Koichi Kishi

Sirolimus-Eluting Stent Versus Balloon Angioplasty for Sirolimus-Eluting Stent Restenosis: Insights From the j-Cypher Registry

Background— Optimal treatment strategies for restenosis of sirolimus-eluting stents (SES) have not been adequately addressed yet. Methods and Results— During the 3-year follow-up of 12 824 patients enrolled in the j-Cypher registry, 1456 lesions in 1298 patients underwent target-lesion revascularization (TLR). Excluding 362 lesions undergoing TLR for stent thrombosis or TLR using treatment modalities other than SES or balloon angioplasty (BA), 1094 lesions with SES-associated restenosis in 990 patients treated with either SES (537 lesions) or BA (557 lesions) constituted the study population for the analysis of recurrent TLR and stent thrombosis after the first TLR. Excluding 24 patients with both SES- and BA-treated lesions, 966 patients constituted the analysis set for the mortality outcome. Cumulative incidence of recurrent TLR in the SES-treated restenosis lesions was significantly lower than that in the BA-treated restenosis lesions (23.8% versus 37.7% at 2 years after the first TLR; P<0.0001). Among 33 baseline variables evaluated, only hemodialysis was identified to be the independent risk factor for recurrent TLR by a multivariable logistic regression analysis. After adjusting for confounders, repeated SES implantation was associated with a strong treatment effect in preventing recurrent TLR over BA (odds ratio, 0.44; 95% confidence interval, 0.32 to 0.61; P<0.0001). The 2-year mortality and stent thrombosis rates between the SES- and the BA-treated groups were 10.4% versus 10.8% (P=0.4) and 0.6% versus 0.6%, respectively. Conclusions— Repeated implantation of SES for SES-associated restenosis is more effective in preventing recurrent TLR than treatment with BA, without evidence of safety concerns.

Incidence and impact on midterm outcome of controlled subintimal tracking in patients with successful recanalisation of chronic total occlusions: J-PROCTOR registry.

AIMS To assess the incidence and impact on clinical outcomes of subintimal tracking in patients undergoing percutaneous coronary intervention for chronic total occlusion (CTO). Patients at 27 centres were consecutively enrolled when guidewire crossing of the CTO by either the antegrade or the retrograde approach was confirmed by intravascular ultrasound (IVUS). IVUS images were examined to identify the course of the wire. Clinical follow-up at one year and angiographic follow-up at nine months were performed after everolimus-eluting stent implantation. Among a total of 163 patients (59 antegrade and 104 retrograde), subintimal tracking was more frequent with the retrograde approach (24.2% vs. 12.3%, p=0.10). Although there was no difference in the one-year target vessel revascularisation rate between intimal and subintimal tracking with either the antegrade or the retrograde approach, angiographic follow-up revealed greater late loss in the subintimal group compared with the intimal group. Multivariate analysis identified the pre-procedural reference diameter as a predictor of subintimal tracking. Subintimal tracking was more frequent with the retrograde approach. After medium-term follow-up, no negative clinical impact of subintimal tracking was observed in this small study. However, further evaluation of the angiographic impact is needed.

Acute hyperglycaemia prevents the protective effect of pre-infarction angina on microvascular function after primary angioplasty for acute myocardial infarction

Background: Acute hyperglycaemia has been associated with impaired microvascular function after acute myocardial infarction (AMI), whereas pre-infarction angina (PIA) occurring shortly before the onset of AMI has been shown to reduce microvascular injury after reperfusion. Objective: To examine whether acute hyperglycaemia prevents the protective effect of PIA on microvascular function after AMI. Methods: We studied 205 patients with a first anterior wall AMI who underwent primary angioplasty within 12 hours of onset. Coronary flow velocity parameters were assessed immediately after reperfusion using a Doppler guidewire. Severe microvascular injury was defined as the presence of systolic flow reversal and diastolic deceleration time <600 ms. Echocardiographic wall motion was analysed before revascularisation and 4 weeks later. Results: Acute hyperglycaemia, defined as a blood glucose level of ⩾198 mg/dl on admission, was found in 67 (33%) patients. In patients without acute hyperglycaemia, PIA was associated with a lower incidence of systolic flow reversal, a longer diastolic deceleration time and a higher coronary flow reserve. However, in patients with acute hyperglycaemia there was no significant difference in these same parameters between patients with and without PIA. In the presence of acute hyperglycaemia PIA did not improve the change in wall motion score. In a multivariate model, the absence of PIA was an independent determinant of severe microvascular injury in patients without acute hyperglycaemia (odds ratio 6.28, p = 0.001), but not in patients with acute hyperglycaemia. Conclusion: The protective effect of PIA on microvascular function was attenuated in patients with acute hyperglycaemia, resulting in unfavourable functional recovery.

Relation between the TIMI frame count and the degree of microvascular injury after primary coronary angioplasty in patients with acute anterior myocardial infarction

Objective: To investigate the relation between thrombolysis in myocardial infarction (TIMI) frame count (TFC) and coronary blood flow velocity (CBFV) parameters reflecting the degree of microvascular injury in patients with acute myocardial infarction. Results: TFC and CBFV were measured after primary coronary angioplasty in 103 consecutive patients with their first anterior wall acute myocardial infarction. TFC correlated inversely with the averaged peak velocity (r  =  −0.43, p < 0.0001). However, TFC did not correlate significantly with diastolic deceleration time and with the averaged systolic peak velocity (r  =  −0.16, p  =  0.22, and r  =  −0.23, p  =  0.16, respectively). The patients were divided into two groups according to presence (35 patients) or absence (68 patients) of systolic flow reversal. There was no significant difference in TFC between the two groups (29 (16) v 25 (13), p  =  0.20). Conclusions: These findings suggest that the TFC reflects epicardial CBFV. However, it is not accurate enough to assess the degree of microvascular injury after primary coronary angioplasty.

The potential benefits and risks of the use of dual antiplatelet therapy beyond 6 months following sirolimus-eluting stent implantation for low-risk patients

BACKGROUND The optimal duration of dual antiplatelet therapy (DAT) in patients undergoing intracoronary sirolimus-eluting stent implantation remains controversial. OBJECTIVE To evaluate the clinical effects of long duration DAT in patients undergoing intracoronary sirolimus-eluting stent implantation in daily practice. In addition, to attempt to identify the optimal duration of DAT after implantation of a sirolimus-eluting stent. METHODS We retrospectively report on 1293 consecutive patients who underwent successful intracoronary sirolimus-eluting stent implantation. We analyzed the cumulative incidence of stent thrombosis, non-fatal myocardial infarction (MI), death from cardiac causes, and the cumulative incidence of bleeding complications. RESULTS We compared the study end point in patients who received DAT for <6 months (n=1136) with that for patients who received DAT for >6 months (n=157). The median follow-up period was 1260 ± 462 days. Major bleeding occurred in 35 patients and intracranial hemorrhage in 8. In patients on DAT for >6 months, the incidence of any bleedings, major bleedings, and intracranial hemorrhage was significantly increased. On the other hand, there was no significant difference between the two groups in the risk of the primary end points (stent thrombosis, non-fatal MI, death from cardiac causes, death or MI). CONCLUSIONS Prolonged DAT for more than 6 months was not significantly more beneficial than aspirin monotherapy in reducing the risk of the occurrence of acute MI, stent thrombosis, and death, although it was associated with an increase in bleeding complications for low-risk patients.

Waist circumference reduction is more strongly correlated with the improvement in endothelial function after acute coronary syndrome than body mass index reduction

BACKGROUND Endothelial function predicts recurrence of adverse cardiac events in patients with acute coronary syndromes (ACS). Moreover, the recovery of endothelial function correlates with cardiac event-free survival. OBJECTIVES The aim of this study was to determine which clinical factors correlate with the improvement in endothelial function after ACS. METHODS Vascular endothelial function was assessed in 98 patients with ACS by flow-mediated dilation (FMD) of the brachial artery using high-resolution ultrasound at 2 weeks and 6 months after ACS. We measured several risk parameters including plasma markers of glucose homeostasis, lipids, and blood pressure at baseline and at 6 months after ACS. Body mass index (BMI) and waist circumference (WC) were also measured as anthropometric assessments. RESULTS At baseline, FMD was significantly correlated with BMI, WC, high-density lipoprotein cholesterol, the homeostasis model assessment of insulin resistance, and brachial artery diameter (r=-0.32, p=0.001; r=-0.44, p<0.0001; r=0.34, p=0.0006; r=-0.21, p=0.04; r=-0.47, p<0.0001, respectively). In a stepwise multivariate regression analysis at baseline, larger WC and brachial artery diameter were independently correlated with lower brachial artery FMD (R(2)=0.319, p<0.0001). At 6 months, the change in FMD was significantly correlated with the change in WC and BMI (r=-0.59, p<0.0001; r=-0.33, p=0.001, respectively). In a stepwise multivariate regression analysis, WC reduction was independently correlated with improved FMD (R(2)=0.349, p<0.0001). CONCLUSIONS WC reduction is more strongly correlated with the improvement of endothelial function after ACS than BMI reduction.

Impact of lesion calcification on angiographic outcomes after Absorb everolimus-eluting bioresorbable vascular scaffold implantation: An observation from the ABSORB Japan trial

AIMS We aimed to investigate the impact of lesion calcification on angiographic outcomes after Absorb everolimus-eluting bioresorbable vascular scaffold (BVS) implantation in comparison with those after cobalt-chromium everolimus-eluting stent (CoCr-EES) implantation. METHODS AND RESULTS The present post hoc analysis of the ABSORB Japan randomised trial compared post-procedure and 13-month angiographic outcomes between patients implanted with BVS and CoCr-EES based on the presence or absence of calcification, excluding extremely heavily calcified lesions or lesions requiring rotational atherectomy. The study population comprised 384 patients with 384 lesions (including 114 lesions [29.7%] with moderate or severe calcification), classified into two subgroups: calcification, 114 (BVS: n=72 and CoCr-EES: n=42) and non-calcification, 270 (BVS: n=181 and CoCr-EES: n=89). Follow-up angiography was performed in 94.8% of patients. Both post-procedure and follow-up in-device minimal lumen diameters were comparable in both the BVS arm (calcification vs. non-calcification: 2.43±0.32 mm vs. 2.43±0.39 mm, p=0.91 and 2.17±0.49 mm vs. 2.27±0.47 mm, p=0.17) and in the CoCr-EES arm (2.68±0.34 mm vs. 2.65±0.42 mm, p=0.62 and 2.57±0.52 mm vs. 2.47±0.53 mm, p=0.36). CONCLUSIONS Moderate or severe lesion calcification (excluding patients with extremely heavily calcified lesions or lesions requiring rotational atherectomy) does not negatively affect angiographic outcomes at both post-procedure and 13-month follow-up after BVS implantation.

Sirolimus-Eluting Stent Implantation for Ostial Left Anterior Descending Coronary Artery Lesions

Background—Ostial left anterior descending coronary artery (LAD) lesion has been regarded as a lesion subset unsuitable for coronary stenting. Long-term outcomes of sirolimus-eluting stent (SES) implantation for ostial LAD lesions have not been adequately evaluated. Methods and Results—Among 12 824 patients enrolled in the j-Cypher Registry, 3-year outcomes were compared between 481 patients with SES-treated ostial LAD lesions and 5369 patients with SES-treated nonostial proximal LAD lesions. Patients with ostial LAD lesions had similar incidences of target lesion revascularization (TLR) as those with nonostial proximal LAD lesions (9.4% versus 9.7%; P=0.98; adjusted hazard ratio [HR], 0.99; 95% CI, 0.7 to 1.36; P=0.94) and death/myocardial infarction (MI) (10.7% versus 11.4%; P=0.82; adjusted HR, 1.05; 95% CI, 0.76 to 1.4; P=0.77). Among the patients with ostial LAD lesions, those undergoing both main and side branch stenting (n=62) compared to main branch stenting alone (n=419) had a higher risk for TLR (adjusted HR, 4.65; 95% CI, 2.32 to 9.25; P<0.0001) but similar risk for death/MI (adjusted HR, 1.15; 95% CI, 0.49 to 2.41; P=0.73). In patients with main branch stenting alone, outcomes after crossover stenting across the circumflex coronary artery (n=225) were not different from those after ostial stenting (n=194) for TLR (adjusted HR, 0.77; 95% CI, 0.33 to 1.82; P=0.55) and for death/MI (adjusted HR, 1.54; 95% CI, 0.78 to 3.2; P=0.22). Conclusions—In terms of both safety and efficacy, 3-year outcomes of percutaneous coronary intervention using SES for ostial LAD lesions were comparable to those for nonostial proximal LAD lesions. Crossover stenting with a 1-stent approach might be a reasonable option in treating ostial LAD lesions.

The impact of gender difference on the effects of preinfarction angina on microvascular damage with reperfused myocardial infarction.

Few studies have addressed gender differences in evoking preconditioning. In an experimental study, it was reported that the preconditioning effect disappeared after gonadectomy.

Comparison of results of rotational atherectomy for diffuse coronary artery disease in diabetics versus nondiabetics.

patients undergoing stress testing have VPCs at rest and/or during exercise. In our own database, the incidence of VPCs at rest and/or during exercise was only 6% in 13,000 records reviewed. Another confounding element was that data came from a major cardiac center where the referral pattern may influence the prevalence of disease. This same bias exists in any study where angiograms are compared with exercise tests.