Masahiko Goya

Very Long-Term (15 to 20 Years) Clinical and Angiographic Outcome After Coronary Bare Metal Stent Implantation

Background—We previously reported that the long-term luminal response after coronary bare metal stenting is triphasic, with an early restenosis phase spanning the 6 months after the index procedure, an intermediate-term regression phase from 6 months to 3 years, and a late renarrowing phase beyond 4 years. However, the clinical significance of late luminal renarrowing remains unknown. Methods and Results—Angiographic and clinical follow-up of the same cohort of 405 patients with successful Palmaz-Schatz stent placement was extended beyond 15 years. Clinical follow-up was completed in 98% of patients at 5 years and in 81% at 15 years. The incidence of death and cardiac death at 15 years was 45.4% and 20.6%, respectively. Paired long-term (4 to 10 years) and very long-term (>10 years) angiographic studies without intercurrent target lesion revascularization were performed in 55 lesions, and minimal luminal diameter further decreased from 1.88±0.50 mm to 1.60±0.73 mm (P=0.002). Late target lesion revascularization after initial stabilization of the stented segments occurred rarely within 4 years. Beyond 4 years, however, the incidence of late target lesion revascularization increased steadily from 3.3% at 4 years to 24.7% at 15 years. The incidence of definite very late stent thrombosis was low (1.5% at 15 years). Conclusions—Luminal renarrowing of the stented segment beyond 4 years was a progressive process extending beyond 10 years. The angiographic observation of late in-stent restenosis was clinically relevant because a corresponding progressive increase in the incidence of late target lesion revascularization was observed beyond 4 years and up to 15 to 20 years after bare metal stent implantation.

Incidence and Clinical Impact of Stent Fracture After Everolimus-Eluting Stent Implantation

Background—Stent fracture (SF) after drug-eluting stent implantation has recently become an important concern because of its potential association with in-stent restenosis and stent thrombosis. However, the incidence and clinical impact of SF after everolimus-eluting stent implantation remain unclear. Methods and Results—A total of 1035 patients with 1339 lesions undergoing everolimus-eluting stent implantation and follow-up angiography 6 to 9 months after index procedure were analyzed. SF was defined as complete or partial separation of the stent, as assessed by plain fluoroscopy or intravascular ultrasound during follow-up. We assessed the rates of SF and major adverse cardiac events, defined as cardiac death, myocardial infarction, stent thrombosis, and clinically driven target lesion revascularization within 9 months. SF was observed in 39 of 1339 lesions (2.9%) and in 39 of 1035 patients (3.8%). Ostial stent location and lesions with hinge motion, tortuosity, or calcification were independent predictors of SF. The rate of myocardial infarction and target lesion revascularization were significantly higher in the SF group than in the non-SF group (5.1% versus 0.4%; P=0.018 and 25.6% versus 2.0%; P<0.001, respectively). Stent thrombosis was more frequently observed in the SF group than in the non-SF group (5.1% versus 0.4%; P=0.018). Major adverse cardiac events within 9 months were significantly higher in the SF group than in the non-SF group (25.6% versus 2.3%; P<0.001). Conclusions—SF after everolimus-eluting stent implantation occurs in 2.9% of lesions and is associated with higher rate of major adverse cardiac events, driven by higher target lesion revascularization and stent thrombosis.

Impact of multiple and long sirolimus-eluting stent implantation on 3-year clinical outcomes in the j-Cypher Registry.

OBJECTIVESnOur aim was to study the relationships between total stent length (TSL) and long-term clinical outcomes after sirolimus-eluting stent (SES) implantation.nnnBACKGROUNDnSES compared with bare-metal stent use for long lesion treatment is associated with reduced restenosis rates.nnnMETHODSnThree-year follow-up data were available for 10,773 patients (14,651 lesions) that had been treated with only SES (Cypher, Cordis Corp., Warren, New Jersey) in the j-Cypher registry. Patients and lesions were divided into quartile groups: TSL per patient (Q1: 8 to 23 mm, Q2: 24 to 36 mm, Q3: 37 to 54 mm, Q4: 55 to 293 mm), and TSL per lesion (QA: 8 to 18 mm, QB: 19 to 23 mm, QC: 24 to 33 mm, QD: 34 to 150 mm).nnnRESULTSnIn per-lesion data, longer TSL increased target lesion revascularization (TLR) rates but did not increase stent thrombosis rates (p = 0.2324). In per-patient data, the incidences of TLR remarkably increased with increasing TSL. Incidence of composite of death and myocardial infarction also increased with increasing TSL; however, after adjustment for baseline differences, there was no statistical significance. Definite stent thrombosis rate in group Q4 was significantly higher than in other groups, both unadjusted (hazard ratio: 1.770, p = 0.0081) and adjusted (hazard ratio: 1.727, p = 0.0122) for baseline differences.nnnCONCLUSIONSnTSL per lesion and patient had significantly impacts on TLR rates. Longer TSL per patient was associated with increased incidence of stent thrombosis through 3 years.

Importance of nonpulmonary vein foci in catheter ablation for paroxysmal atrial fibrillation.

BACKGROUNDnPulmonary vein (PV) isolation is an established treatment strategy for paroxysmal atrial fibrillation (PAF). However, the recurrence rate of PAF is 8% to 37%, despite repeated procedures, and the catheter ablation strategy for PAF with non-PV foci is unclear.nnnOBJECTIVEnThe purpose of this study was to assess the PAF ablation strategy for non-PV foci.nnnMETHODSnThe study included 304 consecutive patients undergoing PAF ablation (209 males, age 63.0 ± 10.4 years) divided into 3 groups: group 1 (245 patients) with no inducible non-PV foci; group 2 (34 patients) with atrial fibrillation (AF) originating from non-PV foci and all the foci successfully ablated; and group 3 (25 patients) with AF originating from non-PV triggers, but without all foci being ablated or with persistently inducible AF.nnnRESULTSnMean follow-up period was 26.9 ± 11.8 months, and AF recurrence rates since the last procedure were 9.8%, 8.8%, and 68.0% in groups 1, 2, and 3, respectively. There was no statistically significant difference in recurrence rate between groups 1 and 2 (P = .89); however, there were statistically significant differences between groups 3 and 1 (P <.0001) and groups 3 and 2 (P <.0001). The patients in group 2 had an AF-free outcome to equivalent to those who had PV foci in group 1 (P = .83).nnnCONCLUSIONnSuccess rates can be improved for PAF ablation if non-PV foci are detected and eliminated.

Safety of early exercise training after elective coronary stenting in patients with stable coronary artery disease

Background Early exercise after coronary stenting is considered to have a risk of stent thrombosis (ST). We investigate the safety of submaximal exercise training based on the Borg scale from the next day after coronary stenting. Methods We enrolled 2351 patients who underwent successful coronary stenting. They were divided into early exercise training (EET) group (n = 865) and control group (n = 1486). Submaximal exercise training based on the Borg scale was performed on the next day after coronary stenting and same degree exercise was continued more than two times a week after discharge. Primary endpoint was the incidence of ST. Secondary endpoint was major adverse cardiovascular event (death, myocardial infarction, and stroke), incidence of postoperative complications, and rate of exercise continuation. Results Exercise training was performed in 800 (92.5%) patients. No serious complication developed during and after exercise. Clinical follow-up data were obtained in 99% patients. At 30 days, there was no significant difference in the incidence of ST (0.58 vs. 0.47%, P = 0.73), major adverse cardiovascular event (1.4 vs. 1.3%, P = 0.72), and complication rate (6.9 vs. 7.3%, P =0.72). No exercise-related ST was found in either group. The rate of exercise continuation was significantly higher in the EET group (49.3 vs. 28.3%, P >0.001). Conclusion EET up to submaximal level based on the Borg scale from the day after elective coronary stenting does not increase the incidence of ST or postoperative complications.

Complex anatomy surrounding the left atrial posterior wall: analysis with 3D computed tomography

Few studies have explored the topographic anatomy of the esophagus, posterior wall of the left atrium (LA), or fat pads using multidetector computed tomography (MDCT) to prevent the risk of esophageal injury during atrial fibrillation (AF) ablation. MDCT was performed in 110 consecutive patients with paroxysmal or persistent AF before the ablation procedure to understand the anatomic relationship of the esophagus. Two major types of esophagus routes were demonstrated. Leftward (type A) and rightward (type B) routes were found in 90 and 10% of the patients, respectively. A type A route had a larger mean size of the LA than type B. The fat pad was identifiable at the level of the inferior pulmonary vein in 91% of the patients without any predominance of either type. The thickness of the fat pad was thinner in the patients with a dilated LA (>42xa0mm) than in those with a normal LA size (≤42xa0mm) (pxa0=xa00.01). The results demonstrated that the majority of cases had a leftward route of the esophagus. There was a close association between the LA dilatation and fat pad thinning. With a dilated LA, the esophagus may become easily susceptible to direct thermal injury during AF ablation. Visualization of the anatomic relationship may contribute to the prevention of the potential risk of an esophageal injury.

No severe pulmonary vein stenosis after extensive encircling pulmonary vein isolation: 12-month follow-up with 3D computed tomography.

Few studies have explored the utility of local electrogram-guided extensive encircling pulmonary vein isolation (EEPVI) by analyzing the pulmonary vein (PV) anatomy and occurrence of stenosis using multidetector computed tomography (MDCT). One hundred seventy-six paroxysmal atrial fibrillation (AF) patients underwent EEPVI with a double lasso technique. MDCT was performed in all patients before and at 3, 6 and 12xa0months after the ablation procedures to screen for PV stenosis. PV stenosis was defined as a >30% reduction in its diameter. A total of 700 PVs were analyzed. PV stenosis was observed in 15 of 700 PVs (2.1%). All stenoses were mild (mean 34.5xa0±xa03.3%). They were all asymptomatic, and none required treatment. After 12 months of follow-up, the PV narrowing regressed significantly compared with that at 3xa0months in the patients with PV stenosis (34.5xa0±xa03 to 30.4xa0±xa05%, Pxa0<xa00.05). The remaining PVs exhibited a stable anatomy, and there was no significant progression of the PV narrowing. The results of this study demonstrated that detectable PV stenosis occurred in 2.1% of the PVs, and all stenoses were mild. Moreover, a significant regression of the PV narrowing was observed after 12-months of follow-up. This indicates that the local electrocardiogram-guided EEPVI was relatively safe regarding severe PV stenosis.

Long-term outcomes of catheter ablation of ventricular tachycardia in patients with structural heart disease

Catheter ablation of ventricular tachycardia (VT) is feasible. However, the long‐term outcomes for different underlying diseases have not been well defined.

Impact of Catheter Ablation for Paroxysmal Atrial Fibrillation in Patients With Sick Sinus Syndrome – Important Role of Non-Pulmonary Vein Foci –

BACKGROUNDnThe clinical efficacy of catheter ablation (CA) for paroxysmal atrial fibrillation (PAF) in patients with sick sinus syndrome (SSS) and the mechanism and predictors of recurrence are not yet completely elucidated.nnnMETHODSANDRESULTSnOf 963 consecutive patients who underwent PAF ablation during the study period, a total of 108 patients with SSS (SSS group) and 108 matched controls without SSS (non-SSS group) were followed up. During the follow-up period (mean, 32.8±17.5 months), the SSS group had significantly higher AF recurrence rate since the last procedure than the non-SSS group (26.9% vs. 12.0%; P=0.02). The SSS group had significantly higher prevalence of non-pulmonary vein (non-PV) foci than the non-SSS group (25.9% vs. 13.9%; P=0.027). On multivariate analysis congestive heart failure (HR, 13.7; 95% CI: 1.57-119; P=0.02) and non-PV foci (HR, 5.75; 95% CI: 1.69-19.6; P=0.005) were independent predictors of recurrence following CA in the SSS group. In the SSS group, 88 patients had bradycardia-tachycardia syndrome without prior permanent pacemaker implantation. Of these, 6 required pacemaker implantation because of AF and sinus pause recurrence.nnnCONCLUSIONSnPatients with SSS are at higher risk of AF recurrence after CA. Non-PV foci are associated with AF recurrence following PAF with SSS.

Implantable cardioverter defibrillator infection due to Mycobacterium mageritense

Rapidly growing non-tuberculous mycobacteria (RGM) are usually detected in blood cultures after 4-5 days of incubation, so it is important to differentiate RGM from contamination of commensal organisms on human skin. We report an unusual case of Mycobacterium mageritense bacteremia and infection of an implantable cardioverter defibrillator originally misidentified as Corynebacterium spp. or Nocardia spp. in gram-stained smears. 16S rRNA gene sequencing had utility in the definitive identification of isolates. We should be aware that RGM infection may exist in repeated implantable device infections.