Masanori Kawaguchi

Afterload Mismatch After MitraClip Insertion for Functional Mitral Regurgitation

Afterload mismatch, defined as acute impairment of left ventricular function after mitral surgery, is a major issue in patients with low ejection fraction and functional mitral regurgitation (FMR). Safety and efficacy of MitraClip therapy have been assessed in randomized trials, but limited data on its acute hemodynamic effects are available. This study aimed to investigate the incidence and prognostic role of afterload mismatch in patients affected by FMR treated with MitraClip therapy. We retrospectively analyzed patients affected by FMR and submitted to MitraClip therapy from October 2008 to December 2012. Patients were assigned to 2 groups according to the occurrence of the afterload mismatch: patients with afterload mismatch (AM+) and without afterload mismatch (AM-). Of 73 patients, 19 (26%) experienced afterload mismatch in the early postoperative period. Among preoperative variables, end-diastolic diameter (71 ± 8 vs 67 ± 7 mm, p = 0.02) and end-systolic diameter (57 ± 9 vs 53 ± 7 mm, p = 0.04) were both significantly larger in AM+ group. An increased incidence of right ventricular dysfunction (68% vs 31%, p = 0.049) and pulmonary hypertension (49 ± 10 vs 40 ± 10 mm Hg, p = 0.0009) was found in AM+ group. Before hospital discharge, left ventricular ejection fraction (LVEF) became similar in both groups (31 ± 9% vs 33 ± 11%, p = 0.65). Long-term survival was comparable between the 2 groups (p = 0.44). A low LVEF in the early postoperative period (LVEF <17%) was significantly associated with higher mortality rate in long-term follow-up (p = 0.048). In conclusion, reduction of mitral regurgitation with MitraClip can cause afterload mismatch; however, this phenomenon is transient, without long-term prognostic implications.

The Role of Drug-Eluting Balloons Alone or in Combination With Drug-Eluting Stents in the Treatment of De Novo Diffuse Coronary Disease

OBJECTIVESnThis study sought to investigate the role of drug-eluting balloons (DEB) alone or in combination with drug-eluting stents (DES) in the treatment of diffuse de novo coronary artery disease (CAD) (>25 mm).nnnBACKGROUNDnThe use of DEB in diffuse CAD, either alone or in combination with DES, offers an alternative to stenting alone. Data regarding DEB in this context are limited.nnnMETHODSnWe retrospectively evaluated all patients treated with DEB for diffuse CAD between June 2009 and October 2012. Endpoints analyzed were major adverse cardiac events, defined as all-cause death, myocardial infarction, and target vessel revascularization (TVR), as well as TVR and target lesion revascularization separately. Results were compared with those obtained from a cohort of patients with similar characteristics treated with DES alone.nnnRESULTSnA total of 69 patients (93 lesions) were treated with DEB ± DES, and 93 patients with DES alone (93 lesions). A high proportion of patients were diabetic (46.4% vs. 44.1%, pxa0= 0.77). Of the DEB-treated lesions, 56.0% were treated with DEB alone, 7.4% with DEB and DES as bail out, and 36.6% with DES and DEB as part of a hybrid approach for very long disease. Outcome rates with DEB ± DES were comparable to those with DES alone at 2-year follow-up (major adverse cardiac eventsxa0= 20.8% vs. 22.7%, pxa0= 0.74; TVRxa0= 14.8% vs. 11.5%, pxa0= 0.44; target lesion revascularizationxa0= 9.6% vs. 9.3%, pxa0= 0.84).nnnCONCLUSIONSnDEB may have a role in the treatment of diffuse de novo CAD, either alone in smaller vessels or in combination with DES in very long disease.

Comparison of First- and Second-Generation Drug-Eluting Stents in Saphenous Vein Grafts Used as Aorto-Coronary Conduits

Saphenous vein grafts (SVGs) are prone to an aggressive atherosclerotic process, and the efficacy of drug-eluting stents (DES) in treating this is still debated. In recent years, second-generation DES have been increasingly used in SVG intervention. The main objective of this study was to compare midterm clinical outcomes between first- and second-generation DES in SVGs because data regarding the use of second-generation DES in SVG are lacking. Patients treated with first-generation DES (127 patients with 143 lesions) and those treated with second-generation DES (84 patients with 100 lesions) were included in the study. Major adverse cardiac events, defined as the composite of all-cause death, myocardial infarction, and target vessel revascularization, as well as target vessel revascularization and target lesion revascularization separately, were evaluated at 30-day, 12-month, and 18-month follow-up. Baseline characteristics were similar between the 2 groups. Older grafts were treated with second-generation DES (11.6 ± 5.3 vs 14.3 ± 6.0 years, p = 0.001). Stent length was longer in the first-generation group (34.1 ± 25.1 vs 30.5 ± 19.4 mm, p = 0.006), and maximum balloon diameter was smaller in the second-generation group (3.42 ± 0.42 vs 3.30 ± 0.41 mm, p = 0.003). Embolic protection device use was higher in the second-generation DES group (55.2% vs 72.0%, p = 0.012). At 18-month follow-up, rates of major adverse cardiac events, target vessel revascularization, and target lesion revascularization for the first- and second-generation groups were 24.4% versus 20.2% (p = 0.479), 18.1% versus 14.2% (p = 0.465), and 15.0% versus 10.7% (p = 0.373), respectively. In conclusion, second-generation DES are at least comparable with first-generation DES with regard to clinical outcomes at midterm follow-up.

The long-term clinical outcome of T-stenting and small protrusion technique for coronary bifurcation lesions.

OBJECTIVESnThis study sought to report long-term clinical outcomes in patients treated with the provisional T-stenting and small protrusion (TAP) technique.nnnBACKGROUNDnSeveral strategies have been proposed for treating bifurcation lesions, each with its own merits and technical challenges. The TAP technique is a relatively new strategy that is technically less challenging, ensures complete coverage of the side-branch ostium, and minimizes stent overlap. Although there is reasonable amount of data for other bifurcation strategies, the long-term clinical outcomes for TAP technique are limited.nnnMETHODSnWe retrospectively evaluated all patients who underwent TAP technique with drug-eluting stents between July 2005 and January 2012. The measured endpoints at follow-up were major adverse cardiac events defined as composite of cardiac death, myocardial infarction, and target vessel revascularization.nnnRESULTSnA total of 95 patients (81.1% men) with a mean age of 64.8 years underwent TAP stenting. Procedural success was achieved in 100% of cases. True bifurcation was observed in 75 (78.9%) patients. First-generation drug-eluting stents were used in 55.8% of patients. The outcome rates at 3-year follow-up of major adverse cardiac events, cardiac death/follow-up myocardial infarction, target vessel revascularization, and target lesion revascularization were 12.9%, 3.1%, 9.7%, and 5.1%, respectively. There were no cases of follow-up myocardial infarction or stent thrombosis (definite and probable).nnnCONCLUSIONSnThese results demonstrate that TAP technique is associated with acceptable clinical outcomes with no episodes of definite and probable stent thrombosis. Further studies should compare TAP technique with other 2-stent strategies.

First- versus second-generation drug-eluting stents for the treatment of coronary bifurcations☆

BACKGROUNDnRandomized controlled trials have demonstrated that second-generation drug-eluting stents (DESs) for the treatment of obstructive coronary artery disease are associated with comparable, if not improved, clinical outcomes as compared to those of their first-generation counterparts. The aim of this study was to compare the long-term clinical outcomes associated with first- versus second-generation DESs for the treatment of coronary bifurcation lesions.nnnMETHODS AND MATERIALSnThis was a retrospective study of consecutive de novo bifurcation lesions, excluding those at the left main, treated with either second-generation DES (everolimus-eluting or resolute zotarolimus-eluting stents) between October 2006 and October 2011 (199 bifurcation lesions in 192 patients) or first-generation DES (sirolimus-eluting or paclitaxel-eluting stents) between April 2002 and December 2005 (289 bifurcation lesions in 273 patients).nnnRESULTSnSecond-generation DES use in this setting was associated with less major adverse cardiac events (MACE) (23.1% vs. 14.4%, p=0.02) as well as lower target vessel revascularization (TVR) rates (15.5% vs. 8.3%, p=0.01) at 2-year follow-up. Target lesion revascularization, both per patient (12.6% vs. 7.4%, p=0.02) and per bifurcation (11.8% vs. 7.0%, p=0.03), was also improved with second-generation DES over the same follow-up period. Propensity-score adjusted analysis suggested that second-generation DES was associated with a lower incidence of MACE (HR, 0.53; 95% CI, 0.33-0.85; p=0.01) and TVR (HR, 0.44; 95% CI, 0.24-0.83; p=0.01).nnnCONCLUSIONSnOur results suggest that the use of second-generation DES for the treatment of bifurcation lesions is associated with better clinical outcomes as compared to first-generation DES, largely due to a lower need for repeat revascularization.

The role of intravascular ultrasound and quantitative angiography in the functional assessment of intermediate coronary lesions: Correlation with fractional flow reserve

BACKGROUNDnThe correlation between fractional flow reserve (FFR) and intravascular ultrasound (IVUS) metrics including minimal lumen area (MLA), plaque burden and morphology remain a matter of debate.nnnMETHODSnBetween June 2008 and May 2013, 132 intermediate stenoses in 109 patients were assessed by FFR, IVUS and quantitative angiography. Receiver-operating characteristic (ROC) curve analyses were used to identify MLA/lesion length/plaque burden cut-off values predictive of FFR <0.80.nnnRESULTSnFFR <0.80 was observed in 39 lesions. In the entire cohort, MLA value <2.70mm(2) had 79.5% sensitivity, 76.3% specificity, 0.822 area under curve (AUC), 58.5% positive predictive value, 89.9% negative predictive value and 77.3% accuracy in predicting a positive FFR. In lesions with reference diameter vessel (RVD) ≥3.0mm, the MLA cut-off value was 2.84mm(2) (sensitivity 72.2%, specificity 83.0%, AUC 0.842) whereas in lesions with RVD <3.0mm, 2.59mm(2) (sensitivity 90.5%, specificity 69.6%, AUC 0.823). A moderate correlation was observed between MLA and FFR (r=0.429, p<0.001). The cut-off lesion length predictive of FFR <0.80 was 11.0mm with a weak correlation between the two (r=-0.348, p<0.001). Plaque morphology did not significantly affect FFR (p=0.485). On multivariable analysis, MLA (OR: 0.15; 95% CI: 0.05-0.40; p<0.001) and plaque burden (OR: 1.11; 95% CI: 1.04-1.20; p<0.003) were independent predictors of FFR <0.80.nnnCONCLUSIONnA modest, yet significant correlation was observed between MLA and FFR. The high negative predictive value of large MLAs (using afore-mentioned cut-off values) may provide some degree of confidence that the lesion in question is not functionally significant.

Comparison of abluminal biodegradable polymer biolimus-eluting stents and durable polymer everolimus-eluting stents in the treatment of coronary bifurcations.

To compare biodegradable polymer biolimus‐eluting (BES) with abluminal drug elution and durable polymer everolimus‐eluting (EES) stents in the treatment of bifurcation lesions.

TCT-80 Incidence of Periprocedual Myocardial Infarction in Chronic Total Occlusion PCI and Impact on Clinical Outcome

Periprocedual myocardial infarction (PMI) in percutaneous coronary intervention was reported to associate with increased risk of death in long-term follow-up. However, there is a paucity of information about PMI in patients undergoing percutaneous coronary intervention for chronic total occlusion (