Randomized comparison between provisional and routine kissing-balloon technique after main vessel crossover stenting for coronary bifurcation lesions.

We compared the myocardial ischemic burden of provisional and routine final kissing-balloon inflation (FKI) with the 1-stent strategy using a second-generation drug-eluting stent for coronary bifurcation lesions (CBL). There are no established guidelines for side branch (SB) intervention after main vessel stenting. In total, 113 CBL patients were randomized to receive different SB intervention strategies: provisional-FKI group (n = 57; FKI only when SB flow was TIMI <3) and routine-FKI group (n = 56; mandatory FKI with aggressive treatment until SB-residual stenosis <50%). Dipyridamole-stress myocardial perfusion scintigraphy with 99mTc was performed after 8 months. The regional summed-difference score (r-SDS) was calculated according to the coronary territory. The primary endpoint included target vessel ischemia (TVI; r-SDS ≥ 2) at 8 months, whereas the clinical primary endpoint was major adverse cardiovascular events (MACE) at 3 years. The percent (%) myocardial ischemia (100 × SDS/68) was also calculated. At 8 months, TVI was identified in 11 and 4% in the provisional-FKI and routine-FKI groups, respectively (p = 0.226). SB-binary restenosis (48 vs. 4%, p < 0.001) and myocardial ischemia at the SB territory (11 vs. 0%, p = 0.030) were more common in the provisional-FKI group; however, in TVI patients, % myocardial ischemia (4.12 ± 1.23% vs. 3.68 ± 1.04%; p = 0.677) did not significantly differ. Moderate/severe ischemia (>10% myocardial ischemia) was not observed in the target vessel in either group. Long-term cumulative MACE were similar between the groups (9 vs. 14%; p = 0.358). Provisional-FKI according to TIMI-SB flow grade led to similar and acceptable myocardial ischemia, in comparison with routine-FKI, which may contribute to the identical long-term follow-up.

Attenuated early diastolic interventricular septum bulging by pulmonary hypertension due to later developed aortic regurgitation.

A woman was admitted due to dyspnea. She had familial pulmonary arterial hypertension and typical echocardiographic findings including early diastolic bulging of the interventricular septum toward the left ventricular cavity. Her symptoms improved with medication. Five months later, she was hospitalized again due to severe dyspnea. Echocardiography demonstrated aortic valve vegetation and its regurgitation. Echocardiography also showed attenuation of early diastolic compression of the interventricular septum, however, the peak tricuspid regurgitant flow velocity did not improve. It is likely that development of left-sided heart failure attenuated abnormal interventricular septal motion due to pulmonary hypertension.

Efficacy of cilostazol after endovascular therapy for femoropopliteal artery disease in patients with intermittent claudication.

OBJECTIVES: The purpose of this study was to investigate whether cilostazol reduces restenosis and revascularization after endovascular therapy (EVT) for femoropopliteal lesions. BACKGROUND: Cilostazol improves walking distance in patients with intermittent claudication and reduces restenosis after coronary intervention, but its efficacy remains unclear after EVT for femoropopliteal disease. METHODS: This study was performed as a multicenter, randomized, open-label clinical trial. Eighty patients (mean age 70.7 +/- 6.2 years, 84% men) with intermittent claudication due to a femoropopliteal lesion were randomly assigned to receive or not receive cilostazol in addition to aspirin. The primary end point was freedom from target vessel revascularization, and the secondary end points were the rate of restenosis and freedom from target lesion revascularization and major adverse cardiovascular events, defined as all-cause death, myocardial infarction, stroke, repeat revascularization, and leg amputation. RESULTS: Clinical follow-up information was obtained in all patients. Patient, lesion, and procedural characteristics did not differ significantly between the 2 groups. Stenting was performed in 36 patients (cilostazol, 16; control, 20; p = 0.36). Freedom from target vessel revascularization at 2 years after EVT was significantly higher compared with the control group (84.6% vs. 62.2%, p = 0.04). The rate of restenosis was lower in the cilostazol group (43.6% vs. 70.3%, p = 0.02), and freedom from target lesion revascularization and major adverse cardiovascular events was higher in the cilostazol group (87.2% vs. 67.6%, p = 0.046, 76.8% vs. 45.6%, p = 0.006, respectively). There was no major bleeding in either group during follow-up period. CONCLUSIONS: Cilostazol reduced restenosis and repeat revascularization after EVT in patients with intermittent claudication due to femoropopliteal disease.

Noninvasive evaluation of coronary reperfusion by transthoracic Doppler echocardiography in patients with anterior acute myocardial infarction before coronary intervention.

BACKGROUND: Transthoracic Doppler echocardiography (TTDE) enables evaluation of distal left anterior descending coronary artery (LAD) flow. The purpose of this study was to test whether TTDE can differentiate coronary reperfusion with Thrombolysis in Myocardial Infarction (TIMI) grade 3 from TIMI grade < or =2 in patients with anterior acute myocardial infarction (AMI). METHODS AND RESULTS: In 46 consecutive patients with a first anterior AMI in the acute phase before emergent coronary intervention, the presence of antegrade distal LAD flow and its diastolic peak velocity were evaluated by color and pulsed TTDE and compared with TIMI grades by subsequent coronary angiography performed 29+/-12 minutes later. Nineteen patients had TIMI 0 reperfusion, 4 had TIMI 1, 10 had TIMI 2, and 13 had TIMI 3. Visual antegrade distal LAD flow was present in 22 of the 46 patients. TIMI 2 and 3 reperfusions were both generally visualized by color TTDE. However, peak distal LAD flow velocity by pulsed TTDE was significantly greater in patients with TIMI 3 compared with those with TIMI 2 (40+/-10 vs 20+/-6 cm/s, P<0.0001). The diagnosis of TIMI 3 based on diastolic peak distal LAD flow velocity > or =25 cm/s by TTDE had a sensitivity, specificity, and accuracy of 77%, 94%, and 89%, respectively. CONCLUSIONS: TTDE enables noninvasive differentiation of TIMI 3 from TIMI < or =2 coronary reperfusion in patients with AMI in the acute phase before emergent coronary intervention.

Reactive hyperemia following coronary balloon angioplasty, but not dipyridamole-induced hyperemia, predicts resolution of exercise-induced ST-segment depression.

OBJECTIVES: To characterize delayed restoration of coronary blood flow following successful percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND: Delayed restoration of coronary blood flow following successful PTCA is common and likely the result of multiple factors. Temporary myocardial ischemia and dipyridamole administration both result in increased coronary blood flow, but by different mechanisms. The relationship between these phenomena and exercise-induced ST-segment depression after PTCA was investigated to determine if any correlation existed. METHODS: Forty consecutive patients with single-vessel coronary artery disease underwent treadmill exercise testing before and after PTCA. The percentage change in coronary blood flow before and after 90 s balloon inflation was assessed. After a new steady state had been reached, dipyridamole was infused and changes in coronary blood flow were again determined. The relationship between changes in coronary blood flow and the presence of ST-segment depression during exercise testing after PTCA was determined. RESULTS: Peak coronary blood flow induced by reactive hyperemia was significantly greater than that in the steady state after balloon inflation (48.5+/-38.8 compared with 15.1+/-13.2 ml/min, P<0.0001). Dipyridamole administration also resulted in significant increases in coronary blood flow (15.1+/-13.2 ml/min compared with 31.0+/-24.9 ml/min, P<0.0001). ST-segment depression after PTCA was significantly less than before (0.10+/-0.07 mV compared with 0.19+/-0.08 mV, P<0.001). Further, reactive hyperemia, but not dipyridamole-induced hyperemia, correlated with attenuation of exercise-induced ST-segment depression after PTCA (r=0.62, P<0.0001). CONCLUSIONS: Reactive hyperemia following temporary coronary occlusion recreates local conditions associated with delayed resolution of myocardial ischemia following successful PTCA. Further, this phenomenon appears to be distinct from changes in coronary blood flow induced by dipyridamole.

A new predictor of improvement in regional left ventricular function assessed by ST/HR slope derived from ST elevation on exercise testing in patients with healed myocardial infarction.

This study evaluates the clinical usefulness of ST/HR slope derived from ST elevation on exercise to predict the improvement in regional wall motion following coronary revascularization in patients with healed myocardial infarction. We studied 58 patients with a diseased, infarct-related and single-vessel coronary artery. The decline calculated from the final 12 data points relating ST-segment elevation to heart rate during exercise were derived (ST/HR slope). Hypokinesis in the infarcted region was assessed by the centerline method and expressed in terms of standard deviations (SD/chord). The increase more than 30% of the SD/chord, which was defined as the improvement in regional wall motion, was seen in 23 of the 30 patients with a ST/HR slope of > or = 5.0 (microV/bpm), and in 4 of the 28 patients with a ST/HR slope <5.0 (microV/bpm) (P <.0001). Thus, a ST/HR slope derived from ST elevation on exercise identifies subgroups of patients who show a good recovery of regional wall motion.