Mikihiro Kijima

Effects of adjunctive balloon angioplasty after intravascular ultrasound-guided optimal directional coronary atherectomy: The result of adjunctive balloon angioplasty after coronary atherectomy study (ABACAS)☆

OBJECTIVES This study was conducted to evaluate: 1) the effect of adjunctive percutaneous transluminal coronary angioplasty (PTCA) after directional coronary atherectomy (DCA) compared with stand-alone DCA, and 2) the outcome of intravascular ultrasound (IVUS)-guided aggressive DCA. BACKGROUND It has been shown that optimal angiographic results after coronary interventions are associated with a lower incidence ofrestenosis. Adjunctive PTCA after DCA improves the acute angiographic outcome; however, long-term benefits of adjunctive PTCA have not been established. METHODS Out of 225 patients who underwent IVUS-guided DCA, angiographically optimal debulking was achieved in 214 patients, then theywere randomized to either no further treatment or to added PTCA. RESULTS Postprocedural quantitative angiographic analysis demonstrated an improved minimum luminal diameter (2.88 +/- 0.48 vs. 2.6 +/- 0.51 mm; p = 0.006) and a less residual stenosis (10.8% vs.15%; p = 0.009) in the adjunctive PTCA group. Quantitative ultrasound analysis showed a larger minimum luminal diameter (3.26 +/- 0.48 vs. 3.04 +/- 0.5 mm; p < 0.001) and lower residual plaque mass in the adjunctive PTCA group (42.6% vs. 45.6%; p < 0.001). Despite the improved acute findings in the adjunctive PTCA group, six-month angiographic and clinical results were not different. The restenosis rate (adjunctive PTCA 23.6%, DCA alone 19.6%; p = ns) and target lesion revascularization rate (20.6% vs. 15.2%; p = ns) did not differ between the groups. CONCLUSIONS With IVUS guidance, aggressive DCA can safely achieve optimal angiographic results with low residual plaque mass, and this was associated with a low restenosis rate. Although adjunctive PTCA after optimal DCA improved the acute quantitative coronary angiography and quantitative coronary ultrasonography outcomes, its benefit was not maintained at six months.

Increased plasminogen activator inhibitor-1 and apolipoprotein (a) in coronary atherectomy specimens in acute coronary syndromes.

BACKGROUND Although increased tissue factor expression is known in vulnerable plaques, there is no reported study to compare plaque fibrinolysis in stable and unstable plaques. This study investigates the extent of plasminogen activator inhibitor-1 (PAI-1) and apolipoprotein (a) [apo(a)] in the plaques of different types of coronary artery disease as well as the correlation between these molecules and infiltration of macrophages to plaques. METHODS Using immunohistochemical staining, we examined PAI-1 expression and apo(a) deposition in coronary atherosclerotic specimens obtained by directional coronary atherectomy from 19 patients with acute myocardial infarction (AMI), 12 with unstable angina pectoris (UAP), and 13 with stable angina pectoris (SAP). The percentages of the total areas of specimens stained with PAI-1 or apo(a) were estimated by an NIH image program. The proportion of macrophages as a percentage of all cells in plaques was calculated as the macrophage density. RESULTS We found significantly higher percentages of total areas of specimens stained with PAI-1 in AMI (25.5 +/- 8.6%, P < 0.001) and UAP (22.2 +/- 10.4%, P < 0.005) than in SAP (9.5 +/- 5.0%), as well as with apo(a) (AMI; 11.7 +/- 7.1%, P < 0.005, UAP; 11.1 +/- 5.5%, P < 0.01 versus SAP; 3.9 +/- 1.5%). Linear regression analysis of all the samples showed a correlation between PAI-1 or apo(a) and macrophage density (PAI-1: r = 0.75, P < 0.001 and apo(a): r = 0.56, P < 0.001). CONCLUSIONS Our results suggest a possible contribution of increased PAI-1 and apo(a) in plaques to the pathogenesis of acute coronary syndromes including impaired fibrinolysis.

Impact of the Great East Japan Earthquake on Acute Myocardial Infarction in Fukushima Prefecture

OBJECTIVE The incidence of cardiovascular disease (CVD) reportedly increases following a huge disaster. On March 11, 2011, the Great East Japan Earthquake hit a large area of eastern Japan. In Fukushima prefecture, many people suffered from the consequences of the earthquake, the subsequent tsunami, and especially the Fukushima Daiichi Nuclear Power Plant accident. We assessed whether the incidence of acute myocardial infarction (AMI) increased after the earthquake. METHODS We enrolled AMI patients admitted to 36 hospitals in Fukushima prefecture between March 11, 2009, and March 10, 2013 (n = 3068). We compared the incidence of AMI after the earthquake for more than 3 months and 1 year with that in the control years. RESULTS The incidence of Fukushimas annual AMI patients (per 100 000 persons) in 2011 was similar to that of previous years (n = 38.9 [2011] vs 37.2 [2009] and 38.5 [2010], P = .581). However, a significantly higher incidence of AMI was found in the Iwaki district after the disaster that corresponded to the 1-year period of observation (n = 38.7 [2011] vs 27.3 [2009] and 32.8 [2010], P = .045). CONCLUSION The Great East Japan Earthquake affected the incidence of AMI only in limited areas of Fukushima prefecture.

Coronary artery spasm after aortic valve replacement

We report a patient who received aortic valve replacement and experienced early postoperative coronary artery spasm, which led to inferolateral myocardial infarction. The spasm was unresponsive to conventional medication. However, after systemic circulatory and respiratory control, a good prognosis was obtained.

Lone aspiration thrombectomy without stenting for a patient with ST-segment elevation myocardial infarction associated with coronary ectasia

A 57-year-old male with a previous history of inferior myocardial infarction suffered from chest pain and diagnosed as ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed a thrombus with delayed filling in the distal right coronary artery. After an aspiration thrombectomy, TIMI 3 flow was restored successfully. An intracoronary ultrasound imaging revealed coronary ectasia. Stenting and ballooning were deferred. A successful lone aspiration thrombectomy was performed for a patient with STEMI associated with coronary ectasia.

Quadricuspid pulmonary valve stenosis treated by transcatheter pulmonary valvuloplasty with inoue balloon catheter

The quadricuspid pulmonary valve is a relatively common congenital anomaly which is rarely complicated clinically and also tends to be under-diagnosed. The following case report shows a 62-year-old man with exertional dyspnea due to quadricuspid pulmonary valve stenosis that was diagnosed by using electrocardiography-gated multiple detector computed tomography. He was then treated effectively by transcatheter balloon pulmonary valvuloplasty using an Inoue balloon catheter. <Learning Objective: The quadricuspid pulmonary valve is a congenital anomaly which is rarely complicated clinically and tends to be under-diagnosed. Electrocardiography-gated multiple detector computed tomography is a useful imaging modality for diagnosing the quadricusid pulmonary valve. Transcatheter pulmonary valvuloplasty with an Inoue balloon catheter was effective for treating quadricuspid pulmonary valve stenosis.>.

Effects of Vasodilators on Coronary Vasospasm Induced by Ergonovine Malate

Coronary vasospasm sometimes causes sudden cardiac death; evaluation of the effects of vasodilators would thus be of importance. Twenty patients (25 coronary arteries) with vasospastic angina were examined. Coronary vasodilators were withdrawn at least 48 h before the first coronary angiography (CAG) was performed. None of the patients had fixed stenosis of more than 50% of the coronary diameter. Total or subtotal occlusion of the coronary artery was induced in all patients by the intracoronary infusion of ergonovine malate (EM). On the 2nd day, 40 mg of long-acting isosorbide dinitrate (ISDN) was administrated at 1:00 a.m. and CAG was performed at 8:00 a.m. On the 3rd day, 20 mg of nifedipine, and on the 4th day, 60 mg of diltiazem, were added and the CAG with EM test was performed at the same time (protocol A). In protocol B, we changed the order of drug administration, i.e., on the 2nd day nifedipine, on the 3rd day diltiazem, on the 4th day nicorandil, and on the 5th day ISDN, were added. There was a significant increase in coronary diameter after the administration of vasodilators at the spasm sites in both protocols A and B. After a single administration of ISDN (protocol A) or nifedipine (protocol B), in 12 of 13 (protocol A) and in 10 of 12 coronary arteries (protocol B), spasms were again induced by EM at almost the same doses as those used before drug administration.