CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update 2022.

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Interventional and Therapeutics (CVIT) society proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018. Updated guidelines for the management of AMI were published by the European Society of Cardiology (ESC) in 2017 and 2020. Major changes in the guidelines for STEMI patients included: (1) radial access and drug-eluting stents (DES) over bare-metal stents (BMS) were recommended as a Class I indication, (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. In 2020, updated guidelines for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients, the followings were changed: (1) an early invasive strategy within 24 h is recommended in patients with NSTEMI as a Class I indication, (2) complete revascularization in NSTEMI patients without cardiogenic shock is considered as Class IIa recommendation, and (3) in patients with atrial fibrillation following a short period of triple antithrombotic therapy, dual antithrombotic therapy (e.g., DOAC and single oral antiplatelet agent preferably clopidogrel) is recommended, with discontinuation of the antiplatelet agent after 6 to 12 months. Furthermore, an aspirin-free strategy after PCI has been investigated in several trials those have started to show the safety and efficacy. The Task Force on Primary PCI of the CVIT group has now proposed the updated expert consensus document for the management of AMI focusing on procedural aspects of primary PCI in 2022 version.

Effectiveness of high flow-volume intermittent hemodiafiltration during and after intervention to prevent contrast-induced nephropathy in patients with advanced chronic kidney disease: A pilot study.

OBJECTIVES: We analyzed the effect of high flow-volume intermittent hemodiafiltration (HF-IHDF) on patients with advanced chronic kidney disease (CKD) undergoing procedures requiring administration of contrast medium. BACKGROUND: There is no effective method for preventing contrast-induced nephropathy (CIN), especially in patients with advanced CKD. We established HF-IHDF as a renal protective therapy with a filtration flow rate up to 5 times greater than standard continuous HDF. In this study, we tested whether HF-IHDF could prevent CIN in patients with advanced CKD more effectively than saline hydration only. METHODS: We retrospectively analyzed the incidence of CIN and clinical outcomes up to 1 year after performance of a procedure in 76 patients with advanced CKD. HF-IHDF was performed from just before the procedure until 2.5 hr after it. Hydration with 0.9% saline was also administered. RESULTS: The incidence of CIN was significantly lower in the HF-IHDF group than the saline group 2-3 days (0%, 0/76 patients vs. 9.3%, 5/54 patients; p < .05) and 1 month (3.9%, 3/76 patients vs. 14.8%, 8/54 patients; p < .05) after intervention. No difference between the two groups was detected in the proportion of patients requiring permanent hemodialysis within 1 year after intervention or the 1 year mortality rate. However, the number of patients free from progression of renal dysfunction after 1 year of follow-up was significantly higher in the HF-IHDF group (86.8%, 66/76 patients vs. 64.8%, 35/54 patients; p < .01). CONCLUSIONS: HF-IHDF during and after interventional procedure requiring administration of contrast medium may prevent CIN in patients with advanced CKD.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018.

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

ECG-edited middiastolic phase reconstruction improves image quality at 64-MDCT coronary angiography of patients with atrial fibrillation.

OBJECTIVE: The aims of this study were to evaluate image quality at the absolute middiastolic and absolute end-systolic phases of 64-MDCT coronary angiography of patients with atrial fibrillation and to compare the findings with those among patients in sinus rhythm. SUBJECTS AND METHODS: Nineteen consecutively registered patients with atrial fibrillation and 19 patients in sinus rhythm taking heart-rate-lowering agents as needed underwent MDCT. Images were reconstructed with a half-scan reconstruction algorithm after ECG editing (deletion of short R-R intervals, insertion of additional temporal windows into the middiastolic phase of long R-R intervals, and shift of R points). We used a 5-point scale (4, no motion artifacts; 0, unevaluable) to evaluate motion artifacts and coronary artery image discontinuities greater than 1 mm on the curved multiplanar reconstruction images. Each coronary artery image with a motion score of 2 or greater for all segments and with 2 or fewer discontinuities was considered acceptable for diagnosis. RESULTS: Middiastolic images of patients with atrial fibrillation showed fewer motion artifacts and image discontinuities than did end-systolic images of patients with atrial fibrillation. Despite greater heart rate variability under the condition of similar mean heart rates in patients with atrial fibrillation, motion artifacts and image discontinuities on middiastolic images were not significantly different from those on sinus rhythm images. Acceptable quality was achieved on 91% of middiastolic atrial fibrillation images and 93% of sinus rhythm images. CONCLUSION: ECG-edited middiastolic atrial fibrillation images with aggressive heart rate control were of better quality than end-systolic images in patients with atrial fibrillation. The diagnostic image quality of the middiastolic images was comparable with that of sinus rhythm images.

Debulking of chronic coronary total occlusions with rotational or directional atherectomy before stenting: Final results of DOCTORS study.

OBJECTIVE: To evaluate the safety and efficacy of pre-stent plaque debulking strategy for percutaneous coronary intervention for CTO. BACKGROUND: Drug-eluting stents (DES) reduce lesion recurrence after percutaneous coronary intervention for chronic total occlusion (CTO). However, massive plaque burden or calcified plaque sometime hinders optimal stenting. The aim of the study was to investigate the safety and the effectiveness of pre-stent plaque debulking in CTOs. The primary end-point was the angiographic restenosis rate at 6 months. Secondary end-points were the major adverse cardiac event (MACE) at 30 days and at 1 year. METHOD: Between October 2000 and July 2003, 266 patients with CTOs were evaluated in 21 Japanese centers. After successful wire crossing, an operator judged the indications for a debulking strategy (177 patients for rotational and 89 for directional atherectomy). The subjects were then randomly assigned to a debulking (rotational: 90, directional: 48) or non-debulking (rotational: 87, directional: 41) group. RESULT: Baseline clinical and lesion characteristics showed no differences between the groups. The debulking group tended to have the higher 30-day MACE rate than the non-debulking group (15.9% vs 8.5%, P=0.07). Although binary 6 month restenosis rates did not reach statistical significance (debulking 23.8% vs non-debulking 34.6%; P=0.072), the 1-year MACE rate was lower in the debulking group than in the non-debulking group (27.5% vs 39.8%; P=0.033). CONCLUSION: This study demonstrated that pre-stent plaque debulking of CTO was associated with a favorable mid-term outcome with lower target revascularization rate in the debulking group than in the non-debulking group.

Continuous administration of nicorandil decreases QT dispersion during the chronic phase of acute myocardial infarction.

We previously reported that continuous intravenous (IV) administration of nicorandil (NIC) inhibits QT dispersion (QTd). However, no prior study has evaluated the efficacy of NIC when administered orally to acute myocardial infarction (AMI) patients following continuous IV administration. Thirty patients with anteroseptal infarction in whom revascularization was performed successfully within 6 hours of AMI onset were included in the study and assigned to one of 3 groups: group A (continuous IV administration of NIC), group B (continuous IV and oral administration of NIC), and group C (no treatment with NIC). After 24 hours, QTd in groups A and B was significantly decreased compared to QTd in group C (P < 0.01) (group A, 58.1; group B, 58.2; and group C, 81.3). The QTd obtained 3 months later was significantly shorter in group B subjects who were orally administered NIC, and QTd before percutaneous coronary intervention (PCI) was restored in group A, in which no NIC had been administered orally [group A, 66.7; group B, 54.1; and group C, 73.9; P < 0.05 (group A versus group B) and P < 0.01 (group B versus group C)]. The effects were evaluated by comparing different routes of administration. Continuous IV and subsequent oral administration of NIC inhibited prolongation of QTd, suggesting that these effects may prevent the occurrence of cardiac events during both the acute and chronic phases of AMI.

Carotid intima-media thickness is increased in subjects with ischemic heart disease having a familial incidence.

OBJECTIVES: A family history of ischemic heart disease (IHD) is an independent risk factor for cardiovascular events. However, the mechanisms underlying this susceptibility have not been fully elucidated. The authors hypothesized that an important mediator of the familial incidence of IHD is subclinical atherosclerosis, which is detectable by noninvasive imaging. METHODS: One hundred forty-seven consecutive subjects (mean age 61.9 years, 57% men) were studied for one year using carotid ultra-sonogrophy for general medical screening, and familial IHD events were validated. Using a 7.5 MHz linear array transducer, carotid intima-media thickness (IMT) and carotid plaque were assessed. Subjects were subsequently divided into four groups based on the severity of IMT. RESULTS: The familial incidence of IHD and incidence of plaque were associated with the severity of IMT. No significant differences in risk factors were found between subjects with and without a family history of IHD. CONCLUSIONS: These findings suggest that subclinical atherosclerosis, as assessed in the carotid arteries, is more prevalent in individuals with a family history of IHD.

Acute and long-term outcomes of rotational atherectomy in small (< 3.0 mm) coronary arteries.

Conventional balloon angioplasty (BA) of small coronary arteries (SCA) is followed by a high rate of restenosis. Rotational atherectomy may be effective as an alternate treatment of stenoses unsuitable for other devices. The purpose of this study was to assess the efficacy of RA in the treatment of SCA. A retrospective analysis was performed of 226 lesions in 159 consecutive patients who underwent RA of SCA (mean diameter = 2.36 +/- 0.49 mm). One hundred forty-eight lesions (65.5%) were type B2 or C of AHA/ACC criteria. Follow-up angiography was performed at 3 and 6 months after the procedure. Procedural success was achieved in 96.9% of patients. The mean burr-to-artery ratio was 0.74 +/- 0.17. Adjunctive BA and stent implantation were needed in 94.2% and 22.6% of lesions, respectively. Minimal lumen diameter (MLD) increased from 0.66 +/- 0.35 mm to 1.97 +/- 0.58 mm (P < 0.01). Angiographic complications consisted of acute reclosure (3.5%), no reflow/slow flow (12.4%), and coronary artery perforation (1.8%). No death, Q-wave myocardial infarction (MI), or coronary artery bypass graft (CABG) occurred during the initial hospitalization. Restenosis rates at 3 and 6 months were 40.6% and 44.2%, respectively, and target lesion revascularization (TLR) rates were 28.5% and 33.0%, respectively. Restenosis and TLR rates during follow-up were comparable among patients who underwent RA + adjunctive BA versus patients who underwent RA + stenting. Long-term clinical follow-up was complete in 143 patients over a mean period of 348 +/- 166 days. The survival free from cardiac death, MI, CABG or repeated BA was 59.6% at 1 year. In conclusion, RA of SCA has relatively high restenosis rates, but may be appropriate for more complex, calcified lesions unsuitable for other devices.

Effect of intracoronary nicorandil administration on preventing no-reflow/slow flow phenomenon during rotational atherectomy.

A major limitation of the rotational atherectomy (RA) procedure is the occurrence of the no-reflow/slow flow phenomenon and the optimal strategy is still evolving. Recent clinical studies have demonstrated the beneficial effects of nicorandil, an adenosine triphosphate (ATP)-sensitive potassium channel opener, on no-reflow in patients with acute myocardial infarction. The purpose of this study was to evaluate the effect of nicorandil on no-reflow/slow flow phenomenon during RA procedures. Sixty-one patients who underwent RA of complex coronary lesions were randomly divided into 2 groups: (i) nicorandil cocktail (n=24 patients, 37 lesions) and (ii) verapamil cocktail (n=37 patients, 63 lesions). In each group, the drug cocktail mixed with pressurized saline was infused through the 4Fr Teflon sheath of the rotablator system during the RA procedure. In the nicorandil group, the drug cocktail consisted of 24 mg of nicorandil, 5 mg of nitroglycerin, and 10,000 U of heparin. In the verapamil group, the drug cocktail consisted of 10 mg of verapamil, 5 mg of nitroglycerin, and 10,000 U of heparin. Baseline and procedure characteristics did not differ between the 2 groups. RA was performed successfully, and death, Q-wave myocardial infarction, or emergency coronary artery bypass surgery did not occur in any patients. The no-reflow/slow flow phenomenon was observed in 11/63 (17.4%) lesions of the verapamil group, but in only 1/37 (2.7%) lesions of the nicorandil group (p=0.03). No untoward complications were observed during nicorandil infusion. These data indicate that the intracoronary continuous infusion of nicorandil during RA procedures is easy and safe, and prevents no-reflow/slow flow phenomenon more effectively than infusion of verapamil.

Shunt between the ventricular chamber and coronary arteries preserves left ventricular function in acute myocardial infarction.

It is controversial whether newly created channels made by transmyocardial laser revascularization are functionally significant, so the present study evaluated the shunt flow from the left ventricular (LV) cavity to the ischemic myocardium in 51 patients with acute myocardial infarction (AMI) caused by complete occlusion of the proximal left anterior descending coronary artery. All patients underwent left heart catheterization within 24 h of onset and all underwent successful coronary reperfusion using primary coronary angioplasty with no angiographic restenosis on follow-up coronary angiography (CAG). The presence of the LV shunt flow was evaluated by selective left CAG after successful reperfusion. The LV global ejection fraction (EF) and regional function (centerline method) were analyzed by ventriculography in both the acute and chronic phases. The patients were divided into the 3 groups (Group A, no LV shunt without collaterals, n=20; Group B, no LV shunt with collaterals, n=24; Group C, LV shunt with collaterals, n=7). There was no difference in the grade of collateral circulation between Groups B and C. The improvements in LVEF and regional function from the acute phase to the chronic phase were significantly greater in Group C than in Groups A and B. Not only collateral circulation but also LV shunt contributes to the functional recovery of infarct myocardium in patients with AMI.