Masayasu Arihara

Prognostic impact of systolic blood pressure at admission on in-hospital outcome after primary percutaneous coronary intervention for acute myocardial infarction

BACKGROUND Data regarding the relationship between systolic blood pressure (SBP) at admission and in-hospital outcome in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) are still lacking in Japan. METHODS AND RESULTS A total of 1475 primary PCI-treated AMI patients were classified into quintiles based on admission SBP (<105 mmHg, n=300; 105-125 mmHg, n=294; 126-140 mmHg, n=306; 141-158 mmHg, n=286; and ≥159 mmHg n=289). The patients with SBP<105 mmHg tended to have higher age, previous myocardial infarction, chronic kidney disease (CKD), Killip class≥3 at admission, right coronary artery, left main trunk (LMT), or multivessels as culprit lesions, larger number of diseased vessels, lower Thrombolysis In Myocardial Infarction (TIMI) grade in the infarct-related artery before primary PCI, and higher value of peak creatine phosphokinase concentration. Patients with SBP<105 mmHg had a significantly higher mortality, while mortality was not significantly different among the other quintiles: 24.3% (<105 mmHg), 4.8% (105-125 mmHg), 4.9% (126-140 mmHg), 2.8% (141-158 mmHg), and 5.2% (≥159 mmHg) (p<0.001). On multivariate analysis, Killip class≥3 at admission, LMT or multivessels as culprit lesions, admission SBP<105 mmHg, CKD, and age were the independent positive predictors of in-hospital mortality, whereas admission SBP 141-158 mmHg and TIMI 3 flow after PCI were the negative ones, but admission SBP 105-125 mmHg, admission SBP 126-140 mmHg, and admission SBP≥159 mmHg were not. CONCLUSIONS These results suggest that admission SBP 141-158 mmHg might be correlated with better in-hospital prognosis, whereas admission SBP<105 mmHg was associated with in-hospital death in Japanese AMI patients undergoing primary PCI.

Prognostic impact of pulse pressure at admission on in-hospital outcome after primary percutaneous coronary intervention for acute myocardial infarction

Data regarding relationship between pulse pressure (PP) at admission and in-hospital outcome in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) are still lacking. A total of 1413 primary PCI-treated AMI patients were classified into quintiles based on admission PP (<40, n = 280; 40–48, n = 276; 49–57, n = 288; 58–70, n = 288; and ≥71 mmHg, n = 281). The patients with PP < 40 mmHg tended to have higher prevalence of male, smoking, and Killip class ≥3 at admission; right coronary artery, left main trunk (LMT), or multivessels as culprit lesions; larger number of diseased vessels; lower Thrombolysis in Myocardial Infarction (TIMI) grade in the infarct-related artery before/after primary PCI; and higher value of peak creatine phosphokinase concentration. Patients with PP < 40 mmHg had highest mortality, while patients with PP 49–57 mmHg had the lowest: 11.8 % (<40), 7.2 % (40–48), 2.8 % (49–57), 5.9 % (58–70), and 6.0 % (≥71 mmHg). On multivariate analysis, Killip class ≥3 at admission, LMT or multivessels as culprit lesions, chronic kidney disease, and age were the independent positive predictors of the in-hospital mortality, whereas admission PP 49–57 mmHg, hypercholesterolemia, and TIMI 3 flow before/after PCI were the negative ones, but admission PP < 40 mmHg was not. These results suggest that admission PP 49–57 mmHg might be correlated with better in-hospital prognosis in Japanese AMI patients undergoing primary PCI.

Primary percutaneous coronary intervention and intravascular ultrasound imaging for coronary thrombosis after cisplatin-based chemotherapy

Although cisplatin is indispensable for the chemotherapy treatment of many malignancies, cisplatin-associated thrombosis is attracting increasing attention. However, experience of primary percutaneous coronary intervention (PCI) and intravascular ultrasound imaging (IVUS) for coronary thrombosis, possibly due to cisplatin-based chemotherapy, has been limited. Case 1 with postoperative gastric cancer developed acute myocardial infarction (AMI) on the sixth day of the second chemotherapy course with conventional doses of cisplatin and tegafur gimeracil oteracil potassium. Emergency coronary angiography (CAG) showed a filling defect in the proximal left anterior descending coronary artery (LAD) concomitant with no reflow in the distal LAD. Case 2 with advanced lung cancer and brain metastasis suffered AMI on the fifth day of the first chemotherapy course with conventional doses of cisplatin and gemcitabine. Emergency CAG delineated a total occlusion in the proximal right coronary artery. In both cases, thrombectomy using aspiration catheter alone obtained optimal angiographic results and subsequent IVUS revealed no definite atherosclerotic plaque, while slow flow still remained even after selective intra-coronary infusion of vasodilator in the case 1. These cases suggest that primary PCI using thrombus-aspiration catheter might be safe and effective for coronary thrombosis due to cisplatin-based chemotherapy.

Systolic blood pressure at admission, clinical manifestations, and in-hospital outcomes in patients with acute myocardial infarction

BACKGROUND Several clinical studies have demonstrated an inverse relationship between systolic blood pressure (SBP) at admission and in-hospital mortality in patients hospitalized for acute myocardial infarction (AMI). However, data on the relation between admission SBP and in-hospital prognosis in AMI patients are still lacking in Japan. METHODS AND RESULTS A total of 1211 AMI patients were classified into quintiles based on SBP at hospital admission (<106 mmHg, n = 241; 106-125 mmHg, n = 239; 126-140 mmHg, n = 244; 141-159 mmHg, n = 238; and ≥ 160 mmHg, n = 249). The patients with SBP < 106 mmHg tended to have higher age, Killip class ≥ 3 at admission, right coronary artery, left main trunk, or multivessels as culprit lesions, larger number of diseased vessels, lower Thrombolysis In Myocardial Infarction grade in the infarct-related artery before primary percutaneous coronary intervention (PCI), and higher value of peak creatine phosphokinase concentration. Patients with SBP <106 mmHg had a significantly higher mortality, while mortality was not significantly different among the other quintiles: 25.7% (<106 mmHg), 5.4% (106-125 mmHg), 5.7% (126-140 mmHg), 2.5% (141-159 mmHg), and 5.6% (≥ 160 mmHg) (p<0.001). On multivariate analysis, Killip class ≥ 3 at admission, admission SBP <106 mmHg, and age were the independent positive predictors of in-hospital mortality, whereas admission SBP 141-159 mmHg and primary PCI were the negative ones, but admission SBP 106-125 mmHg, admission SBP 126-140 mmHg, and admission SBP ≥ 160 mmHg were not. CONCLUSIONS These results suggest that admission SBP 141-159 mmHg might be correlated with better in-hospital prognosis, whereas admission SBP <106 mmHg was associated with in-hospital death in Japanese patients hospitalized for AMI.

Predictors of nonoptimal coronary flow after primary percutaneous coronary intervention with stent implantation for acute myocardial infarction.

BACKGROUND Predictors of suboptimal coronary flow in the infarct-related artery (IRA) after stent-based primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) have not been fully investigated. METHODS AND RESULTS Using the AMI-Kyoto Multi-Center Risk Study database, we retrospectively compared clinical manifestations and in-hospital prognosis between AMI patients undergoing stent-based primary PCI with final Thrombolysis In Myocardial Infarction (TIMI) grade < or = 2 in the IRA (nonoptimal group, n=69) and those with final TIMI grade 3 (optimal group, n=1200). The nonoptimal group had higher prevalence of Killip class > or = 3 at admission, higher frequency of mechanical support devices during procedures, larger value of maximal creatine phosphokinase, and a significantly higher in-hospital mortality rate (27.5% for nonoptimal vs. 9.0% for optimal, P<0.001), compared with the optimal group. On multivariate analysis, Killip class > or = 3 at admission was the independent predictor of the final nonoptimal flow (odds ratio 2.33, 95% confidence intervals 1.27-4.26 P=0.006), but TIMI 3 flow before primary PCI and elapsed time (symptom onset-to-admission time)<24h were not. CONCLUSIONS Killip class > or = 3 at admission is an independent predictor of the final nonoptimal flow in AMI patients undergoing primary PCI with stent implantation.

Influence of previous myocardial infarction site on in-hospital outcome after primary percutaneous coronary intervention for repeat myocardial infarction

BACKGROUND Recurrent acute myocardial infarction (AMI) is a disastrous condition with high in-hospital morbidity and mortality. However, the relation between location of previous myocardial infarction (MI) and in-hospital outcome in repeat-AMI patients undergoing primary percutaneous coronary intervention (PCI) remains unclear. METHODS AND RESULTS Using the AMI-Kyoto Multi-Center Risk Study database, clinical background, angiographic findings, results of primary PCI, and in-hospital prognosis were retrospectively compared between primary PCI-treated AMI patients with previous anterior MI (anterior group, n=151) and those with previous non-anterior MI (non-anterior group, n=157). Clinical backgrounds, angiographic findings, results of primary PCI, and in-hospital outcome did not differ significantly between the two groups. On multivariate analysis, Killip class > or =3 at admission, number of diseased vessels > or =2 or diseased left main trunk at initial coronary angiography, and age were the independent predictors of in-hospital mortality in the recurrent-AMI patients, but not the anterior location of previous MI. CONCLUSIONS These results suggest that among recurrent-AMI patients undergoing primary PCI, in-hospital prognosis mostly depends on the severity of acute heart failure at the onset and the residual myocardial ischemia rather than previous MI sites.

Usefulness and Limitation of Transthoracic Echocardiography in the Diagnosis of Large Coronary Artery Fistula

(Echocardiography 2010;27:1291‐1295)

TCT-677 Efficacy and safety of Refined Balloon Pulmonary Angioplasty for Inoperable Patients with Chronic Thromboembolic Pulmonary Hypertension: A Multicenter Study

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is known as a serious disease with poor prognosis. Pulmonary endarterectomy (PEA) is a treatment option, however, suitable indication is restricted within the proximal lesions and few hospitals routinely perform PEA. In the present situation, we

Zilver stent implantation through 4.5 French guiding sheath in iliac vein compression syndrome complicated with acute deep vein thrombosis

Background Downsized devices for less invasive endovascular treatment are gaining more attention. Case report An 82-year-old woman was admitted to our hospital with pain and swelling in left lower extremity. Ultrasonography showed much thrombus at the left common femoral, superficial femoral, and popliteal veins, confirming a diagnosis of acute deep vein thrombosis (DVT). For lack of therapeutic effect of systemically administered anticoagulative and thrombolytic agents, we performed catheter intervention against DVT. After insertion of a 4.5 French guiding sheath (Parent Plus, Medikit, Tokyo, Japan) into left popliteal vein, venography showed a total occlusion of the common femoral vein. Even after thrombectomy by aspiration catheter, balloon dilation, and catheter-induced thrombolysis, severe stenosis at the proximal site of the left common iliac vein remained. After confirming the presence of iliac vein compression syndrome (IVCS) by intravascular ultrasound imaging, we successfully implanted a Zilver® stent (Cook Inc., Bloomington, IN, USA) in the common-external iliac vein through a 4.5 French guiding sheath, leading to an optimal venous-return flow. Conclusions The present case suggests that in addition to thrombus aspiration, Zilver stent implantation using a 4.5 French guiding sheath has the potential to serve as a minimally invasive strategy for the treatment of IVCS complicated with iliofemoral DVT.<Learning objective: During the interventional treatment of deep vein thrombosis, we should pay attention to procedure-related venous valve dysfunction in addition to bleeding complications and pulmonary embolism. From the point of view, downsized catheter devices might have some advantage with lesser prevalence of those complications.>.

Usefulness of multidetector computed tomography for diagnosis and surgical treatment of large coronary artery fistula

Background Coronary angiography (CAG) has been the mainstay of diagnostic image analysis for coronary artery fistula (CAF). However, it is difficult to fully delineate this complex vessel structure including coronary trees, particularly in cases with large CAF, by this method. Case reports In the present 3 cases with large CAF, contrast-enhanced multidetector computed tomography (MDCT) was performed to examine the whole coronary vessel structure including CAF. Selective CAG was also undertaken. In all 3 cases, based on the echocardiographic findings and the characteristic heart murmur, presence of CAF was suspected. However, transthoracic echocardiography as well as CAG alone could not define the whole abnormal vessel structure precisely. Moreover, CAG could not obtain clear images of the coronary artery with large CAF, because of contrast-steal. In contrast, MDCT could not only define CAF in detail but also depict coronary artery adjacent to CAF. On the basis of the MDCT findings, in cases 1 and 3, surgical exclusions were undertaken without and with coronary artery bypass grafting, respectively. Conclusions Contrast-enhanced MDCT might be useful for the diagnosis of large CAF and for the estimation of the coronary artery adjacent to CAF, which is absolutely indispensable for surgical treatment.