Effect of cutting balloon after rotational atherectomy in severely calcified coronary artery lesions as assessed by optical coherence tomography.

OBJECTIVES: Using optical coherence tomography (OCT), we evaluated the effect of a cutting balloon (CB) compared with a conventional balloon after rotational atherectomy (RA) and before stenting in severely calcified coronary lesions. BACKGROUND: A CB is designed to create discrete incisions to facilitate fracture of severely calcified plaque. METHODS: OCT was performed preintervention (if possible), post-RA, and poststent implantation. RA modification of calcium was defined as a polished, concave, round-shaped surface. Calcium fracture was defined as a break in the calcium plate. The effects of calcium modification and stent expansion between CB (n = 18) versus conventional balloon (n = 23) following RA were compared. RESULTS: Median patient age was 72 years with 24% on hemodialysis. The amount of calcium and the length of RA modification were comparable between the CB and conventional balloon groups. Final poststent OCT showed that the number and thickness of calcium fracture were greater after CB versus conventional balloon, resulting better stent expansion (78.9% [IQR: 72.4-88.1] vs. 66.7% [IQR: 55.0-76.7], p < 0.01). In the multivariable model, after adjusting for the amount of calcium, CB use was an independent predictor of the presence of calcium fracture (odds ratio 30.0; 95% confidence interval 2.7-994.1, p = 0.004) and an independent predictor for greater stent expansion (regression coefficient 7.4; 95% confidence interval 0.5-14.3, p = 0.04). CONCLUSION: In severely calcified lesions calcium fracture was more often associated with RA followed by CB compared with RA followed by conventional balloon predilation before stenting. CB use was also a determinant of greater stent expansion.

Serial 3-Vessel Optical Coherence Tomography and Intravascular Ultrasound Analysis of Changing Morphologies Associated With Lesion Progression in Patients With Stable Angina Pectoris.

BACKGROUND: Optical coherence tomographic (OCT) morphologies associated with lesion progression are not well studied. The aim of this study was to determine the morphological change for untreated lesion progression using both OCT and intravascular ultrasound (IVUS). METHODS AND RESULTS: We used baseline and 8-month follow-up 3-vessel OCT and IVUS to assess 127 nonculprit lesions (IVUS plaque burden ≥40%) in 45 patients with stable angina after target lesion treatment. Lesion progression was defined as an IVUS lumen area decrease >0.5 mm2. A layered pattern was identified as a superficial layer that had a different optical intensity and a clear demarcation from underlying plaque. Lesion progression was observed in 19% (24/127) lesions, and its pattern was characterized into 3 types: type I, new superficial layered pattern at follow-up that was not present at baseline (n=9); type II, a layered pattern at baseline whose layer thickness increased at follow-up (n=7); or type III, no layered pattern at baseline or follow-up (n=8). The increase of IVUS plaque+media area was largest in type I and least in type III (1.9 mm2 [1.6-2.1], 1.1 mm2 [0.9-1.4], and 0.3 mm2 [-0.2 to 0.8], respectively; P=0.002). Type III, but not types I or II, showed negative remodeling during follow-up (IVUS vessel area; from 14.3 mm2 [11.4-17.2] to 13.5 mm2 [10.4-16.7]; P=0.02). OCT lipidic plaque was associated with lesion progression (odds ratio, 13.6; 95% confidence interval, 3.7-50.6; P<0.001). CONCLUSIONS: Lesion progression was categorized to distinct OCT morphologies that were related to changes in plaque mass or vessel remodeling.

Steroid pulse therapy was effective for cardiac sarcoidosis with ventricular tachycardia and systolic dysfunction.

A 32-year-old man presented with palpitation. He was diagnosed with pulmonary sarcoidosis by lung biopsy. The electrocardiogram showed first-degree atrioventricular block and complete right bundle branch block (CRBBB). We planned to examine laboratory data, echocardiography, Holter monitoring, and gallium-67 scintigraphy. Before he went through all these exams, he developed ventricular tachycardia. After defibrillation was performed, his electrocardiogram revealed complete atrioventricular block. We observed elevation of serum angiotensin-converting enzyme levels. In addition, both of gallium-67 scintigraphy and 18F-fluorodeoxyglucose positron emission tomography showed abnormal uptake in the ventricular septum. We diagnosed the patient with cardiac sarcoidosis associated with these arrhythmias. We started treatment with methylprednisolone pulse therapy (1 g daily). After 3 days of steroid pulse therapy, we administered prednisolone 30 mg daily. On day 15, electrocardiogram changed from complete atrioventricular block to first-degree atrioventricular block and CRBBB. He was discharged with no progression with cardiac sarcoidosis for 2 years.

The Efficacy of Tolvaptan in Congestive Heart Failure Patients with and Without Hypoalbuminemia: A Pilot Study.

BACKGROUND: Heart failure (HF) with hypoalbuminemia is associated with poor response to conventional therapy. We investigated whether tolvaptan, a potent aquaretic agent, might be of benefit in HF patients with hypoalbuminemia. METHODS: We prospectively enrolled 40 patients hospitalized for HF. Patients received conventional therapy including loop diuretics. We subsequently added tolvaptan in the range of 3.75-15 mg daily and it was discontinued after improvement of HF symptoms. We compared clinical and laboratory data in HF patients with and without hypoalbuminemia (defined as serum albumin <3.0 g/dL). RESULTS: Tolvaptan was administered in 18 HF patients with hypoalbuminemia (Group A) and 22 HF patients without hypoalbuminemia (Group B). The mean serum albumin was 2.63 ± 0.27 and 3.46 ± 0.25 g/dL, respectively. The average urine output on tolvaptan increased significantly in both groups (1644.4 ± 797.6-3011.6 ± 1453.8 mL/day, P = 0.004; 1459 ± 612.7-2112.2 ± 724.5 mL/day, P = 0.008; respectively). In addition, we observed higher urine output on therapy in Group A than in Group B (P = 0.015). There was a moderate negative correlation between serum albumin and average urine output on tolvaptan (r = -0.42, P = 0.007). CONCLUSIONS: The addition of tolvaptan to low dose loop diuretics might be an effective strategy for treatment of HF patients with hypoalbuminemia.

Association between increased epicardial adipose tissue volume and coronary plaque composition.

To assess the relationship between epicardial adipose tissue volume (EATV) and plaque vulnerability in significant coronary stenosis using a 40-MHz intravascular ultrasound (IVUS) imaging system (iMap-IVUS), we analyzed 130 consecutive patients with coronary stenosis who underwent dual-source computed tomography (CT) and cardiac catheterization. Culprit lesions were imaged by iMap-IVUS before stenting. The iMAP-IVUS system classified coronary plaque components as fibrous, lipid, necrotic, or calcified tissue, based on the radiofrequency spectrum. Epicardial adipose tissue was measured as the tissue ranging from -190 to -30 Hounsfield units. EATV, calculated as the sum of the fat areas on short-axis images, was 85.0 ± 34.0 cm(3). There was a positive correlation between EATV and the percentage of necrotic plaque tissue (R (2) = 0.34, P < 0.01), while there was a negative correlation between EATV and the percentage of fibrous tissue (R (2) = 0.24, P < 0.01). Multivariate analysis revealed that an increased low-density lipoprotein cholesterol level (ß = 0.15, P = 0.03) and EATV (ß = 0.14, P = 0.02) were independently associated with the percentage of necrotic plaque tissue. An increase in EATV was associated with the development of coronary atherosclerosis and, potentially, with the most dangerous type of plaque.

Local injection of tissue-plasminogen activator using a pulse spray catheter as a treatment option for proximal deep vein thrombosis: A case report.

A 24-year-old woman was admitted to our hospital with the diagnosis of pulmonary thromboembolism (PTE) and left common iliac vein thrombosis. She had used low-dose contraceptive pill for dysmenorrhea. Otherwise, her laboratory data did not show any other thrombotic risk factors. Thrombus in the common iliac vein usually requires a permanent inferior vena cava (IVC) filter. However, the use of long-term warfarin should have been avoided for her potential future pregnancy. A retrievable IVC filter was placed and catheter directed thrombolysis was performed for her deep vein thrombosis (DVT). Local injection of monteplase from a pulse spray catheter was performed for 4 days. After the catheter-based treatment, the thrombus resolved and the IVC filter was successfully removed on day 19. The patient was discharged on day 21. Warfarin therapy was discontinued 6 months after discharge. .

Repeat drug-eluting stent implantation for in-stent restenosis: first- or second-generation stent.

OBJECTIVE: To investigate the efficacy and safety of a second-generation drug-eluting stent (DES) for in-stent restenosis (ISR) after first-generation DES implantation. BACKGROUND: The everolimus-eluting stent is a second-generation DES that is very effective for de novo coronary lesions. METHODS: The subjects were 145 consecutive patients who underwent re-stenting, including 93 given a first-generation DES and 52 given a second-generation DES. The two groups were followed up for 37.8 ± 16.7 months and 13.8 ± 2.1 months, respectively. The primary endpoint was in-stent late luminal loss at 8-month angiographic follow-up. RESULTS: Baseline clinical and angiographic parameters were similar in the 2 groups. Follow-up angiography showed that late luminal loss (0.26 ± 0.31 mm vs 0.58 ± 0.67 mm; P=.01), the binary restenosis rate (2.6% vs 16.7%; P=.03), and the target lesion revascularization (TLR) rate (1.9% vs 11.8%; log-rank = 0.04) were smaller in the second-generation group than in the first-generation group. There was no definite stent thrombosis in either group. During follow-up, there were no significant between-group differences of major adverse cardiac events without TLR, myocardial infarction, death, and death + myocardial infarction. Multivariate analysis demonstrated that using a first-generation DES was the only independent predictor of TLR after 1 year (odds ratio, 2.78; 95% confidence interval, 1.22-5.43; P=.03). CONCLUSION: When ISR occurs after DES implantation, treatment with a second-generation DES reduces late luminal loss, binary restenosis, and TLR after 1 year compared with a first-generation DES.