optical Coherence Tomography-Assessed Coronary Plaque Morphology With Periprocedural Myocardial Injury in Patients With Stable Angina Pectoris.

BACKGROUND: Periprocedural myocardial injury (PMI) is not an uncommon complication and is related to adverse cardiac events after percutaneous coronary intervention (PCI). We investigated the predictors of PMI in patients with stable angina pectoris (SAP) on intravascular imaging. METHODS AND RESULTS: We enrolled 193 SAP patients who underwent pre-PCI intravascular ultrasound (IVUS) and optical coherence tomography (OCT). Clinical characteristics, lesion morphology, and long-term follow-up data were compared between patients with and without PMI, defined as post-PCI elevation of high-sensitivity cardiac troponin-T. PMI were observed in 79 patients (40.9%). Estimated glomerular filtration rate (odds ratio [OR], 0.973; 95% confidence interval [CI]: 0.950-0.996; P=0.020), ≥2 stents (OR, 3.100; 95% CI: 1.334-7.205; P=0.009), final myocardial blush grade 0-2 (OR, 4.077; 95% CI: 1.295-12.839; P=0.016), and IVUS-identified echo-attenuated plaque (EA; OR, 3.623; 95% CI: 1.700-7.721; P<0.001) and OCT-derived thin-cap fibroatheroma (OCT-TCFA; OR, 3.406; 95% CI: 1.307-8.872; P=0.012) were independent predictors of PMI on multivariate logistic regression analysis. A combination of EA and OCT-TCFA had an 82.4% positive predictive value for PMI. On Cox proportional hazards analysis, PMI was an independent predictor of adverse cardiac events during 1-year follow-up (hazard ratio, 2.984; 95% CI: 1.209-7.361; P=0.018). CONCLUSIONS: Plaque morphology assessment using pre-PCI IVUS and OCT may be useful for predicting PMI in SAP patients.