Daisuke Ueshima

Factors leading to failure to diagnose acute aortic dissection in the emergency room

BACKGROUND Acute aortic dissection (AAD) is often missed on initial assessment. PURPOSE The aim of our study was to identify features associated with misdiagnosis of AAD. METHODS AND RESULTS We examined a total of 109 emergency room (ER) patients who were ultimately diagnosed with AAD. Misdiagnosis of AAD was defined as failure to diagnose AAD at the end of the initial assessment in the ER, and occurred in 17 patients (16%). The alternate diagnosis consisted of acute coronary syndrome (n=10), other cardiovascular disease (n=3), abdominal disease (n=3), and cerebral infarction (n=1). In the misdiagnosed patients, walk-in mode of admission to the ER (29% vs. 10%, p=0.042) and anterior chest pain (71% vs. 41%, p=0.025) were more frequent, and widened mediastinum (25% vs. 55%, p=0.023) was less frequent than in diagnosed patients. The number of imaging studies performed per patient was also fewer in misdiagnosed patients than in diagnosed patients (0.82 ± 0.81 vs. 1.53 ± 0.52, p<0.001). However, there was no significant difference in in-hospital mortality (18% vs. 15%, p=0.520). Multivariate analysis showed that the strongest predictor of misdiagnosis was walk-in mode of admission (odds ratio 4.777; 95% confidence interval 1.267-18.007; p=0.021). CONCLUSIONS Both diversity of symptoms and variability of the severity of symptoms, especially walk-in mode of admission lead ER physicians to miss AAD in about 1 in 6 cases of AAD. It is therefore important to keep AAD as a differential diagnosis in mind, even when patients present with mild enough symptoms that allow them to walk into the ER.

Aborted Sudden Cardiac Death Associated with Short QT Syndrome

A 43‐year‐old male was transferred to our institute. His heart rhythm on admission was ventricular fibrillation (VF) which was successfully defibrillated with a direct current shock (DC). A diagnosis of short QT syndrome (SQTS) was made on the basis of an abnormally short QT interval of 280 ms during the sinus rhythm. During treatment for mild total hypothermia, VF recurred repeatedly necessitating DCs. Nifekalant at a dose of 0.3 mg/kg was intravenously administered, the QT interval was prolonged from 280 to 370 ms and VF no longer recurred. Subsequently the patient underwent implantation of an implantable cardioverter defibrillator.

The Hypercholesterolemia Paradox in Percutaneous Coronary Intervention: An Analysis of a Multicenter PCI Registry

Objective The aim of this study was to assess the relationship between hypercholesterolemia (HC) and clinical events through a percutaneous coronary intervention (PCI) registry. HC is a well-known independent risk factor for long-term cardiovascular events after PCI. However, it has been reported to be associated with a lower risk of adverse events in patients with cancer or acute coronary syndrome. Methods We analyzed the relationship between HC and adverse events in patients treated with everolimus-eluting stents (EESs) through the Tokyo-MD PCI study (an all-comer, multicenter, observational registry). The propensity score method was applied to select two groups with similar baseline characteristics. Results The unadjusted population included 1,536 HC patients and 330 non-HC patients. Propensity score matching yielded 314 matched pairs. After baseline adjustment, the outcomes of HC patients were significantly better than those of the non-HC patients with respect to the primary endpoint, which was a combination of mortality from all causes, nonfatal myocardial infarction (MI), nonfatal neurological events, and major bleeding [hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.39-0.81; p=0.002], and the secondary endpoints, which included a combination of mortality from all causes, nonfatal MI, and nonfatal neurological events (HR 0.59, 95% CI 0.39-0.88; p=0.01), and major bleeding (HR 0.42, 95% CI 0.20-0.88; p=0.02). A subgroup analysis showed age as an interaction factor for the primary endpoint (interaction p=0.035). Conclusion HC was associated with better outcomes in patients who underwent EES implantation, even after baseline adjustment.

The interplay between permanent pacemaker implantation and mortality in patients treated by transcatheter aortic valve implantation: A systematic review and meta-analysis

Previous implantation of a permanent pacemaker (PPM) is common among patients undergoing transcatheter aortic valve implantation (TAVI). Moreover, onset of conduction disturbances needing new PPM implantation after TAVI is frequent. The interplay of pre‐existing and new‐PPM on mortality after TAVI remains controversial.

Effect of drug-coated balloon on stent restenosis, neointimal proliferation, and coronary dissection: an optical coherence tomography analysis

Aim The aim of this study was to assess the acute and mid-term effects of drug-coated balloon (DCB) in terms of the healing process of non-flow-limiting dissections and changes in the neointimal area after DCB treatment using frequency domain optical coherence tomography (FD-OCT). Patients and methods Thirty-six consecutive patients with in-stent restenosis pretreated with a scoring balloon were evaluated (19 and 17 patients with and without a DCB, respectively). FD-OCT was performed before and after each procedure during percutaneous coronary intervention and at 6 months of follow-up. Results Clinical characteristics and baseline FD-OCT findings were comparable between the two groups. No patient required stent implantation because of low-pressure DCB-related dissections. In the acute phase, the DCB distributed paclitaxel to the vessel wall without increasing dissections. The DCB did not reduce the neointimal area by itself. At 6 months, more dissections healed in the DCB group (−4.5±2.3 vs. −2.7±1.3, P=0.02). The DCB group showed less change in the neointimal area (−0.04±0.92 vs. 1.06±1.57 mm2, P=0.03). Conclusion The low-pressure DCB was not intended to expand the lumen, but instead to attach paclitaxel to the vessel wall by using FD-OCT examination. The DCB reduced the number of dissections and prevented neointimal proliferation during the mid-term follow-up.

TCT-235 Effect of Additional Lower-speed Rotational Atherectomy on Acute Lumen Gain in vivo and in vitro: Evaluation using OFDI

The association between the platform speed and acute lumen gain remains unknown. The purpose of this study is to evaluate the effect of additional lower-speed rotational atherectomy (RA) following conventional high-speed RA on acute lumen gain using sequential optical frequency domain imaging (OFDI

The Importance of the Spatial Relationship between the Position of the Non-contact Mapping Balloon Array and the Arrhythmogenic Target Sites for Successful Catheter Ablation

Back ground: Three‐dimensional mapping systems such as the non‐contact mapping system (EnSite) have been utilized for radiofrequency catheter ablation (RFCA) in cases with various kinds of arrhythmias.