Recurrent very late stent thrombosis in a systemic lupus erythematous patient.

Coronary artery disease is the most important cause of mortality in patients with systemic lupus erythematous (SLE). After stenting for coronary artery disease in SLE patients similar to non-SLE patients, the risk of stent thrombosis is always present. Although there are reports of stent thrombosis in SLE patients, very late recurrent stent thrombosis is rare. We experienced a case of very late recurrent stent thrombosis (4 times) in a patient with SLE.

A case of cryptogenic stroke associated with patent foramen ovale coexisting with pulmonary embolisms, deep vein thromboses, and renal artery infarctions.

A paradoxical embolism is defined as a systemic arterial embolism requiring the passage of a venous thrombus into the arterial circulatory system through a right-to-left shunt, and is commonly related to patent foramen ovale (PFO). However, coexisting pulmonary embolisms, deep vein thromboses (DVT), and multipe systemic arterial embolisms, associated with PFO, are rare. Here, we report a patient who had a cryptogenic ischemic stroke, associated with PFO, which is complicated with a massive pulmonary thromboembolism, DVT, and renal infarctions, and subsequently, the patient was treated using a thrombolytic therapy.

Impact of plaque components on no-reflow phenomenon after stent deployment in patients with acute coronary syndrome: a virtual histology-intravascular ultrasound analysis.

AIMS: We used virtual histology-intravascular ultrasound (VH-IVUS) to evaluate the relation between coronary plaque characteristics and no-reflow in acute coronary syndrome (ACS) patients. METHODS AND RESULTS: A total of 190 consecutive ACS patients were imaged using VH-IVUS and analysed retrospectively. Angiographic no-reflow was defined as TIMI flow grade 0, 1, and 2 after stenting. Virtual histology-intravascular ultrasound classified the colour-coded tissue into four major components: fibrotic, fibro-fatty, dense calcium, and necrotic core (NC). Thin-cap fibroatheroma (TCFA) was defined as focal, NC-rich (≥10% of the cross-sectional area) plaques being in contact with the lumen in a plaque burden≥40%. Of the 190 patients studied at pre-stenting, no-reflow was observed in 24 patients (12.6%) at post-stenting. The absolute and %NC areas at the minimum lumen sites (1.6±1.2 vs. 0.9±0.8 mm2, P<0.001, and 24.5±14.3 vs. 16.1±10.6%, P=0.001, respectively) and the absolute and %NC volumes (30±24 vs. 16±17 mm3, P=0.001, and 22±11 vs. 14±8%, P<0.001, respectively) were significantly greater, and the presence of at least one TCFA and multiple TCFAs within culprit lesions (71 vs. 36%, P=0.001, and 38 vs. 15%, P=0.005, respectively) was significantly more common in the no-reflow group compared with the normal-reflow group. In the multivariable analysis, %NC volume was the only independent predictor of no-reflow (odds ratio=1.126; 95% CI 1.045-1.214, P=0.002). CONCLUSION: In ACS patients, post-stenting no-reflow is associated with plaque components defined by VH-IVUS analysis with larger NC and more TCFAs.

Congenital anomaly of the true double-lumen right coronary artery: An extremely rare case.

Double right coronary artery is a rare anomaly which is mostly identified by two separate pathways with a common ostium (one-two way). We report herein an extremely rare case of congenital true double-lumen right coronary artery, an anomaly, where a common pathway from the ostium to the proximal segment diverged into two separate pathways from the proximal to the mid-segment and then converged into one pathway (one-two-one way).

Efficacy of triple anti-platelet therapy including cilostazol in acute myocardial infarction patients undergoing drug-eluting stent implantation.

BACKGROUND AND OBJECTIVES: Triple anti-platelet therapy is known to prevent restenosis after drug-eluting stent (DES) implantation. However, there is little available data concerning the efficacy of triple anti-platelet therapy for acute myocardial infarction (AMI). SUBJECTS AND METHODS: We analyzed 528 consecutive patients with AMI undergoing DES implantation between Nov 2005 and Apr 2008. We compared clinical outcomes in the triple anti-platelet therapy (group I, n=413: cilostazol combined with aspirin and clopidogrel for at least one month) and dual antiplatelet therapy groups (group II, n=115: aspirin and clopidogrel). RESULTS: There were no significant differences in baseline characteristics. However, ST elevation myocardial infarction (STEMI) and use of TAXUS(R) stents were more common (70.9% vs. 55.7%, p=0.002; 83.5% vs. 73.0%, p=0.011) in Group I. Group I had lower incidences of cardiac death, 6-month target lesion revascularization (TLR), and major adverse cardiac and cerebrovascular events (MACCE) compared to Group II (1.7% vs. 5.7%, p=0.022; 5.7% vs. 11.5%, 0.035; 7.9% vs. 16.0%, p=0.011). On subgroup analysis, the incidence of 6-month TLR was lower among patients with American College of Cardiology/American Heart Association (ACC/AHA) B2 or C lesions and non-STEMI (6.0% vs. 14.9%, p=0.012; 4.3% vs. 19.1%, p=0.002) in Group I compared to those in Group II. The rates of bleeding complications were no different between the two groups. On multivariate analysis, Killip III or IV and triple anti-platelet therapy were independent predictors of 6-month MACCE {hazard ratio (HR)=3.382; 95% confidence interval (CI)=1.384-8.262, HR=0.436; 95% CI=0.203-0.933}. CONCLUSION: Triple anti-platelet therapy is safe and efficacious, and it prevents TLR in patients with AMI, especially those with complex lesions and non-STEMIs.

Left Ventricular Dyssynchrony After Acute Myocardial Infarction is a Powerful Indicator of Left Ventricular Remodeling.

BACKGROUND AND OBJECTIVES: Left ventricular (LV) remodeling (LVR) after an acute myocardial infarction (AMI) has important clinical implications. We have investigated the prognostic relevance of ventricular systolic dyssnchrony as an indicator of LVR after an AMI. SUBJECTS AND METHODS: We enrolled 92 patients (males, 72.8%; mean age, 61.0+/-13.0 years) with an AMI who underwent successful percutaneous coronary intervention. We analyzed the baseline characteristics, the laboratory and echocardiographic findings, and we performed follow-up echocardiography 6 months after the AMI. The patients were divided into two groups: 1) the presence of LVR, which was defined as an increment of LV end systolic volume (LVESV) >20% compared with the baseline examination; and 2) the absence of LVR. RESULTS: Twenty-seven patients (29.3%) developed LVR after a 6 month follow-up. There was no statistically significant difference in the clinical and angiographic findings between the two groups. With respect to the laboratory findings, the LVR group had a higher peak creatine kinase MB (CK-MB) (149.9+/-155.0 vs. 74.6+/-69.7 U/L, p=0.001) and troponin-I (70.2+/-73.3 vs. 43.2+/-39.5 ng/mL, p=0.024) level than the group without LVR. With respect to echocardiographic findings, the baseline LV ejection fraction (EF) and LVESV were not significantly different (LVESV, 73.0+/-37.3 vs. 91.3+/-52.0 mL, p=0.013; and EF, 58.3+/-13.3 vs. 55.6+/-11.8%, p=0.329) between the groups with and without LVR, respectively. The degree of LV dyssynchrony, which was assessed by tissue Doppler imaging, was significantly higher in the LVR group than the group without LVR (75.2+/-43.4 vs. 38.3+/-32.5 ms), and the degree of LV dyssynchrony was an independent predictor for LVR based on multivariate analysis {hazard ratio (HR)=0.097, p<0.001}. In receiver operating characteristics (ROC) curve analysis, the area under the curve (AUC) was 0.754 and a cutoff value of 45.9 predicted the development of LVR with 74.1% sensitivity and 72.3% specificity. CONCLUSION: The presence of LV dyssynchroncy immediately after a myocardial infarction is an important predictive factor for development LVR.

Predictors of no-reflow after percutaneous coronary intervention for culprit lesion with plaque rupture in infarct-related artery in patients with acute myocardial infarction.

BACKGROUND: We investigated the predictors of the no-reflow phenomenon after percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) patients with plaque rupture (PR). METHODS: The study group comprised 112 AMI patients who underwent pre- and post-PCI intravascular ultrasound (IVUS) and stent implantation. Angiographic no-reflow was defined as TIMI flow grade 0, 1, and 2 after PCI. IVUS findings included multiple ruptured plaques (PRs separated by a >5-mm length of artery containing smooth lumen contours), thrombus (had a layered lobulated appearance, evidence of blood flow within the mass, and speckling or scintillation), and plaque prolapse (tissue extrusion through the stent struts). RESULTS: Of 112 patients, no-reflow was observed in 17 patients (15.2%). High-sensitivity C-reactive protein (hs-CRP) was significantly higher (6.2+/-6.0 mg/dl vs. 2.2+/-2.9 mg/dl, p=0.002) and baseline TIMI flow grade was significantly lower in no-reflow group (TIMI flow grade<3: 59% vs. 18%, p<0.001). Lesion site plaque plus media area was significantly greater (12.9+/-2.6 mm(2) vs. 10.8+/-4.2 mm(2), p=0.009), remodeling index was significantly higher (1.14+/-0.17 vs. 1.03+/-0.20, p=0.031), and the presence of IVUS-detected thrombus (88% vs. 56%, p=0.012), culprit lesion multiple PRs (71% vs. 37%, p=0.009), and plaque prolapse (65% vs. 34%, p=0.015) were significantly more common in no-reflow group. In the multivariate analysis, plaque prolapse (OR=33.02; 95% CI 3.38-322.75, p=0.003), hs-CRP (OR=1.03; 95% CI 1.01-1.05, p=0.013), and culprit lesion multiple PRs (OR=15.73; 95% CI 1.61-153.46, p=0.018) were independent predictors of post-PCI no-reflow in AMI patients with PR. CONCLUSIONS: Elevated hs-CRP and IVUS-detected multiple PRs and plaque prolapse are associated with no-reflow after PCI for PR-containing culprit lesion in infarct-related arteries in AMI patients.

Clinical outcomes and optimal treatment for stent fracture after drug-eluting stent implantation.

BACKGROUND: Many studies have suggested that in the era of drug-eluting stents (DES) one of the causes of in-stent restenosis is stent fracture (SF). Yet there have been few studies of the major adverse cardiac events and treatment of DES SF. METHODS AND RESULTS: From September 2003 to May 2008, 3365 patients received successful stent implantation with DES, of whom 1009 patients underwent a follow-up coronary angiography irrespective of symptoms. Seventeen SFs were detected in 15/1009 patients (1.5%). All SF patients were continued on medication with combination antiplatelet therapy, regardless of angina symptoms. If in-stent restenosis at the fractured site was significant, we performed coronary interventions even in patients without ischemic symptoms. Patients were treated with heterogenous DES for restenosis lesions (5/8 patients), and the rest were treated with either homogenous DES (2 patients), or plain old balloon angioplasty (1 patient) or medical treatment (7 patients). None of the SF patients suffered from cardiac death during a follow-up period of 20.4+/-12.3 months. CONCLUSION: If patients with SF were continued on combination antiplatelet therapy irrespective of ischemic symptoms, there would occur a low rate of major adverse cardiac events, especially cardiac death associated with SF.

Plaque characteristics in culprit lesions and inflammatory status in diabetic acute coronary syndrome patients.

OBJECTIVES: The aim of this study was to assess the plaque characteristics in culprit lesions in diabetic patients with acute coronary syndrome (ACS). BACKGROUND: Data of the relationship between diabetes mellitus and plaque characteristics in patients with ACS are lacking. METHODS: We performed grayscale intravascular ultrasound (IVUS) analysis in 422 ACS patients and virtual histology (VH)-IVUS in 310 ACS patients. By subgroup analysis, 112 patients with acute myocardial infarction (AMI) with plaque ruptures also were evaluated. RESULTS: In the diabetic subgroup, high-sensitivity C-reactive protein (hs-CRP) was significantly increased (p = 0.008), multivessel disease was more common (65% vs. 29%, p < 0.001), and plaque burden was greater (79.7 +/- 9.8 mm2 vs. 74.2 +/- 8.9 mm2, p < 0.001). In the subgroup analysis of 112 AMI patients with plaque ruptures, the presence of multiple plaque ruptures (60% vs. 29%, p = 0.001) and thrombus (72% vs. 52%, p = 0.032) were more common in diabetic group. Diabetes mellitus was the independent predictor of hs-CRP elevation (odds ratio [OR]: 3.030, 95% confidence interval [CI]: 1.204 to 7.623, p = 0.019), and multiple plaque ruptures (OR: 2.984, 95% CI: 1.311 to 6.792, p = 0.009) by multivariable analysis. In 310 VH-IVUS subsets, the absolute and percent necrotic core volumes were significantly greater (16.9 +/- 15.1 mm3 vs. 11.5 +/- 11.4 mm3, p < 0.001, and 17.3 +/- 9.4% vs. 13.7 +/- 7.5%, p < 0.001, respectively), and the presence of at least one thin-cap fibroatheroma (TCFA) (60% vs. 42%, p = 0.003) and multiple TCFAs (28% vs. 11%, p < 0.001) were more common in the diabetic group. Diabetes mellitus was the only independent predictor of TCFA by multivariable analysis (OR: 2.139, 95% CI: 1.266 to 3.613, p = 0.004). CONCLUSIONS: Diabetic patients with ACS have more plaques with characteristics of plaque vulnerability, different composition of plaques, and have increased inflammatory status compared with nondiabetic patients with ACS.

Positive remodeling is associated with more plaque vulnerability and higher frequency of plaque prolapse accompanied with post-procedural cardiac enzyme elevation compared with intermediate/negative remodeling in patients with acute myocardial infarction.

BACKGROUND: We assessed the impact of remodeling patterns on pre- and post-procedural intravascular ultrasound (IVUS) findings and cardiac enzyme elevation after stenting in 310 acute myocardial infarction (AMI) patients. METHODS: The positive remodeling (PR) (PR group, n=113) was defined as remodeling index (lesion/reference external elastic membrane cross-sectional area) >1.05, intermediate remodeling (IR) as between 0.95 and 1.05, and negative remodeling (NR) as<0.95 (IR/NR group, n=197). IVUS findings included ruptured plaque (a cavity that communicated with the lumen with an overlying residual fibrous cap fragment), multiple ruptured plaques (different plaque ruptures separated by a >5-mm length of artery containing smooth lumen contours), thrombus (discrete intraluminal filling defects), and plaque prolapse (tissue extrusion through the stent strut at post-stenting). We compared pre- and post-procedural IVUS findings and cardiac-specific troponin I (cTnI) elevation after stenting according to the remodeling pattern. RESULTS: The plaque rupture (60% vs. 42%, p=0.004), multiple plaque ruptures (22% vs. 14%, p=0.014), and IVUS-detected thrombus (42% vs. 28%, p=0.012) were more common in the PR group compared with the IR/NR group. Post-stenting plaque prolapse was observed more frequently (36% vs. 22%, p=0.008), and cTnI was elevated more significantly after stenting in the PR group compared with the IR/NR group (DeltacTnI; +7.8+/-51.1 ng/ml vs. +0.9+/-41.1 ng/ml, p=0.008). Multivariate analysis showed that PR [odds ratio (OR)=1.92; 95% CI 1.04-2.98, p=0.028], plaque rupture (OR 1.98; 95% CI 1.16-3.45, p=0.025), IVUS-detected thrombus (OR 2.30; 95% CI 1.22-3.98, p=0.008), and plaque prolapse (OR 8.40; 95% CI 4.19-16.84, p<0.001) were independently associated with post-stenting cTnI elevation. CONCLUSIONS: AMI patients with PR have more plaque vulnerability and higher frequency of plaque prolapse accompanied by post-procedural cardiac enzyme elevation compared with AMI patients with IR/NR.

Very late stent thrombosis associated with multiple stent fractures and peri-stent aneurysm formation after sirolimus-eluting stent implantation.

Previous randomized trials have shown that drug-eluting stents (DES) are superior to bare-metal stents in reducing the need for target lesion revascularization, but safety issues with DES have recently been raised. We report a rare case of very late stent thrombosis 35 months after sirolimus-eluting stent implantation associated with delayed 5-segment stent fractures and peri-stent aneurysm formation.