Safety of Percutaneous Coronary Intervention for Chronic Total Occlusion in Patients With Multi-Vesel Disease: Sub-Analysis of the Japanese Retrograde Summit Registry.

BACKGROUND: The success rate of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has gradually increased thanks to the continuous development of devices and techniques. However, the impact of multi-vessel disease (MVD) on its success rate and safety is not well known. METHODS: The clinical records of 5009 patients enrolled in the Japanese Retrograde Summit Registry and who had undergone PCI for CTO at 65 centers between 2012 and 2015 were reviewed. We compared the outcome for patients with and without MVD. RESULTS: Two thousand nine hundred and seventy-eight patients (59%) had MVD. Although there was no significant difference in the J-CTO score between the two groups [MVD group 1.51 ± 1.07 vs. SVD group 1.48 ± 1.07, p = 0.48], the procedural success rate of CTO-PCI in the MVD group was significantly lower than that in the SVD group (87.2% vs. 90.2%, p = 0.001). However, occurrence of procedure-related adverse events (4% vs. 5%, p = 0.11), total fluoroscopy (70 ± 45 min vs. 69 ± 50 min, p = 0.75) and procedural time (154 ± 86 min vs. 151 ± 89 min, p = 0.36), and total amount of contrast media (219 ± 102 mL vs. 222 ± 105 mL, p = 0.33) did not differ between the two groups. CONCLUSIONS: Although MVD had an impact on the success rate of CTO-PCI, it did not affect procedure-related adverse events.

Efficacy of drug-coated balloon angioplasty after directional coronary atherectomy for coronary bifurcation lesions (DCA/DCB registry).

OBJECTIVES: To evaluate the efficacy and safety of additional drug-coated balloon (DCB) angioplasty after directional coronary atherectomy (DCA) for coronary bifurcation lesions. BACKGROUND: The optimal therapy for bifurcation lesions has not been established, even in the drug-eluting stent era. DCA possibly prevents plaque and carina shift in bifurcation lesions by plaque debulking; however, the efficacy of combined DCA and DCB (DCA/DCB) for bifurcation lesions remains unclear. METHODS: This multicenter registry retrospectively recruited patients with bifurcation lesions who underwent DCA/DCB and follow-up angiogram at 6-15 months. The primary endpoint was the 12-month target vessel failure (TVF) rate. The secondary endpoints were procedure-related major complications, major cardiovascular events at 12 months, restenosis at 12 months, target lesion revascularization (TLR) at 12 months, and target vessel revascularization (TVR) at 12 months. RESULTS: We enrolled 129 patients from 16 Japanese centers. One hundred and four lesions (80.6%) were located around the left main trunk bifurcations. No side branch compromise was found intraoperatively. Restenosis was observed in three patients (2.3%) at 12 months. TLR occurred in four patients (3.1%): 3 (2.3%) in the main vessel and 1 (0.8%) in the ostium of the side branch at 12 months. TVF incidence at 12 months was slightly higher in 14 patients (10.9%), and only two patients (1.6%) had symptomatic TVR. One patient (0.8%) had non-target vessel-related myocardial infarction. CONCLUSIONS: Our data suggested that DCA/DCB provided good clinical outcomes and minimal side branch damage and could be an optimal non-stent percutaneous coronary intervention strategy for bifurcation lesions.

Derivation and validation of the J-CTO extension score for pre-procedural prediction of major adverse cardiac and cerebrovascular events in patients with chronic total occlusions.

We developed a prediction model of long-term risk after percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) based on pre-procedural clinical information. A total of 4,139 eligible patients, who underwent CTO-PCI at 52 Japanese centers were included. Specifically, 1,909 patients with 1-year data were randomly divided into the derivation (n = 1,273) and validation (n = 636) groups. Major adverse cardiac and cardiovascular event (MACCE) was the primary endpoint, including death, stroke, revascularization, and non-fatal myocardial infarction. We assessed the performance of our model using the area under the receiver operating characteristic curve (AUC) and assigned a simplified point-scoring system. One-hundred-thirty-eight (10.8%) patients experienced MACCE in the derivation cohort with hemodialysis (HD: odds ratio [OR] = 2.55), left ventricular ejection fractions (LVEF) <35% (OR = 2.23), in-stent occlusions (ISO: OR = 2.27), and diabetes mellitus (DM: OR = 1.72). The AUC of the derivation model was 0.650. The model's performance was similar in the validation cohort (AUC, 0.610). When assigned a point for each associated factor (HD = 3, LVEF <35%, ISO = 2, and DM = 1 point), the average predicted versus the observed MACCE probability using the Japan-CTO extension score for the low, moderate, high, and very high risk groups was 8.1% vs. 7.3%, 16.9% vs. 15.9%, 22.0% vs. 26.1%, and 56.2% vs. 44.4%, respectively. This novel risk model may allow for the estimation of long-term risk and be useful in disseminating appropriate revascularization procedures.

Intravascular ultrasound imaging of isolated and non aorto-ostial coronary Takayasu arteritis: a case report.

BACKGROUND: Isolated coronary Takayasu arteritis is a rare form of ischemic heart disease that typically appears as an aorto-ostial lesion. Although several vascular imaging modalities including ultrasonography, computed tomographic angiography, magnetic resonance angiography or catheter angiography, play crucial roles for diagnosing Takayasu arteritis, the intravascular ultrasound imaging of Takayasu arteritis is not well studied. CASE PRESENTATION: A 55-year-old woman who was diagnosed with heterozygous familial hypercholesterolemia underwent coronary angiography due to effort angina, which showed ostial left anterior descending coronary artery (LAD) stenosis. Although directional coronary atherectomy followed by drug-coated balloon was successfully performed, 6 months later restenosis occurred at the ostial LAD, and the ostial left circumflex coronary artery (LCx) progressed significantly. The intravascular ultrasound imaging in these lesions was noteworthy, in which the media was partly unrecognizable and an echo intensity similar to fibrotic intimal thickening traversed from the intima to the adventitia, thereby causing the whole image of the coronary artery to become unclear. Directional coronary atherectomy followed by drug-coated balloon procedures for both LAD and LCx lesions were performed again. Systemic examination of computed tomographic angiography found no other stenotic lesions except for those in the coronary arteries. Five months later, the LAD and LCx lesions progressed diffusely, therefore the coronary artery bypass graft was done. The histopathological findings of specimens of the coronary artery that were obtained during the bypass graft showed excessive fibrous thickening of the intima and adventitia, with granulomatous inflammation in the media, which led to the diagnosis of isolated coronary Takayasu arteritis. Systemic corticosteroid therapy was then started. CONCLUSIONS: We described an extremely rare case of isolated and non aorto-ostial Takayasu arteritis. The characteristic intravascular ultrasound images of diseased coronary arteries may help in the diagnosis of coronary Takayasu arteritis.

Short-term outcome of percutaneous coronary intervention with directional coronary atherectomy followed by drug-coated balloon: a preliminary report.

Directional coronary atherectomy (DCA) is a unique technique used in percutaneous coronary intervention (PCI) which involves the removal of plaque from the coronary artery. Treatment with a drug-coated balloon (DCB) appears to be effective, especially when a predilatation of the lesion is performed appropriately. We hypothesize that the combination therapy of DCA with DCB is an effective strategy in PCI. PCI with DCA followed by DCB was performed for 23 patients from December 2014 to April 2017. All DCA procedures were performed under the guidance of intravascular ultrasound (IVUS) findings and all procedures were successfully performed without incurring major complications such as a coronary perforation. Plaque area (PA) was reduced from 77.3 ± 10.4% at baseline to 50.9 ± 9.2% after DCA and luminal cross-sectional area (CSA) after PCI was enlarged from 3.6 ± 1.8 to 9.3 ± 3.3 mm2. Follow-up coronary angiography (CAG) performed at 6-10 months showed no cases having incurred restenosis. Plaque area at follow-up CAG was 52.0 ± 8.5% and luminal CSA was 9.5 ± 2.1 mm2. There were no cases undergoing target vessel revascularization (TVR) and target lesion revascularization (TLR) during the follow-up periods. PCI with DCA followed by DCB might be an effective strategy for de novo lesions.

Quadricuspid pulmonary valve stenosis treated by transcatheter pulmonary valvuloplasty with inoue balloon catheter.

The quadricuspid pulmonary valve is a relatively common congenital anomaly which is rarely complicated clinically and also tends to be under-diagnosed. The following case report shows a 62-year-old man with exertional dyspnea due to quadricuspid pulmonary valve stenosis that was diagnosed by using electrocardiography-gated multiple detector computed tomography. He was then treated effectively by transcatheter balloon pulmonary valvuloplasty using an Inoue balloon catheter. .

Impact of the Great East Japan Earthquake on acute myocardial infarction in Fukushima prefecture.

OBJECTIVE: The incidence of cardiovascular disease (CVD) reportedly increases following a huge disaster. On March 11, 2011, the Great East Japan Earthquake hit a large area of eastern Japan. In Fukushima prefecture, many people suffered from the consequences of the earthquake, the subsequent tsunami, and especially the Fukushima Daiichi Nuclear Power Plant accident. We assessed whether the incidence of acute myocardial infarction (AMI) increased after the earthquake. METHODS: We enrolled AMI patients admitted to 36 hospitals in Fukushima prefecture between March 11, 2009, and March 10, 2013 (n = 3068). We compared the incidence of AMI after the earthquake for more than 3 months and 1 year with that in the control years. RESULTS: The incidence of Fukushima's annual AMI patients (per 100 000 persons) in 2011 was similar to that of previous years (n = 38.9 [2011] vs 37.2 [2009] and 38.5 [2010], P = .581). However, a significantly higher incidence of AMI was found in the Iwaki district after the disaster that corresponded to the 1-year period of observation (n = 38.7 [2011] vs 27.3 [2009] and 32.8 [2010], P = .045). CONCLUSION: The Great East Japan Earthquake affected the incidence of AMI only in limited areas of Fukushima prefecture.

Lone aspiration thrombectomy without stenting for a patient with ST-segment elevation myocardial infarction associated with coronary ectasia.

A 57-year-old male with a previous history of inferior myocardial infarction suffered from chest pain and diagnosed as ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed a thrombus with delayed filling in the distal right coronary artery. After an aspiration thrombectomy, TIMI 3 flow was restored successfully. An intracoronary ultrasound imaging revealed coronary ectasia. Stenting and ballooning were deferred. A successful lone aspiration thrombectomy was performed for a patient with STEMI associated with coronary ectasia.

A case of massive pericardial effusion associated with hypocalcemic cardiomyopathy.

A 60-year-old woman with a 6-year history of numbness in her hands was admitted to hospital with dyspnea. Laboratory findings showed the elevation of creatine kinase (creatine kinase MB isoenzyme was less than 4 IU/l). Chest X-ray revealed cardiomegaly and pulmonary edema. Electrocardiogram showed a T wave inversion in V2-5 and a prolonged QT interval. Echocardiography demonstrated reduced left ventricular ejection fraction (LVEF) and massive pericardial effusion. The patient was diagnosed with heart failure. Further testing found hypocalcemia and idiopathic hypoparathyroidism. In addition to diuretics, calcium replacement therapy for hypocalcemia improved the LVEF and reduced pericardial effusion. Hypocalcemia rarely leads to heart failure and pericardial effusion. In our case, heart failure and the massive pericardial effusion were secondary to hypocalcemia due to idiopathic hypoparathyroidism. .

Start and initial results of the Fukushima Prefecture acute myocardial infarction registration survey.

Acute myocardial infarction (AMI) remains one of the most serious heart diseases and elucidation of its pathogenesis and advances in treatment strategies have been desired. In 2009, to understand the status of AMI in Fukushima Prefecture for improving treatment outcomes, a new AMI registration survey system was conducted throughout the prefecture. A total of 1,556 cases were registered in the initial 2 years from 2009 to 2010. The hospital-based overall incidence of AMI in Fukushima Prefecture was 37.9 people per population of 100,000 per year. Mortality from AMI within 30 days of onset was 10.2%. We report herein the actual situation of AMI onset and treatment in Fukushima Prefecture based on the initial results of the survey.

Contemporary retrograde approach for the recanalisation of coronary chronic total occlusion: on behalf of the Japanese Retrograde Summit Group.

AIMS: The retrograde approach to CTO is promising, but questions remain with regard to its wider application and the potential risks. This study evaluated the feasibility and efficacy of retrograde recanalisation of chronic total occlusion (CTO) of the coronary arteries. METHODS AND RESULTS: A total of 378 consecutive patients (previously failed PCI 32.0%) who enrolled in 27 institutions in Japan underwent retrograde recanalisation for CTO. We analysed the data on lesion characteristics, procedural materials, technique used, complications and clinical outcomes. Successful retrograde recanalisation was achieved in 70.4% and the overall procedural success was 83.6%. Collateral crossing was achieved via a septal route in 68.9%, epicardial in 27.2% and bypass grafts in 2.6%, respectively. The retrograde approach was completed with implementation of reverse CART in 42.5%, direct wire crossing in 23.1%, bilateral wiring in 22.7%, and CART in 11.7%. Major and minor collateral injuries and coronary perforations were noted in 1.3%, 10.3% and 2.9% of cases, respectively. Stroke occurred in 0.3%, QWMI and emergency PCI in 0.3% of patients with successful recanalisation. CONCLUSIONS: Wider application of retrograde CTO PCI achieved a high rate of success in recanalisation with an acceptable rate of complications in Japan.

Role of bare-metal stents for left main coronary artery disease in the era of drug-eluting stents. -Which coronary stent should be used for left main trunk disease? BMS or DES? (BMS-side)-.

In the past, coronary artery bypass graft surgery has been applied to revascularization for unprotected left main coronary artery (ULMCA) disease. In recent years, due to the advent of drug-eluting stents (DES), restenosis rates have decreased in comparison to conventional bare-metal stents (BMS), and the range of applications of percutaneous coronary intervention (PCI) for ULMCA disease has been expanded. However, even if DES is used, outcomes of PCI for distal left main coronary artery bifurcation lesions are not sufficient. Moreover, problems specific to DES, such as late stent thrombosis and late catch-up phenomenon, have been identified. There are still unknown points regarding remote-stage outcomes of DES. Thus, further investigation is needed on PCI for ULMCA disease, along with further analysis of remote-stage outcomes of BMS.

Impact of insulin-treated diabetes and hemodialysis on long-term clinical outcomes following sirolimus-eluting stent deployment. Insights from a sub-study of the Cypher Stent Japan Post-Marketing Surveillance(Cypher J-PMS) Registry.

BACKGROUND: Long-term clinical outcomes of diabetes mellitus (DM) patients who underwent drug-eluting stent deployment has not well investigated. METHODS AND RESULTS: A total of 2,050 cases were enrolled consecutively from 50 sites in Japan into the Cypher stent Japan Post-Marketing Surveillance (Cypher J-PMS) registry, and the 3-year outcomes of DM patients were analyzed. Subjects were divided into 2 groups based on the treatment of DM (insulin-treated diabetes (IT) group, n=207; and non insulin-treated diabetes (NIT) group, n=682). Major adverse cardiac event (MACE) rates in the IT group and the NIT group were 26.0% and 14.5% at 3 years, respectively (P<0.001). There were no significant differences in stent thrombosis rates (definite and probable by Academic Research Consortium (ARC) definition) (0% and 1.08%, respectively). Multivariate analysis suggested that hemodialysis and insulin-treated DM were independent predictors for MACE, and insulin-treated DM, hemodialysis and long lesions were strong independent predictors for target-lesion revascularization (TLR). CONCLUSIONS: Hemodialysis and insulin-treated DM were strong independent predictors of mortality and TLR in DM patients. These results might suggest that special attention to patients with hemodialysis and insulin-treated DM is warranted in the setting of sirolimus-eluting stent deployment for DM patients.

Acute myocardial infarction in Fukushima area of Japan.

Although acute myocardial infarction (AMI) is the most serious coronary disease, the background of its onset and the mortality are not fully understood, especially in Japan. From June 1999 to May 2005, we mailed an annual questionnaire to eighteen hospitals in which emergency cardiac catheterization and percutaneous coronary intervention (PCI) were available in the Fukushima area of Japan. A total of 1,590 patients were included. The onset time of AMI had two peaks, i.e., from 9:00 AM to 10:00 AM and 9:00 PM to 10:00 PM. As for reperfusion therapy, four groups were analyzed, the non-reperfusion therapy group (Group N, n = 233), thrombolysis alone group (Group T, n = 80), PCI without thrombolysis group (Group P, n = 1106), and PCI with thrombolysis group (Group TP, n = 151). The in-hospital mortality rate was significantly reduced in Group P (8.4%) compared with that in Group N (33.0%, p < 0.01) and Group T (18.8%, p < 0.01). However, the in-hospital mortality in Group P did not differ from that in Group TP (9.9%). The in-hospital mortality was analyzed by the logistic regression analysis among age, arrival time after onset, peak creatine kinase (CK) values, coronary risk factors, reperfusion therapy, PCI, and thrombolysis. There were significant differences in age (P < 0.01), peak CK values (p < 0.01), hypertension (p < 0.05), and diabetes mellitus (p < 0.01). These results suggest that the onset of AMI may be partly related to human biorhythms, and that PCI would be effective in reducing the in-hospital mortality.

Prediction of remote left ventricular volumes and functions after acute myocardial infarction with successful coronary intervention.

BACKGROUND: The scintigraphic perfusion defect size (DS) at 1 week after acute myocardial infarction (AMI) predicts remote left ventricular (LV) volumes and LV ejection fraction (LVEF). The present study examined whether LV volumes and LVEF 6 months after AMI may be better predicted by the combination of LV volumes and LVEF just after reperfusion, and DS at 1 week, after AMI in patients with Thrombolysis In Myocardial Infarction (TIMI) grade III reperfusion by percutaneous coronary intervention. METHODS AND RESULTS: In 48 patients with AMI and TIMI grade III reperfusion, quantitative gated SPECT (QGS) was performed just after reperfusion, and at 1 week and 6 months after AMI. LV end-diastolic volume index decreased (108+/-8 to 93+/-6 ml/m(2), p<0.05) and LVEF increased (44+/-3 to 50+/-2%, p<0.05) 6 months after AMI. In addition, they were better predicted by a combination of LV volumes and LVEF just after reperfusion and DS at 1 week after AMI. CONCLUSIONS: In AMI with TIMI grade III reperfusion, LV volumes and LVEF at 6 months after MI correlate with the values obtained just after reperfusion. Myocardial perfusion imaging combined with QGS at reperfusion may predict these late-phase parameters.

Pre-drug-eluting stent debulking of bifurcated coronary lesions.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) before drug-eluting stent (DES) implantation for bifurcated coronary lesions. BACKGROUND: The introduction of DES significantly reduces restenosis and repeated revascularization. However, percutaneous coronary intervention of bifurcated lesions using DES alone remains challenging regardless of whether simple or complex stenting is used. METHODS: Patients with bifurcated lesions were recruited in this prospective multicenter registry. Pre-DES plaque debulking by DCA was conducted. All patients were scheduled to undergo a 9-month coronary angiography. The primary end point was the 9-month binary angiographic restenosis rate. Secondary end points included procedure-related events and major adverse cardiac events (MACE) at 1 year. RESULTS: A total of 99 patients with bifurcated lesions were enrolled in this registry. Directional coronary atherectomy was performed successfully in all cases without any major procedure-related events. Simple stenting was achieved in all but 2 cases. No in-hospital MACE were observed. The 9-month binary restenosis rates in the main branch and side branch were 1.1% and 3.4%, respectively. Target lesion revascularization was performed in 2 patients (1 for the main branch and the other for the side branch). No deaths, no coronary artery bypass grafting, and no myocardial infarctions were reported in the patients within the first year. CONCLUSIONS: Directional coronary atherectomy before DES implantation can possibly avoid complex stenting. This strategy may provide a good long-term outcome in patients with bifurcated lesions.

Intravascular two-dimensional tissue strain imaging.

Our goal is to achieve the precise quantitative imaging of tissue elasticity in clinical settings. In the present study, we measured basic ultrasonic characteristics of atherosclerosis by two-dimensional (2D) intravascular tissue velocity imaging. Radio-frequency (RF) signal from a clinically used IVUS apparatus was digitized at 500 MSa/s and stored in a workstation. First, the correlation coefficient between two consecutive frames was calculated in the rotational direction and the rotational disuniformity was corrected to obtain the maximum correlation coefficient. Then, the polar coordinate images were converted into rectangular coordinate images and the images were divided into 64 by 64 square shaped regions of interest (ROIs). The correlation and displacement of the ROIs between the consecutive two frames were calculated by template matching method. Two-dimensional tissue velocity was defined as the vectors of displacement of ROI with 0.7 and more correlation. IVUS studies were performed in directional coronary atherectomy (DCA) procedures. The specimens excised by DCA were stained with Elastica-Masson's trichrome staining and CD68 immunochemical staining. Eleven cases (including two no re-flow cases and one perforation case) were intraoperatively observed by IVUS and the specimens obtained by DCA were observed by optical microscopy. The specimen from homogeneous 2D strain was collagen dominant fibrosis and the specimen from a lesion with complex vectors contained CD68 positive cells and degenerated collagen fibers, which indicated the plaque was vulnerable.

Effects of angiotensin-converting enzyme inhibitors or an angiotensin receptor blocker in combination with aspirin and cilostazol on in-stent restenosis.

It remains to be determined whether adding an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) to antiplatelet therapy has a therapeutic benefit on in-stent restenosis. After successful coronary stenting, 165 patients (167 lesions) were randomly assigned to a basal (aspirin 162 mg + cilostazol 200 mg/day), ACEI (basal treatment + quinapril 10 mg or perindopril 4 mg/day), or ARB (basal treatment + losartan 50 mg/day) treatment group. Quantitative coronary angiography was performed before, immediately following, and 6 months after stenting. Follow-up coronary angiography was completed in 126 patients (128 lesions). Restenosis rates tended to be higher (12, 26, and 12% for the basal, ACEI, and ARB groups, respectively), and target lesion revascularization rates were higher in the ACEI group than in the other groups (9, 23,* and 5%, respectively, *P < 0.05 versus basal group). Moreover, late lumen loss was higher in the ACEI group than in the basal group (0.60 +/- 0.55, 0.98 +/- 0.61* and 0.73 +/- 0.64 mm in the basal, ACEI, and ARB groups, respectively). The combinations of an ACEI or ARB with aspirin and cilostazol are ineffective for the prevention of in-stent restenosis, and an ACEI may even promote intimal proliferation after stent implantation.