Ikuko Teraguchi

Long-Term Outcome After Deferral of Revascularization in Patients With Intermediate Coronary Stenosis and Gray-Zone Fractional Flow Reserve

BACKGROUND A strategy of deferred percutaneous coronary intervention for coronary stenosis with fractional flow reserve (FFR) 0.75-0.80, termed the gray zone, remains a matter of debate. The aim of this study was to assess the safety of deferring revascularization for patients with FFR 0.75-0.80 compared with those with FFR >0.80. METHODS AND RESULTS We assessed 3-year clinical outcome in 150 patients with angiographically intermediate stenosis who had revascularization deferred on the basis of FFR ≥ 0.75 (FFR 0.75-0.80, n=56; FFR >0.80, n=94). Target vessel failure (TVF), defined as a composite of cardiac death, target vessel-related myocardial infarction (MI), and ischemia-driven target vessel revascularization (TVR) was evaluated during follow-up. Cardiac death was observed in 1 patient with FFR 0.75-0.80. There was no target vessel-related MI in either group. The incidence of ischemia-driven TVR was higher in patients with FFR 0.75-0.80 than in those with FFR >0.80 (14% vs. 3%, P=0.020). TVF-free survival was significantly worse for the patients with FFR 0.75-0.80 than those with FFR >0.80 (hazard ratio, 5.2; 95% confidence intervals: 1.4-19.5; P=0.015). CONCLUSIONS Patients with FFR 0.75-0.80 were at higher risk of TVF mainly due to TVR than those with FFR >0.80.

Impact of glucose fluctuation and monocyte subsets on coronary plaque rupture

BACKGROUND AND AIMS It remains unclear whether glycemic fluctuation can affect plaque rupture in acute myocardial infarction (AMI). Here we investigate the impact of glucose fluctuation on plaque rupture, as observed by optical coherence tomography (OCT), and monocyte subsets in patients with AMI. METHODS AND RESULTS We studied 37 consecutive patients with AMI. All patients underwent OCT examination, which revealed 24 patients with plaque rupture and 13 patients without plaque rupture at the culprit site. Peripheral blood sampling was performed on admission. Three monocyte subsets (CD14(+)CD16(-), CD14(bright)CD16(+), and CD14(dim)CD16(+)) were assessed by flow cytometry. Glycemic variability, expressed as the mean amplitude of glycemic excursion (MAGE), was determined by a continuous glucose monitoring system 7 days after the onset of AMI. MAGE was significantly higher in the rupture patients than in the non-rupture patients (P=0.036). Levels of CD14(bright)CD16(+) monocytes from the rupture patients were significantly higher than those from the non-rupture patients (P=0.042). Of interest, levels of CD14(bright)CD16(+) monocytes correlated positively and significantly with MAGE (r=0.39, P=0.02). CONCLUSION Dynamic glucose fluctuation may be associated with coronary plaque rupture, possibly through the preferential increase in CD14(bright)CD16(+) monocyte levels.

Feasibility of Optical Coronary Tomography in Quantitative Measurement of Coronary Arteries With Lipid-Rich Plaque

BACKGROUND The aim of the present study was to evaluate the feasibility of optical coherence tomography (OCT) for measurement of vessel area in coronary arteries with lipid-rich plaque as compared with intravascular ultrasound (IVUS). METHODS AND RESULTS: We investigated 80 coronary artery segments with lipid-rich plaque on OCT and non-attenuated plaque on IVUS. According to the lipid arc on OCT, the plaques were classified into 4 groups: group 1, lipid arc ≤90°; group 2, 90°270°. Vessel circular arcs that could not be identified due to OCT signal attenuation were interpolated using an approximating algorithm. OCT-measured vessel area was well-correlated with IVUS-measured vessel area (R=0.834, P<0.001). On Bland-Altman plot, there was a good agreement between OCT-measured vessel area and IVUS-measured vessel area, although mean difference and limits of agreement increased with increase of lipid arc (mean difference in groups 1-4: -0.21, -0.31, -1.02, and -2.13 mm(2); lower limit: -1.49, -3.22, -5.24, and -9.25 mm(2); and upper limit: 1.07, 2.60, 3.20, and 4.99 mm(2)). Intra-observer (R=0.97-0.99, P<0.001) and inter-observer (R=0.97-0.99, P<0.001) reproducibility for OCT measurement of vessel area was excellent. CONCLUSIONS Like IVUS, OCT can be used to measure vessel area in coronary arteries with lipid-rich plaque.

Association between P-selectin glycoprotein ligand-1 and pathogenesis in acute coronary syndrome assessed by optical coherence tomography

OBJECTIVE Although monocytes appear to be actively involved in the onset of acute coronary syndrome (ACS), they are heterogenous in human peripheral blood. How up-regulation of monocyte subsets leads to coronary plaque rupture followed by thrombus formation remains unclear. Recent studies have shown that P-selectin glycoprotein ligand-1 (PSGL-1) is involved in monocyte activation in patients with thrombus formation. We therefore investigated the relationship between the expression of PSGL-1 on monocyte subsets and thrombus formation using frequency-domain optical coherence tomography (FD-OCT) in patients with ACS. METHODS We enrolled a total of 100 individuals in this study: patients with acute myocardial infarction (AMI, n=25), unstable angina pectoris (UAP, n=20), or stable angina pectoris (n=35) who underwent coronary angiography, and control subjects (n=20). Three monocyte subsets (CD14++CD16-, CD14++CD16+, and CD14+CD16+) and the expression of PSGL-1 were measured by flow cytometry. In patients with AMI and UAP, FD-OCT was performed before percutaneous coronary intervention. RESULTS Circulating peripheral CD14++CD16+ monocytes expressed PSGL-1 more frequently than CD14++CD16- and CD14+CD16+ monocytes in patients with ACS. The expression of PSGL-1 on circulating peripheral CD14++CD16+ monocytes was significantly elevated in patients with AMI compared with the other 3 groups. Moreover, the expression levels of PSGL-1 on CD14++CD16+ monocytes were significantly higher in patients with plaque rupture or intracoronary thrombus assessed by FD-OCT. CONCLUSION Up-regulation of PSGL-1 on CD14++CD16+ monocytes may be a crucial role in plaque rupture and thrombus formation.

Circulating CD14++CD16+ Monocyte Subsets as a Surrogate Marker of the Therapeutic Effect of Corticosteroid Therapy in Patients With Cardiac Sarcoidosis

BACKGROUND We aimed to evaluate whether specific monocyte subsets could serve as surrogate markers of disease activity in cardiac sarcoidosis (CS) evaluated by 18F-fluoro-2-deoxyglucose positron emission tomography (18F-FDG PET). METHODS AND RESULTS We studied 28 patients with CS (8 men; mean age: 61±9 years) diagnosed according to consensus criteria. We divided the patients into 2 groups: known CS receiving corticosteroid therapy (Rx(+); n=13) and new-onset CS (Rx(-); n=15), and analyzed 3 distinct monocyte subsets (CD14+CD16-, CD14++CD16+, and CD14+ -CD16+). Monocyte subsets were also analyzed in 10 Rx(-) patients before and 12 weeks after starting corticosteroid therapy. Inflammatory activity was quantified by 18F-FDG PET using the coefficient of variation (COV) of the standardized uptake value (SUV). The proportion of CD14++CD16+ monocytes in Rx(+) patients (10.8 [0.2-23.5] %) was significantly lower than in Rx(-) patients (23.0 [11.5-38.4] %, P=0.001). After corticosteroid therapy, the COV of the SUV was significantly improved from 0.32 [0.14-0.62] to 0.17 [0.04-0.43] (P=0.017). The proportion of CD14++16+ monocytes showed a significant decrease from 22.2 [8.8-38.4] % to 8.4 [1.8-16.8] % (P=0.001). The decrease in the proportion of CD14++16+ monocytes significantly correlated with the decrease in the COV of the SUV (r=0.495, P=0.027). CONCLUSIONS CD14++16+ monocytes are a possible surrogate marker of the therapeutic effect of corticosteroid therapy in CS.

Prognosis of spontaneous coronary artery dissection treated by percutaneous coronary intervention with optical coherence tomography

BACKGROUND Although about half of patients with spontaneous coronary artery dissection (SCAD) face ongoing necrosis, conservative therapy is recommended due to a high complication rate in angiography-guided percutaneous coronary intervention (PCI). The aim of this study was to investigate clinical outcomes of SCAD treated by optical coherence tomography (OCT)-guided PCI. METHODS This study consisted of consecutive 306 patients with acute coronary syndrome (ACS) who underwent OCT-guided PCI. Based on the culprit lesion morphology by OCT, patients were assigned to four groups: a SCAD group, a plaque rupture (PR) group, a calcified nodule (CN) group, and an undetermined etiology (UE) group. Successful PCI was defined as thrombolysis in myocardial infarction flow grade 3 in final angiography without any complications. Primary endpoint was defined as occurrence rate of major adverse cardiac events (MACE) including cardiac death, myocardial infarction, and unstable angina pectoris. RESULTS OCT revealed 12 SCADs, 149 PRs, 16 CNs, and 129 UEs, respectively. No significant difference was observed in the success rate of PCI (SCAD 91.7%, PR 85.2%, CN 81.2%, UE 86.8%, p=0.88), while wire repositioning was needed in 2 SCAD cases (p<0.01). The mean follow-up periods were 17.1±13.3 months. No significant difference was observed in MACE among the groups (p=0.56). CONCLUSIONS The clinical outcomes of OCT-guided PCI for SCAD were favorable, as well as those for other ACS etiologies. OCT-guided PCI could become a therapeutic option for SCAD compromised with ongoing necrosis.

Optimal threshold of postintervention minimum stent area to predict in‐stent restenosis in small coronary arteries: An optical coherence tomography analysis

The aim of this study was to determine the best threshold of postintervention minimum stent area (MSA) assessed by optical coherence tomography (OCT) to predict long‐term in‐stent restenosis (ISR) for 2.5 mm‐diameter everolimus‐eluting stents (EES).

PLAQUE MORPHOLOGY CAN BE A PREDICTOR OF FUTURE CORONARY EVENTS IN RELATION TO LESIONS OF DEFERRED FRACTIONAL FLOW RESERVE-NEGATIVE STENOSIS

It is unknown whether plaque characteristics are associated with future plaque progression in coronary lesions after deferral of coronary intervention. Between 2008 and 2013, 234 patients underwent both fractional flow reserve (FFR) and optical coherence tomography (OCT) examination for evaluating

Left ventricular apical aneurysm due to unrecognized sarcoidosis

A 47-year-old woman was hospitalized for syncope. An electrocardiogram showed complete right bundle branch block and T-wave inversion in leads III, aVF, and V2–4. Cardiac catheterization was performed since the echocardiogram demonstrated the existence of a left ventricular apical aneurysm and apical thrombus. Coronary angiography revealed normal coronary arteries. An endomyocardial biopsied specimen from the right ventricular apical wall demonstrated typical noncaseating granulomas with giant cells. There was no evidence suggesting the involvement of other systemic organs. The patient was diagnosed as having cardiac sarcoidosis. Cardiac sarcoidosis should be considered within a spectrum of diseases that cause left ventricular apical aneurysm.