Kwon Bae Kim

Usefulness of coronary pressure measurement for functional evaluation of drug-eluting stent restenosis.

Despite the widespread adoption of drug-eluting stent (DES) implantation, the optimal treatment of DES failures remains challenging. The present study evaluated the relation between quantitative angiography and the fractional flow reserve (FFR) in restenotic lesions after DES implantation and the efficacy of FFR in determining whether to treat these lesions. To assess their functional significance, the coronary pressure-derived FFR was measured in 50 DES restenotic lesions (49 patients). Additional intervention was performed in lesions with a FFR <0.8. Major adverse cardiac events were assessed at 12 months after the reintervention procedure. The mean percent diameter stenosis (%DS) was 58 ± 13%. Of the 50 lesions, 20 (40%) were deferred without additional intervention. The FFR and %DS had a negative correlation (r = -0.61, p <0.001). However, when only the lesions with diffuse-type restenosis (15 lesions) were analyzed, the degree of correlation decreased (r = -0.56, p = 0.12). Although most lesions (89%) with a %DS of ≥70 had significant functional ischemia, among 41 lesions with a %DS <70, only 20 (49%) had demonstrated functional patency. The incidence of adverse events during the 12 months of follow-up after FFR-guided treatment was 18.0% (23.3% in the FFR <0.80 group and 10.0% in FFR ≥0.80 group). In conclusion, a discrepancy was found between functional ischemia measured by the FFR and the angiographic %DS, in particular, in moderate- or diffuse-type restenotic lesions after DES implantation. The outcome of FFR-guided deferral in patients with DES in-stent restenosis seems favorable.

Incidence of Hypertension in Korea: 5-Year Follow-up Study

Limited data are available about the incidence of hypertension over the 5-yr in non-hypertensive subjects. The study subjects were 1,806 subjects enrolled in a rural area of Daegu, Korea for a cohort study from August to November 2003. Of them, 1,287 (71.3%) individuals had another examination 5 yr later. To estimate the incidence of hypertension, 730 non-hypertensive individuals (265 males; mean age = 56.6 ± 11.1 yr-old) at baseline examination were analyzed in this study. Hypertension was defined as either a new diagnosis of hypertension or self-reports of newly initiated antihypertensive treatment; prehypertension was if the systolic blood pressure was 120-139 mmHg and/or diastolic blood pressure was 80-89 mmHg. During the 5-yr follow-up, 195 (26.7%) non-hypertensive individuals developed incident hypertension. The age-adjusted 5-yr incidence rates of hypertension were 22.9% (95% confidence interval [CI] = 19.9-29.0) in overall subjects, 22.2% (95% CI = 17.2-27.2) in men, and 24.3% (95% CI = 20.4-28.2) in women. The incidence rates of hypertension significantly increased with age. In the multivariate analysis, prehypertension (Odds ratio [OR] 2.25; P < 0.001) and older age (OR 2.26; P = 0.010) were independent predictors for incident hypertension. In this rapidly aging society, population-based preventive approach to decrease blood pressure, particularly in subjects with prehypertension, is needed to reduce hypertension.

Usefulness of combined intravascular ultrasound parameters to predict functional significance of coronary artery stenosis and determinants of mismatch.

AIMS Efficacy of combined intravascular ultrasound (IVUS) parameters in functional significance prediction and discrepancy between IVUS and fractional flow reserve (FFR) have not been well defined. This study therefore aimed to: 1) evaluate the diagnostic accuracy of combined IVUS parameters, namely minimal lumen area (MLA) and percent plaque burden (%PB), in functional significance prediction of coronary artery stenosis; and 2) define factors that affect the relation between FFR value and IVUS parameters. METHODS AND RESULTS At 11 international centres, IVUS and FFR measurements were concurrently performed in 945 major epicardial coronary artery lesions (886 patients). Functional significance was defined as FFR ≤0.8. MLA and FFR correlated weakly (r=0.289, p<0.001). Diagnostic accuracy of MLA ≤4.0 mm2, %PB >70% and their combination were 50%, 47% and 51%, respectively, with similar area under the curve (AUC) of 0.561, 0.511 and 0.516, respectively. The best cut-off values (BCV) were MLA ≤3.0 mm2 and %PB >75%, with accuracy of 60% for MLA, 50% for %PB and 56% for their combination, and AUC of 0.618, 0.511 and 0.533, respectively. MLA BCV ≤3.0 mm2 had higher predictive power than %PB BCV >75% or their combination. Independent predictors of functional significance were male gender (odds ratio 1.76 [95% confidence interval: 1.19-2.62]), left ventricular ejection fraction (LVEF, 0.98 [0.96-0.99]), LAD lesion (2.52 [1.73-3.67]), reference vessel diameter (0.60 [0.41-0.86]), lesion length (1.04 [1.02-1.06]) and MLA (0.79 [0.69-0.92]). False negative lesion incidence was 24.4% in association with race (for Asians, 0.391 [0.219-0.698]), LAD lesion (2.677 [1.709-4.191]) and LVEF (0.977 [0.957-0.997]). False positive lesion incidence was 17.0% in association with non-LAD lesion (2.444 [1.620-3.686]). CONCLUSIONS Combined IVUS parameters did not improve the accuracy of functional significance prediction. Discrepancy between IVUS and FFR, which was not rare, should be taken into account in clinical decision making.

Acute Stent Thrombosis and Heparin Induced Thrombocytopenia in a Patient With ST-Segment Elevation Myocardial Infarction.

Heparin is an essential drug in the treatment of acute coronary syndrome and it is used during percutaneous coronary intervention (PCI). Heparin-induced thrombocytopenia (HIT), albeit a serious complication of heparin therapy characterized by thrombocytopenia and high risk for venous and arterial thrombosis, has rarely been previously reported during PCI. We report a case of an acute stent thrombosis due to an unusual cause, HIT during primary PCI, in a patient with acute myocardial infarction.

Ovarian tumor-associated carcinoid heart disease presenting as severe tricuspid regurgitation.

Carcinoid heart disease is characterized by heart valve dysfunction as well as carcinoid symptomatology. We report a case of carcinoid heart disease associated with a primary ovarian tumor. A 60-year-old woman presented for dyspnea evaluation with a history of facial flushing, telangiectatic skin changes, and pitting edema of both lower extremities. Chest radiography showed cardiomegaly, and echocardiography revealed an isolated, severe tricuspid regurgitation without left-sided valvular dysfunction. The tricuspid leaflets were severely retracted and shortened, resulting in poor coaptation. Furthermore, mild pulmonary valve stenosis and moderate regurgitation were found along with this deformation. The 24-hour urine analysis revealed an increased level of 5-hydroxyindoleacetic acid, and an ovarian tumor was apparent on computed tomography images. The mass was surgically removed, and the patient was diagnosed as having a primary ovarian carcinoid tumor. She was treated with chemotherapy and regularly followed-up with supportive treatments, deferring surgical correction.

Two-Year Safety and Efficacy of Biodegradable Polymer Drug-Eluting Stent Versus Second-Generation Durable Polymer Drug-Eluting Stent in Patients With Acute Myocardial Infarction: Data from the Korea Acute Myocardial Infarction Registry (KAMIR)

Despite improved long‐term safety of biodegradable polymer (BP) drug‐eluting stents (DES) compared to first‐generation durable polymer (DP) DES, data on the safety and efficacy of BP‐DES compared with second‐generation (2G) DP‐DES in patients with acute myocardial infarction (AMI) are limited.

Clinical outcomes between different stent designs with the same polymer and drug: comparison between the Taxus Express and Taxus Liberte stents.

Background/Aims The Taxus Liberte stent (Boston Scientific Co.) evolved from the Taxus Express stent, with enhanced stent deliverability and uniform drug delivery. This study was designed to compare angiographic and clinical outcomes in real-world practice between the Taxus Liberte and Taxus Express stents. Methods Between 2006 and 2008, 240 patients receiving the Taxus Liberte stent at three centers were registered and compared to historical control patients who had received the Taxus Express stent (n = 272). After propensity score matching, 173 patients treated with the Taxus Liberte stent and the same number of patients treated with the Taxus Express stent were selected. The primary outcome was a composite of major adverse cardiac events (MACE), including cardiac death, myocardial infarction (MI), ischemia driven target vessel revascularization (TVR), and stent thrombosis (ST) at 1 year. An additional angiographic assessment was conducted at 9 to 12 months. Results The study showed no significant difference between the Taxus Express and Taxus Liberte stents (death, 1.73% vs. 2.31%, p = 1.000; MI, 0% vs. 1.73%, p = 0.2478; TVR, 2.31% vs. 1.16%, p = 0.6848; and ST, 0% vs. 1.16%, p = 0.4986). The total MACE rate at 1 year did not differ between the groups (4.05% in Taxus Express vs. 4.05% in Taxus Liberte, p = 1.000). In addition, the binary restenosis rate did not differ (2.25% in Taxus Express vs. 1.80% in Taxus Liberte, p = 0.6848). Conclusions In real-world experience with the two Taxus stent designs, both stents showed similarly good clinical and angiographic outcomes at 1 year. A long-term follow-up study is warranted.

Evaluation of the impact of statin therapy on the obesity paradox in patients with acute myocardial infarction: A propensity score matching analysis from the Korea Acute Myocardial Infarction Registry.

Abstract The phenomenon of obesity paradox after acute myocardial infarction (AMI) has been reported under strong recommendation of statin therapy. However, the impact of statin therapy on this paradox has not been investigated. This study investigated the impact of statin therapy on 1-year mortality according to obesity after AMI. A total of 2745 AMI patients were included from the Korea Acute Myocardial Infarction Registry after 1:4 propensity score matching analysis (n = 549 for nonstatin group and n = 2196 for statin group). Primary and secondary outcomes were all-cause and cardiac death, respectively. During 1-year follow-up, the incidence of all-cause (8.4% vs 3.7%) and cardiac (6.2% vs 2.3%) death was higher in nonstatin group than in statin (P < .001, respectively). In nonstatin group, the incidence of all-cause (7.2% vs 9.0%) and cardiac (5.5% vs 6.5%) death did not differ significantly between obese and nonobese patients. However, in statin group, obese patients had lower 1-year rate of all-cause (1.7% vs 4.8%) and cardiac (1.2% vs 2.9%) death (P < .05, respectively), and lower cumulative rates by Kaplan–Meier analysis of all-cause and cardiac death compared with nonobese patients (log-rank P < .05, respectively). The overall risk of all-cause death was significantly lower in obese than in nonobese patients only in statin group (hazard ratio: 0.35; P = .001). After adjusting for confounding factors, obesity was independently associated with decreased risk of all-cause death in statin group. In conclusion, the greater benefit of statin therapy for survival in obese patients is further confirmation of the obesity paradox after AMI.

TCT-76 Temporal change of in-stent thrombus immediately after percutaneous coronary intervention within 5 minutes using optical coherence tomography.

nos: 77 80 TCT-77 Association of Residual Mitral Regurgitation after Transcatheter Aortic Valve Replacement with Readmission for Acute Heart Failure: An Analysis from PARTNER 1 John Petersen, Eugene Blackstone, Jeevanantham Rajeswaran, David Cohen, Pamela Douglas, Rebecca Hahn, Susheel Kodali,

Clinical Outcomes in Patients with Deferred Coronary Lesions according to Disease Severity Assessed by Fractional Flow Reserve

Data on the clinical outcomes in deferred coronary lesions according to functional severity have been limited. This study evaluated the clinical outcomes of deferred lesions according to fractional flow reserve (FFR) grade using Korean FFR registry data. Among 1,294 patients and 1,628 lesions in Korean FFR registry, 665 patients with 781 deferred lesions were included in this study. All participants were consecutively categorized into 4 groups according to FFR; group 1: ≥ 0.96 (n = 56), group 2: 0.86–0.95 (n = 330), group 3: 0.81–0.85 (n = 170), and group 4: ≤ 0.80 (n = 99). Primary endpoint was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction, and target vessel revascularization. The median follow-up period was 2.1 years. During follow-up, the incidence of MACE in groups 1–4 was 1.8%, 7.6%, 8.8%, and 13.1%, respectively. Compared to group 1, the cumulative rate by Kaplan-Meier analysis of MACE was not different for groups 2 and 3. However, group 4 had higher cumulative rate of MACE compared to group 1 (log-rank P = 0.013). In the multivariate Cox hazard models, only FFR (hazard ratio [HR], 0.95; P = 0.005) was independently associated with MACE among all participants. In contrast, previous history of percutaneous coronary intervention (HR, 2.37; P = 0.023) and diagnosis of acute coronary syndrome (ACS) (HR, 2.35; P = 0.015), but not FFR, were independent predictors for MACE in subjects with non-ischemic (FFR ≥ 0.81) deferred coronary lesions. Compared to subjects with ischemic deferred lesions, clinical outcomes in subjects with non-ischemic deferred lesions according to functional severity are favorable. However, longer-term follow-up may be necessary.