Kenichi Yanaka

Optical coherence tomography study of chronic-phase vessel healing after implantation of bare metal and paclitaxel-eluting self-expanding nitinol stents in the superficial femoral artery.

BACKGROUND This study aimed to assess chronic-phase suppression of neointimal proliferation and arterial healing following paclitaxel-coated (PTX) and bare metal stent (BMS) implantation in the superficial femoral artery using optical coherence tomography (OCT). METHODS Twenty-five patients with 68 stents underwent an 8-month OCT follow-up. Besides standard OCT variables, neointimal characterization and frequencies of peri-strut low-intensity area (PLIA), macrophage accumulation, and in-stent thrombi were evaluated. RESULTS The mean neointimal thickness was significantly less with PTX stents (544.9±202.2 μm vs. 865.0±230.6 μm, p<0.0001). The covered and uncovered strut frequencies were significantly smaller and larger, respectively, in the PTX stent group vs. the BMS group (93.7% vs. 99.4%; p<0.0001, 4.0% vs. 0.4%; p<0.0001, respectively). Heterogeneous neointima was only observed in the PTX stent group (12.5% vs. 0%, p=0.017). The frequencies of PLIA and macrophage accumulation were significantly greater in the PTX stent group (87.2% vs. 67.6%, p=0.001 and 46% vs. 9.1%, p=0.003, respectively). CONCLUSION After 8 months, reduced neointimal proliferation was observed with PTX stent implantation. On the other hand, delayed arterial healing was observed compared with BMS.

Impact of CD14 ++ CD16 + monocytes on coronary plaque vulnerability assessed by optical coherence tomography in coronary artery disease patients with well-regulated lipid levels

BACKGROUND AND AIMS This study examined the impact of CD14++CD16+ monocytes on coronary plaque vulnerability, as assessed by optical coherence tomography (OCT), and investigated their association with daily glucose fluctuation. Although increased CD14++CD16+ monocyte levels have been reported to increase cardiovascular events, their impact on coronary plaque vulnerability in coronary artery disease (CAD) patients with or without diabetes mellitus (DM) remains unclear. METHODS This prospective observational study included 50 consecutive patients with CAD, receiving lipid-lowering therapy and undergoing coronary angiography and OCT. Patients were divided into 3 tertiles according to the CD14++CD16+ monocyte percentages assessed by flow cytometry. Standard OCT parameters were assessed for 97 angiographically intermediate lesions (diameter stenosis: 30-70%). Daily glucose fluctuation was analyzed by measuring the mean amplitude of glycemic excursion (MAGE). RESULTS CD14++CD16+ monocytes negatively correlated with fibrous cap thickness (r = -0.508, p < 0.01). The presence of thin-cap fibroatheroma (TCFA) was increased stepwise according to the tertile of CD14++CD16+ monocytes (0 [tertile 1] vs. 5 [tertile 2] vs. 10 [tertile 3], p < 0.01). CD14++CD16+ monocytes were a significant determinant of TCFA (OR 1.279, p = 0.001). In non-DM patients, a significant relationship was found between CD14++CD16+ monocytes and MAGE (r = 0.477, p = 0.018). CONCLUSIONS CD14++CD16+ monocytes were associated with coronary plaque vulnerability in CAD patients with well-regulated lipid levels both in DM and non-DM patients. Cross-talk between glucose fluctuation and CD14++CD16+ monocytes may enhance plaque vulnerability, particularly in non-DM patients. CD14++CD16+ monocytes could be a possible therapeutic target for coronary plaque stabilization.

Upfront triple combination therapy-induced pulmonary edema in a case of pulmonary arterial hypertension associated with Sjogren's syndrome

Clinical efficacy of combination therapy using vasodilators for pulmonary arterial hypertension (PAH) is well established. However, information on its safety are limited. We experienced a case of primary Sjogrens syndrome associated with PAH where the patient developed pulmonary edema immediately after the introduction of upfront triple combination therapy. Although the combination therapy successfully stabilized her pre-shock state, multiple ground glass opacities (GGO) emerged. We aborted the dose escalation of epoprostenol and initiated continuous furosemide infusion and noninvasive positive pressure ventilation (NPPV), but this did not prevent an exacerbation of pulmonary edema. Chest computed tomography showing diffuse alveolar infiltrates without inter-lobular septal thickening suggests the pulmonary edema was unlikely due to cardiogenic pulmonary edema and pulmonary venous occlusive disease. Acute respiratory distress syndrome was also denied from no remarkable inflammatory sign and negative results of drug-induced lymphocyte stimulation tests (DLST). We diagnosed the etiological mechanism as pulmonary vasodilator-induced trans-capillary fluid leakage. Following steroid pulse therapy dramatically improved GGO. We realized that overmuch dose escalation of epoprostenol on the top of dual upfront combination poses the risk of pulmonary edema. Steroid pulse therapy might be effective in cases of vasodilator-induced pulmonary edema in Sjogrens syndrome associated with PAH.

The optimization of iloprost inhalation under moderate flow of oxygen therapy in severe pulmonary arterial hypertension

Inhaled iloprost efficiently improves pulmonary hemodynamics, exercise capacity, and quality of life in patients with pulmonary arterial hypertension (PAH). However, the process of inhalation is laborious for patients suffering from resting dyspnea. We describe a 75-year-old man with idiopathic PAH and a low gas transfer. Investigations excluded significant parenchymal lung disease and airflow obstruction (presuming FEV1/FVC ration > 70%). The patient struggled to complete iloprost inhalation due to severe dyspnea and hypoxemia. As such, we optimized the methods of oxygen supply from the nasal cannula to the trans-inhalator during the inhalation. We successfully shortened the inhalation duration that effectively reduced the laborious efforts required of patients. We also recorded pulmonary hemodynamics during inhalation of nebulized iloprost. This revealed significant hemodynamic improvement immediately following inhalation but hemodynamics returned to baseline within 2 hours. We hope that this optimization will enable patients with severe PAH to undergo iloprost inhalation.

Potent effect of prasugrel on acute phase resolution of intra-stent athero-thrombotic burden after percutaneous intervention to acute coronary syndrome

BACKGROUND Recent studies suggested protruding thrombus and atheroma after stent placement could be a substrate for subsequent adverse ischemic events. Although protruded atherothrombotic burden can be assessed as intra-stent tissue (IST) by optical coherence tomography (OCT), the effects of potent antiplatelet therapy on the acute phase resolution of IST in patients with acute coronary syndrome (ACS) was unknown. METHODS Ninety-six consecutive ACS patients with multi-vessel disease were enrolled in this prospective registry. In combination with aspirin, either clopidogrel or prasugrel was selected according to the date of enrolment. OCT examination was done immediately after percutaneous coronary intervention (post-PCI) and 10 days after index PCI (follow-up acute phase) to calculate averaged IST score as semi-quantitative measures of IST. High residual platelet reactivity (HRPR) was defined as platelet reactivity units (PRU)≥240 by VerifyNow P2Y12 assay (Accumetrics Inc., San Diego, CA, USA). RESULTS Thirty two patients (38 stents) were enrolled in the prasugrel group and sixty four patients (72 stents) in the clopidogrel group. Averaged IST scores post-PCI were similar between the two groups (0.68±0.41 vs. 0.68±0.40, p=0.99), which decreased in all of the prasugrel group and in 87.5% of the clopidogrel group (p=0.02). Consequently, changes in averaged IST score (delta averaged IST score) were significantly greater in the prasugrel group compared to those in the clopidogrel group (-0.411±0.288 vs. -0.299±0.270, p=0.045). The frequency of HRPR was significantly lower in the prasugrel group (10.0% vs 32.4%, p=0.028). CONCLUSIONS Prasugrel plus aspirin achieved greater acute phase reduction of IST than clopidogrel plus aspirin, which might underlie the clinical benefit of potent antiplatelet therapy in ACS. (UMIN000018751).

Early Introduction of Pulmonary Endarterectomy or Balloon Pulmonary Angioplasty Contributes to Better Health-Related Quality of Life in Patients With Chronic Thromboembolic Pulmonary Hypertension

Pulmonary endarterectomy (PEA) and balloon pulmonary angioplasty (BPA) have showed beneficial effects on hemodynamics and exercise tolerance in patients with chronic thromboembolic pulmonary hypertension (CTEPH) [(1,2)][1]. Although several publications have demonstrated improvement in health-

Reversible Parkinsonism and Multiple Cerebral Infarctions after Pulmonary Endarterectomy in a Patient with Antiphospholipid Syndrome

Antiphospholipid syndrome (APS) is a cause of chronic thromboembolic pulmonary hypertension (CTEPH) and it is associated with an increased risk of postoperative neurological complications. We experienced a case of reversible parkinsonism after pulmonary endarterectomy (PEA) and subsequent multiple cerebral infarctions under standard anticoagulation therapy in a patient with CTEPH associated with APS. Strict management using a combination of antiplatelet and anticoagulation therapy should be considered in patients with a high titer of triple antiphospholipid antibodies in the perioperative period. We should be aware of the high risk of postoperative neurologic manifestations in patients with APS.

Data on impact of monocytes and glucose fluctuation on plaque vulnerability in patients with coronary artery disease

Data presented in this article are supplementary material to our research article entitled “Impact of CD14++CD16+ monocytes on coronary plaque vulnerability assessed by optical coherence tomography in coronary artery disease patients” [1]. This article contains the data of study population, diagnostic ability of CD14++CD16+ monocytes to identify thin-cap fibroatheromas, and association between laboratory variables and plaque properties.

Successful Pulmonary Artery Embolization for the Management of Hemoptysis in a Patient with Eisenmenger Syndrome Caused by Patent Ductus Arteriosus

The patient was a 19-year-old woman who was diagnosed with patent ductus arteriosus complicating Eisenmenger syndrome at a previous medical institution. She was referred to our hospital and arranged for lung transplantation. She developed hemoptysis after the introduction of i.v. epoprostenol, which was administered as a bridging treatment while the patient awaited lung transplantation. She continued to suffer from recurrent hemoptysis, even after switching from i.v. epoprostenol to i.v. treprostinil. Angiography of the systemic and pulmonary arteries revealed the vessel responsible for the recurrent hemoptysis and pulmonary artery embolization was successfully performed. It is essential to identify the culprit vessel and physicians must not hesitate in performing embolization when patients develop lethal hemoptysis.

TCT-90 Efficacy and safety of sequential hybrid therapy with pulmonary endarterectomy and additional balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension.

nos: 89 92 TCT-89 Balloon pulmonary angioplasty for chronic thromboembolic hypertension: report of a two-year experience in a surgical center Philippe Brenot, Carlos Garcia Alonso, Benoit Gerardin, Ryad Bourkaib, Xavier Jais, Gerald Simonneau, Elie Fadel Minneapolis Heart Institute Foundation; Hôpital Marie Lannelongue, Le Plessis Robinson, France; Hôpital Marie Lannelongue; Evecquemont, Evcequemont, France; Hôpital Bicêtre; Hôpital Bicêtre; Hôpital Marie Lannelongue BACKGROUND Balloon pulmonary angioplasty (BPA) has emerged as a new therapy (beside surgery and medical treatment) for patients suffering of chronic thromboembolic pulmonary hypertension (CTEPH). We describe herein our single-center experience in our first 113 patients. METHODS Patients were selected for BPA at weekly multidisciplinary meetings in collaboration with the national reference center for pulmonary hypertension. Patients underwent functional evaluation (NYHA class and 6 minutes walking test), as well as right heart catheterization and pulmonary artery imaging before BPA and systematically 3 months after the last session. BPA was performed via femoral vein under local anesthesia. Balloon diameter ranged from 1.5 to 9 mm. Several sessions were required to reach our goal of mean PAP < 30 mmHg. RESULTS From February 2014 to May 2016, 113 patients (64 males, 57%), mean age 62 15, underwent BPA. Reasons to perform BPA were: non-surgical distal disease in 82, comorbidities in 22, persistent high pulmonary artery pressure (PAP) after surgery in 7 and refusal to surgery in 2. The mean number of sessions was 5.5 (range 1 to 10). After 620 sessions we deplore 29 hemoptysis (4.5% of procedures), none of which was life threatening, 11 pulmonary artery dissections (1.7%), 5 of which were treated by stent implantation, and 46 reperfusion pulmonary injuries (7,4%), 2 of which required mechanical ventilation. 3 patients died (2.7%), 2 because of reperfusion injury and 1 of an infectious complication. Follow up has been completed for the first 79 patients (mean FU of 8 months, range 3 to 20). 3 patients died (1 sudden death, 1 recurrence of pulmonary embolism and 1 road accident). NYHA status improved from 2.91 to 1.77 (p<0.01). Mean PAP improved from 44.5 to 31.2 mmHg (p<0.01). Cardiac output increased from 2.59 L/min/m2 to 2.95 (p<0.01). Pulmonary vascular resistance (PVR) went down from 7.77 UW to 3.92 UW (p<0.01). CONCLUSION Our short term BPA results confirm the usefulness of this technique to improve hemodynamics and more importantly quality of life in well selected patients. Future analysis should help us select responsive patients while diminishing procedure related complications. To our knowledge this series is one of the largest currently available. CATEGORIES STRUCTURAL: Heart Failure TCT-90 Efficacy and safety of sequential hybrid therapy with pulmonary endarterectomy and additional balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension Kenichi Yanaka, Kazuhiko Nakayama, Toshiro Shinke, Hiromasa Otake, Takayoshi Toba, Hachidai Takahashi, Daisuke Terashita, Yuto Shinkura, Koji Kuroda, Kenzo Uzu, Natsuko Tahara, Yoshinori Nagasawa, Yuichiro Nagano, Naoki Tamada, yoshiro tsukiyama, Hiroyuki Yamamoto, Noriaki Emoto, Ken-ichi Hirata University of Michigan Health System, Kobe city, Japan; CVPath Institute, Inc; Kobe University Hospital, Kobe, Japan; National Institute of Cardiovascular Diseases, Dhaka, Bangladesh; Himeji Cardiovascular Center, Himeji, Japan; Kobe University, Himeji, Japan; Kobe University Hospital; City Clinic, Kobe, Japan; Kobe University J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 8 , N O . 1 8 , S U P P L B , 2 0 1 6 B37 Hospital, kobe city, Japan; Kobe University, Kobe, Japan; Wakayama Medical University; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York; Aichi Medical University, Kobe-shi, Japan; Federal University of São Paulo; Morehouse College; American Heart of Poland; Tufts Medical Center, Kobe, Japan; Center for Cardiovascular Research and Development, American Heart of Poland Inc BACKGROUND Pulmonary endarterectomy (PEA) is a gold standard therapy that can dramatically reduce pulmonary artery pressure (PAP) and improve the prognosis on chronic thromboembolic pulmonary hypertension (CTEPH). However, residual pulmonary hypertension or persistent symptoms even after PEA are still the clinical issues to be solved. We investigated whether additional balloon pulmonary angioplasty (BPA) after PEA was effective. METHODS Since August 2009 until June 2016, 23 patients underwent PEA at Kobe University Hospital. Seven patients with residual pulmonary hypertension or symptom underwent additional BPA. RESULTS The period from PEA to additional BPA was 8.3 8.3 months and the number of BPA sessions was 2.4 0.9. In 7 patients who underwent additional BPA after PEA, mean PAP and pulmonary vascular resistance (PVR) had significantly improved by PEA (39.3 6.0 to 27.9 10.1 mmHg p<0.01, 996 447 to 473 255 dyne・sec・cm5 p1⁄40.02), and improved further (to 19.9 7.9 mmHg p1⁄40.01 ,to 183 96 dyne・sec・cm-5 p1⁄40.01) by additional BPA. Before PEA, 2 patients were NYHA/WHO functional class II and 5 patients were class III. Hybrid therapy improved NYHA/WHO functional class (3 patients classI, 3 patients classII, 1 patients classIII p1⁄40.05)(Figure). No patient died and had severe complication needed mechanical ventilator and extracorporeal membrane oxygenation during whole study period. CONCLUSION Although PEA for CTEPH had improved pulmonary hemodynamic profiles, additional BPA could improve them further. Additional BPA is an effective and safe treatment for residual pulmonary hypertension or persistent symptom. CATEGORIES ENDOVASCULAR: Peripheral Vascular Disease and Intervention TCT-91 Efficacy of aggressive balloon pulmonary angioplasty on chronic thromboembolic pulmonary hypertension beyond normalized mean pulmonary arterial pressure Yuto Shinkura, Kazuhiko Nakayama, Takayoshi Toba, Hachidai Takahashi, Daisuke Terashita, Kenzo Uzu, Koji Kuroda, Natsuko Tahara, Yoshinori Nagasawa, Yuichiro Nagano, Hiroyuki Yamamoto, yoshiro tsukiyama, Kenichi Yanaka, Naoki Tamada, Hiromasa Otake, Toshiro Shinke, Noriaki Emoto, Ken-ichi Hirata City Clinic, Kobe, Japan; CVPath Institute, Inc.; Himeji Cardiovascular Center, Himeji, Japan; Kobe University, Himeji, Japan; Kobe University Hospital; Kobe University, Kobe, Japan; Kobe University Hospital, kobe city, Japan; Wakayama Medical University; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York; Aichi Medical University, Kobe-shi, Japan; American Heart of Poland; Osaka Saiseikai Nakatsu Hospital, Kobe, Japan; University of Michigan Health System, Kobe city, Japan; Federal University of São Paulo; National Institute of Cardiovascular Diseases, Dhaka, Bangladesh; Kobe University Hospital, Kobe, Japan; Tufts Medical Center, Kobe, Japan; Center for Cardiovascular Research and Development, American Heart of Poland Inc BACKGROUND Balloon pulmonary angioplasty (BPA) attracts attention as an alternative treatment option for chronic thromboembolic pulmonary hypertension (CTEPH). Previous studies reported that despite of normalization of resting mean pulmonary artery pressure (mPAP), some patients with CTEPH still suffer from exertional dyspnea. Whether or not additional BPA therapy for these patients might improve the symptoms, however, has not been clarified. METHODS Among 102 patients with CTEPH who treated in Kobe university hospital, a total of 37 patients who achieved normalization of mPAP but still had persistent symptoms (WHO-Fc>II) after BPA with or without pulmonary endarterectomy (PEA). We formerly set normalization of resting mPAP (<25mmHg) as an endpoint of BPA sessions (conventional BPA). Since Sep, 2014 we initiated to perform additional BPA for the patients who still had persistent symptoms (WHO-Fc>II) even after normalization of resting mPAP (aggressive BPA). We analyzed the changes in hemodynamics, exercise capacity, and WHO-Fc between two groups. RESULTS Among 37 patients with normalized mPAP, 15 patients were aggressive BPA group and 22 patients were conventional BPA group. The frequency of PEA procedure before BPA and median follow-up duration since achievement of normalization mPAP were not different between the groups. The 6-minute walking distance (6MWD) and hemodynamics were significantly improved in aggressive BPA group compared with conventional BPA group(D6MWD; 51.2 14.1 vs -5.0 12.5 m ; p1⁄40.01 / DmPAP ; -2.9 0.7 vs 2.1 0.9 mmHg ; p<0.01 / DPulmonary vascular resistance ; -105.9 35.5 vs 10.4 16.6 dyne・sec/ cm-5; p < 0.01). Percentage of the patients who improved WHO-Fc was significantly higher in aggressive BPA group (73.3% vs 32.1%.; p1⁄40.01).