Serial quantitative angiographic study of target lumen enlargement after drug-coated balloon angioplasty for native coronary artery disease.

BACKGROUND: Target lumen enlargement (TLE) or "late lumen enlargement" is often encountered after percutaneous coronary intervention (PCI) with drug-coated balloons (DCB). To date, the prognosis of coronary arterial lesions with or without TLE has not been clearly elucidated. AIMS: This study aimed to assess the long-term prognosis of coronary arterial lesions with or without TLE observed within 1 year (early TLE) after DCB angioplasty using serial quantitative angiographic follow-up. METHODS: One hundred and ninety-three consecutive patients (de novo coronary arterial lesions, 251) who underwent follow-up angiography within 1 year after DCB angioplasty (early follow-up, median: 6 months) were retrospectively evaluated. Of these, 97 patients (125 lesions) also underwent angiography more than 1 year after DCB angioplasty (late follow-up, median: 37 months). TLE was defined as an increase in minimal lumen diameter (MLD) after PCI at each follow-up. RESULTS: Early TLE was detected in 142 lesions (56.6%). Of these, 76 lesions were also evaluated at late follow-up. TLE persisted even at late follow-up in 67 of the 76 lesions (88.2%). An increase in MLD in early TLE (+) lesions was observed in the period between post-PCI and early follow-up (1.84 ± 0.06 vs. 2.12 ± 0.07 mm, p < 0.001) but not between early and late follow-up (2.12 ± 0.07 vs. 2.16 ± 0.07 mm, p = 0.74). In contrast, 49 of 109 lesions without early TLE were evaluated at late follow-up, of which 28 lesions (57.1%) showed TLE at late follow-up. The MLD of early TLE (-) lesions (n = 49) significantly increased from early (1.63 ± 0.061 mm) to late follow-up (1.84 ± 0.06 mm) (p < 0.001). No aneurysms were found in any of these cases. CONCLUSION: Early TLE was observed in more than half of the lesions, with the majority remaining at late follow-up. Alternatively, half of the lesions without early TLE showed late TLE, occurring biphasically after DCB angioplasty.

Late Pennsylvanian carbonate platform facies and coral reef: new insights from southern China (Guizhou Province).

The Pennsylvanian is characterized by intense paleoenvironmental changes related to glacio-eustatic sea-level fluctuations and major tectonic events, which affected the evolution of biocommunities. Most known Pennsylvanian tropical reefs and mounds are predominantly composed of calcareous algae (e.g. phylloid algae, Archaeolithophyllum), calcareous sponges, fenestrate bryozoans, Tubiphytes, and microbialites. However, in Houchang (southern China), the Late Pennsylvanian carbonate platform records a large coral reef lacking any analogs in age (Gzhelian), size (80-100 m thick) and composition (high biodiversity). The large coral reef developed at the border of the Luodian intraplatform basin. The intraplatform basin is characterized by the deposition of green algal grainstone, coated grain grainstone and bioclastic packstone, grainstone, floatstone and rudstone in shallow-waters. In the deep-water shelf, lithofacies are composed of burrowed bioclastic wackestone, microbioclastic peloidal packstone, grainstone, and fine-grained burrowed wackestone and packstone. In this context, the coral reef developed on a deep-shelf margin, in a moderate to low energy depositional environment, below the FWWB. The scarcity of Pennsylvanian coral reefs suggests global unfavorable conditions, which can be attributed to a complex pattern of several environmental factors, including seawater chemistry (aragonite seas), paleoclimatic cooling related to continental glaciation, and the biological competition with the more opportunistic and adaptive phylloid algal community that occupied similar platform margin paleoenvironments. The existence of the large Bianping coral reef in southern China, as well as a few additional examples of Pennsylvanian coralliferous bioconstructions, provides evidence that coral communities were able to endure the Late Paleozoic fluctuating paleoenvironmental conditions in specific settings. One of such settings appears to have been the deep shelf margin, where low light levels decreased competition with the phylloid algal community.

Efficacy of Low-Pressure Inflation of Oversized Drug-Coated Balloon for Coronary Artery Disease.

OBJECTIVES: This study sought to assess the efficacy of oversized drug-coated balloon (DCB) inflation at low pressure for the prevention of acute dissections and late restenosis. BACKGROUND: The major limitation of DCB coronary angioplasty is the occurrence of severe dissection after inflation of DCB. METHODS: Between 2014 and 2018, 273 consecutive patients were retrospectively studied. 191 lesions (154 patients) treated by oversized DCB inflation at low pressure (<4 atm, 2.4 ± 1.2 atm, DCB/artery ratio 1.14 ± 0.22; LP group) were compared with 135 lesions (119 patients) treated by the standard DCB technique (7.1 ± 2.2 atm, DCB/artery ratio 1.03 ± 0.16; SP group). RESULTS: Although the lesions in the LP group were more complex than those in the SP group (smaller reference diameter (2.38 mm vs. 2.57 mm, P=0.011), longer lesions (11.7 mm vs. 10.5 mm, P=0.10), and more frequent use of rotational atherectomy (45.0% vs. 28.1%, P=0.003), there was no significant difference in the NHLBI type of dissections between the two groups (11.5%, 12.0%, 5.2% vs. 12.6%, 12.6%, 2.2% in type A, B, and C, P=0.61), and no bailout stenting was required. In 125 well-matched lesion pairs after propensity score analysis, the cumulative incidence of target lesion revascularization at 3 years was 4.5% vs. 7.0%, respectively (P=0.60). Late lumen loss (-0.00 mm vs. -0.01 mm, P=0.94) and restenosis rates (7.4% vs. 7.1%, P=1.0) were similar in both of the groups. CONCLUSION: The application of oversized DCB at low pressure is effective and feasible for preventing late restenosis comparative to the standard technique of DCB.

Safety and Long-Term Efficacy of Drug-Coated Balloon Angioplasty following Rotational Atherectomy for Severely Calcified Coronary Lesions Compared with New Generation Drug-Eluting Stents.

OBJECTIVES: This study sought to assess the safety and long-term efficacy of drug-coated balloons (DCB) following aggressive intracoronary image-guided rotational atherectomy (iRA) for severe coronary artery calcification (CAC), and to compare this strategy with new generation drug-eluting stents (nDES) following iRA. BACKGROUND: Ischemic events following the treatment of CAC is still relatively high. Thus, more innovative strategies are required. METHODS: We evaluated 123 consecutive patients (166 lesions) with de novo CAC undergoing an iRA (burr size; 0.7 of the mean reference diameter by intracoronary imaging) followed by DCB (DCB-iRA; 54 patients, 68 lesions) or nDES (nDES-iRA; 69 patients, 98 lesions). Follow-up angiography was obtained at > 6 months. RESULTS: The target vessels (right coronary and circumflex), bifurcation (67.6% versus 47.9%), reference diameter (2.28mm versus 2.49mm), and lesion length (11.89mm versus 18.78mm) were significantly different between the two groups. The median follow-up was 732 days. TLR and TVR in DCB-iRA and nDES-iRA at 3 years were similar: 15.6% versus 16.3% (P=0.99) and 15.6% versus 23.3% (P=0.38). In 41 well-matched lesion pairs after propensity score analysis, the cumulative incidence of TLR and TVR in DCB-iRA and nDES-iRA at 3 years was 12.9% versus 16.3% (P=0.70) and 12.9% versus 26.1% (P=0.17), respectively. On QCA analysis, although the acute gain was smaller in DCB-iRA (0.85 mm versus 1.53 mm, P<0.001), the minimum lumen diameter at follow-up was similar (1.69 mm versus 1.87 mm, P=0.29). The late lumen loss was lower (0.09 mm versus 0.52 mm, P=0.009) in DCB-iRA. CONCLUSIONS: DCB-iRA is feasible for CAC.

Outcomes after drug-coated balloon treatment for patients with calcified coronary lesions.

OBJECTIVES: To investigate the efficacy of drug-coated balloon (DCB) for calcified coronary lesions. BACKGROUND: Calcified coronary lesions is associated with poor clinical outcomes after revascularization. Recently, DCB is emerging as an alternative strategy for de novo coronary lesions. However, reports describing the efficacy of DCB for calcified coronary lesions are limited. METHODS: A total of 81 patients (96 lesions) who electively underwent DCB treatment for de novo coronary lesions were enrolled: 46 patients (55 lesions) in the calcified group and 35 patients (41 lesions) in the non-calcified group. Angiographic follow-up data and clinical outcomes after the procedure were evaluated. RESULTS: The diameter of the DCB used was 2.5 ± 0.5 mm. No bail-out stenting was observed after DCB treatment. Rotational atherectomy was used in 82% of lesions in the calcified group. Follow-up angiography (median, 6.5 months after intervention) was performed for 59 patients (30 in the calcified group and 29 in the non-calcified group). Late lumen loss and rates of restenosis were comparable between the groups (0.03 mm in the calcified group vs -0.18 mm in the non-calcified group, P = 0.093 and 13.9% vs 3.03%, P = 0.095, respectively). The survival rates for target lesion revascularization free survival and major adverse cardiac events at 2 years were comparable between the groups (85.3% vs 93.4%, P = 0.64 and 81.4% vs 88.5%, P = 0.57, respectively). CONCLUSION: Calcified coronary lesions might dilute the effect of DCB. However, clinical outcomes in the calcified group were similar to those in the non-calcified group.

Utility of a scoring balloon for a severely calcified lesion: bench test and finite element analysis.

We aimed to investigate the effectiveness of a scoring balloon catheter in expanding a circumferentially calcified lesion compared to a conventional balloon catheter using an in vitro experiment setting and elucidate the underlying mechanisms of this ability using a finite element analysis. True efficacy of the scoring device and the underlying mechanisms for heavily calcified coronary lesions are unclear. We employed a Scoreflex scoring balloon catheter (OrbusNeich, Hong Kong, China). The ability of Scoreflex to dilate a calcified lesion was compared with a conventional balloon catheter using 3 different sized calcium tubes. The thickness of the calcium tubes were 2.0, 2.25, and 2.5 mm. The primary endpoints were the successful induction of cracks in the calcium tubes and the inflation pressures required for inducing cracks. The inflation pressure required for cracking the calcium tubes were consistently lower with Scoreflex (p < 0.05, Student t test). The finite element analysis revealed that the first principal stress applied to the calcified plaque was higher by at least threefold when applying the balloon catheter with scoring elements. A scoring balloon catheter can expand a calcified lesion with lower pressure than that of a conventional balloon. The finite element analysis revealed that the concentration of the stress observed in the outside of the calcified plaque just opposite to the scoring element is the underlying mechanism of the increased ability of Scoreflex to dilate the calcified lesion.

Neointimal calcification after stenting and chronic kidney disease.

The timing and incidence of neointimal calcification after stenting (NIC) is largely unknown. The purpose of our study was to elucidate the characteristics of NIC. The presence of NIC in patients who underwent intravascular ultrasound between June 30, 2009 and June 30, 2012 was analyzed. The patients were divided into two groups based on the follow-up period: < 365 days or ≥ 365 days. A total of 181 images were analyzed. Those with NIC had a lower estimated glomerular filtration rate [51 (6-60) versus 61 (52-72) mL/minute/1.73 m²; P < 0.01] and longer time after stenting [3198 (1710-3684) versus 211 (180-516) days; P < 0.01] compared to those without NIC. NIC during short-term follow-up was observed only in patients who were on hemodialysis. On the other hand, NIC in the long-term follow-up was observed only in patients with bare metal stents. The development of NIC was related to renal function and time after stenting. NIC in the short-term and the long-term follow-up was observed only in patients who were on hemodialysis and who were implanted with a bare metal stent, respectively.

In vitro assessment of mathematically-derived fractional flow reserve in coronary lesions with more than two sequential stenoses.

BACKGROUND: Myocardial fractional flow reserve (FFR) is a reliable index in coronary intervention. A simple FFR measurement does not predict the true functional severity of an individual stenosis in multiple sequential coronary stenoses because of complex interaction between the stenoses. Application of the theoretical equations to predict the true FFR of individual stenosis is limited in a tandem lesion. Two novel equations applicable to a multiple sequential coronary stenoses are mathematically derived. One predicts the true FFR of each stenosis (equation A), and the other predicts the true FFR after releasing a given stenosis (equation B). The present study aimed to validate the two derived equations in an in vitro model of coronary circulation. METHODS AND RESULTS: Predictive FFR was compared with true FFR in an in vitro model of three sequential stenoses using linear regression analysis. The difference between apparent FFR and true FFR was compared with the difference between predictive FFR and true FFR. The legitimacy of equation A was first assessed. A close correlation was found between predictive FFR and true FFR (r² = 0.92). The difference between predictive FFR and true FFR was significantly lower compared to the difference between apparent FFR and true FFR (0.18 ± 0.10 vs 0.05 ± 0.05; P<.001). The legitimacy of equation B was also assessed, and a close correlation was found (r² = 0.97). The difference was significantly lower when we applied equation B (0.13 ± 0.06 vs 0.04 ± 0.02; P<.001). CONCLUSIONS: Equations A and B strongly predict the true value of FFR in the experimental model of coronary circulation.

A case report of acute myocardial infarction induced by coronary spasm. Intravascular findings.

A 53-year-old male complaining of chest pain was admitted to our hospital with suspected acute myocardial infarction (AMI). Emergent coronary angiography (CAG) determined a totally occluded middle right coronary artery (RCA). Thrombus aspiration was conducted, followed by intravascular ultrasound (IVUS) imaging. Diffuse intima plus media thickness was identified at the obstruction site and a thrombus was observed proximally to the occlusion site on IVUS. Following isosorbide dinitrate (ISDN) administration, dilatation of the RCA was confirmed. IVUS study indicated the luminal dilatation was achieved by the release of the diffuse intima plus media thickening. Of note, plaque volume showed no significant difference after administration of ISDN at any vessel site. These results clearly show that luminal dilatation and vessel dilatation were achieved from the redistribution of plaque volume (intima plus media). A follow-up CAG showed no significant stenosis in the RCA. After a provocation test using methylergometrine maleate, the RCA was totally occluded at the very site of the initial event. The involvement of vasospasm as a cause of AMI in the present case was doubly confirmed with characteristic IVUS images of vasospasm in the acute phase and with a provocation test at follow-up.

Difference of tissue characteristics between early and very late restenosis lesions after bare-metal stent implantation: an optical coherence tomography study.

BACKGROUND: Although in-stent restenosis (ISR) after bare-metal stent (BMS) implantation peaks in the early phase, very late (VL) ISR occasionally is observed beyond a few years after BMS implantation. To date, this mechanism has not been fully clarified. METHODS AND RESULTS: We compared the morphological characteristics of VL-ISR (>5 years, without restenosis within the first year) (n=43) to those of early (E) ISR (within the first year) (n=39) using optical coherence tomography (OCT). Qualitative restenotic tissue analysis included assessment of tissue structure (homogeneous or heterogeneous), presence of microvessels, disrupted intima with cavity, and intraluminal material and was performed at every 1-mm slice of the entire stent. The proportions of cross-sections with heterogeneous intima in the entire stent was significantly higher in the VL-ISR group compared to the E-ISR group (60.5±28.5% versus 5.8±11.5%, P<0.0001), with heterogeneous intima being more frequently observed at the minimum lumen area site in the VL-ISR group (90.7% versus 17.9%, P<0.0001). Disrupted intima with cavity and intraluminal material also were observed more frequently in the VL-ISR group for the entire stent (18.6% versus 0%, 20.9% versus 2.6%, P<0.03) as well as at the minimum lumen area site (13.9% versus 0%,16.2% versus 0%, P<0.03). CONCLUSIONS: The morphological characteristics of restenotic tissue in VL-ISR were different from those in E-ISR and similar to atherosclerotic plaque. In BMS, progression of the atherosclerotic process within neointima after stent implantation may be associated with VL-ISR.

Effects of benidipine and some other calcium channel blockers on the prognosis of patients with vasospastic angina. Cohort study with evaluation of the ergonovine coronary spasm induction test.

BACKGROUND: It has been reported that the morbidity rate of vasospastic angina is higher in Japan compared to western countries, and its prognosis has already been reported. However, the prognosis of vasospastic angina in relation to coronary angiographic findings, prognostic risk factors and treatment has not yet been fully investigated. METHODS AND RESULTS: From January 2000 to October 2005, 1047 patients with vasospastic angina diagnosed by coronary angiography at Gifu University Hospital and related hospitals were registered in a cohort study (follow-up rate: 91.4%, median follow-up duration: 3.8 years). The presence of coronary artery stenosis, diabetes mellitus, total spasm, and age of more than 65 years had a negative prognostic impact on cardiovascular events. Patients were treated with calcium channel blockers such as diltiazem (CAS 33286-22-5, CAS 42399-41-7), amlodipine (CAS 111470-99-6), nifedipine (CAS 21829-25-4), and benidipine (CAS 91599-74-5). Among these calcium channel blockers, when patient background was matched by the propensity score in patients treated with calcium channel blockers only, the cardiovascular event rate was significantly lower in the benidipine group than in the diltiazem group. CONCLUSION: The study demonstrated for the first time that total spasm is a risk factor, independent of other factors, for cardiovascular events in patients with vasospastic angina. Treatment with benidipine showed a better prognosis than that with diltiazem.

Clinical features of emergency electrocardiography in patients with acute myocardial infarction caused by left main trunk obstruction.

BACKGROUND: To diagnose left main trunk (LMT) infarction by 12-lead standard electrocardiogram (ECG) is an important emergency technique, but the features in LMT infarctions have not been clarified. METHODS AND RESULTS: The study enrolled 140 subjects who were divided into 4 groups according to the location of the culprit artery: 35 with LMT, 35 with left anterior descending artery (LAD), 35 with right coronary artery and 35 with left circumflex artery. Various parameters obtained from the ECGs were analyzed. Average QTc interval (0.51 +/- 0.06 s) in LMT group was markedly longer than that in the 3 other groups. Average QRS axis (-10 +/- 77 degrees) in LMT infarction showed a remarkable left deviation. ST-segment elevation in lead aVR occurred in 28 patients (80.0%) in the LMT group. The ECG features of the LMT group could be classified into 2 main groups: right bundle branch block (RBBB) with a marked left axis deviation (RBBB + LADEV type) and ST-segment elevation in leads V2-5, I and aVL without abnormal axis deviation (LAD type). CONCLUSION: Either ST-segment elevation in lead aVR and marked prolongation of both the QRS width and QTc interval with a prominent abnormal axis deviation or ST-segment elevation in the broad anterior precordial lead with a normal QRS axis strongly suggests LMT infarction.