Mitsuomi Shimamoto

Role of Autonomic Nervous System in the Pathogenesis of Prinzmetal's Variant Form of Angina

In ten patients with Prinzmetals variant form of angina the effects of various drugs were assessed: subcutaneous injection of methacholine (10 mg), atropine (0.7 mg), and epinephrine (0.7 mg); intravenous infusion of isoproterenol (20-25 &mgr;g/min); and in the three of the above patients who were having recurrent spontaneous attacks at the time of the examination, oral administration of atropine (0.6-1.2 mg), propranolol (30-90 mg), and phenoxybenzamine (10 mg in one patient). Masters triple two-step test and selective coronary arteriography were done on all the patients.In the three patients who were having spontaneous attacks at the time of the examination, the administration of methacholine induced the attacks and that of atropine suppressed the attacks. Epinephrine induced the attacks in two patients and propranolol was without effect in suppressing the attacks. Phenoxybenzamine (in one patient) suppressed the attacks. Neither Masters triple two-step test nor isoproterenol infusion precipitated the attacks, though heart rate increased to more than 110 beats/min and 160 beats/min respectively in all the patients. Coronary arteriograms were normal in seven of the ten patients.It is concluded that enhanced activity of the parasympathetic nervous system, which occurs at rest, is involved in the initiation of the attack by stimulating the sympathetic nerve which in turn probably induces coronary arterial spasm by way of activating alpha (vasoconstrictor) receptors present in the large coronary arteries.

Comparison of Long-Term Outcome After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Unprotected Left Main Coronary Artery Disease (from the CREDO-Kyoto PCI/CABG Registry Cohort-2)

The long-term outcome of percutaneous coronary intervention (PCI) compared to coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease (ULMCAD) remains to be investigated. We identified 1,005 patients with ULMCAD of 15,939 patients with first coronary revascularization enrolled in the CREDO-Kyoto PCI/CABG Registry Cohort-2. Cumulative 3-year incidence of a composite of death/myocardial infarction (MI)/stroke was significantly higher in the PCI group than in the CABG group (22.7% vs 14.8%, p = 0.0006, log-rank test). However, the adjusted outcome was not different between the PCI and CABG groups (hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.79 to 2.15, p = 0.30). Stratified analysis using the SYNTAX score demonstrated that risk for a composite of death/MI/stroke was not different between the 2 treatment groups in patients with low (<23) and intermediate (23 to 33) SYNTAX scores (adjusted HR 1.70, 95% CI 0.77 to 3.76, p = 0.19; adjusted HR 0.86, 95% CI 0.37 to 1.99, p = 0.72, respectively), whereas in patients with a high SYNTAX score (≥33), it was significantly higher after PCI than after CABG (adjusted HR 2.61, 95% CI 1.32 to 5.16, p = 0.006). In conclusion, risk of PCI for serious adverse events seemed to be comparable to that after CABG in patients with ULMCAD with a low or intermediate SYNTAX score, whereas PCI compared with CABG was associated with a higher risk for serious adverse events in patients with a high SYNTAX score.

Comparison of Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting in Unprotected Left Main Coronary Artery Disease – 5-Year Outcome From CREDO-Kyoto PCI/CABG Registry Cohort-2 –

BACKGROUND Studies evaluating long-term (≥5 years) outcome of percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) in patients with unprotected left main coronary artery disease (ULMCAD) are still limited, despite concerns for late adverse events after drug-eluting stents implantation. METHODS AND RESULTS We identified 1,004 patients with ULMCAD (PCI: n=364, CABG: n=640) among 15,939 patients with first coronary revascularization enrolled in the CREDO-Kyoto PCI/CABG registry cohort-2. The primary outcome measure in the current analysis was a composite of death, myocardial infarction, and stroke (death/MI/stroke). The cumulative 5-year incidence of and the adjusted risk for death/MI/stroke were significantly higher in the PCI group than in the CABG group (34.5% vs. 24.1%, log-rank P<0.001, adjusted hazard ratio (HR): 1.48 [95% confidence interval (CI): 1.07-2.05, P=0.02]). The adjusted risks for all-cause death was not significantly different between the 2 groups. Regarding the stratified analysis by the SYNTAX score, the adjusted risk for death/MI/stroke was not significantly different between the 2 groups in patients with low (<23) or intermediate (23-33) SYNTAX score, whereas it was significantly higher in the PCI group than in the CABG group in patients with high (≤33) SYNTAX score. CONCLUSIONS CABG as compared with PCI was associated with better long-term outcome in patients with ULMCAD, especially those with high anatomical complexity.

Three-year outcome after percutaneous coronary intervention and coronary artery bypass grafting in patients with triple-vessel coronary artery disease: observations from the CREDO-Kyoto PCI/CABG registry cohort-2.

AIMS We sought to investigate medium-term outcome of percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG) in patients with triple-vessel coronary artery disease (TVD). METHODS AND RESULTS We identified 2,981 patients with TVD (PCI: N=1,825, CABG: N=1,156) among 15,939 patients with first coronary revascularisation enrolled in the CREDO-Kyoto PCI/CABG registry cohort-2. Excess adjusted three-year risk of the PCI group relative to the CABG group for death/myocardial infarction (MI)/stroke was significant (HR 1.47 [95% CI: 1.13-1.92, p=0.004]). Adjusted risk for all-cause death was also significantly higher with PCI as compared with CABG (HR 1.62 [95% CI: 1.16-2.27, p=0.005]), while risk for cardiac death was neutral between the two groups (HR 1.3 [95% CI: 0.81-2.07, p=0.28]). PCI was also associated with a markedly higher risk for any coronary revascularisation. Regarding the analysis stratified by the SYNTAX score, the adjusted HR of PCI relative to CABG for death/MI/stroke was 1.66 (95% CI: 1.04-2.65, p=0.03) in the low-score (<23: N=874, and N=257), 1.24 (95% CI: 0.83-1.85, p=0.29) in the intermediate-score (23-32: N=638, and N=388), and 1.59 (95% CI: 0.998-2.54, p=0.051) in the high-score (≥ 33: N=280, and N=375) tertiles, respectively. CONCLUSIONS PCI as compared with CABG was associated with significantly higher risk for serious adverse events in TVD patients.

Clinical Efficacy of Thrombus Aspiration on 5‐Year Clinical Outcomes in Patients With ST‐Segment Elevation Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Background Adjunctive thrombus aspiration (TA) during primary percutaneous coronary intervention (PCI) was reported to promote better coronary and myocardial reperfusion. However, long-term mortality benefit of TA remains controversial. The objective of this study is to investigate the clinical impact of TA on long-term clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI. Methods and Results The CREDO-Kyoto AMI Registry is a large-scale cohort study of acute myocardial infarction patients undergoing coronary revascularization in 2005–2007 at 26 hospitals in Japan. Among 5429 patients enrolled in the registry, the current study population consisted of 3536 patients who arrived at the hospital within 12 hours after the symptom onset and underwent primary PCI. Clinical outcomes were compared between the 2 patient groups with or without TA. During primary PCI procedures, 2239 out of 3536 (63%) patients underwent TA (TA group). The cumulative 5-year incidence of all-cause death was significantly lower in the TA group than in the non-TA group (18.5% versus 23.9%, log-rank P<0.001). After adjusting for confounders, however, the risk for all-cause death in the TA group was not significantly lower than that in the non-TA group (hazard ratio: 0.90, 95% CI: 0.76 to 1.06, P=0.21). The adjusted risks for cardiac death, myocardial infarction, stroke, and target-lesion revascularization were also not significantly different between the 2 groups. Conclusions Adjunctive TA during primary PCI was not associated with better 5-year mortality in STEMI patients.

Comparison of Five-Year Outcome of Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting in Triple-Vessel Coronary Artery Disease (from the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2)

Studies evaluating long-term (≥5 years) outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents compared with coronary artery bypass grafting (CABG) in patients with triple-vessel coronary artery disease (TVD) are still limited. We identified 2,978 patients with TVD (PCI: n = 1,824, CABG: n = 1,154) of 15,939 patients with first coronary revascularization enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2. The primary outcome measure in the present analysis was a composite of death, myocardial infarction (MI), and stroke. Median follow-up duration for the surviving patients was 1,973 days (interquartile range 1,700 to 2,244). The cumulative 5-year incidence of death/MI/stroke was significantly higher in the PCI group than in the CABG group (28.2% vs 24.0%, log-rank p = 0.006). After adjusting for confounders, the excess risk of PCI relative to CABG for death/MI/stroke remained significant (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.13 to 1.68, p = 0.002). The excess risks of PCI relative to CABG for all-cause death, MI, and any coronary revascularization were also significant (HR 1.38, 95% CI 1.10 to 1.74, p = 0.006; HR 2.81, 95% CI 1.69 to 4.66, p <0.001; and HR 4.10, 95% CI 3.32 to 5.06, p <0.001, respectively). The risk for stroke was not significantly different between the PCI and CABG groups (HR 0.88, 95% CI 0.61 to 1.26, p = 0.48). There were no interactions for the primary outcome measure between the mode of revascularization (PCI or CABG) and the subgroup factors such as age, diabetes, and Synergy Between PCI With Taxus and Cardiac Surgery score. In conclusion, CABG compared with PCI was associated with better long-term outcome in patients with TVD.

Incidence and Outcome of Surgical Procedures After Coronary Artery Bypass Grafting Compared With Those After Percutaneous Coronary Intervention A Report From the Coronary Revascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2

Background—Noncardiac surgery after percutaneous coronary intervention (PCI) has been reported to be carrying high risk for both ischemic and bleeding complications. However, there has been no report comparing the incidence and outcomes of surgical procedures after coronary artery bypass grafting (CABG) with those after PCI. Methods and Results—Among 14 383 patients undergoing first coronary revascularization (PCI, n=12 207; CABG, n=2176) enrolled in the Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) PCI/CABG Registry Cohort-2, surgical procedures were performed more frequently after CABG (n=560) than after PCI (n=2398; cumulative 3-year incidence: 27% versus 22%; unadjusted P<0.0001), particularly <6 months of coronary revascularization. The risk for the primary ischemic outcome measure (death/myocardial infarction) at 30-day postsurgical procedures was not significantly different between the CABG and PCI groups (cumulative incidence: 3.1% versus 3.2%; unadjusted P=0.9; adjusted hazard ratio, 0.97; 95% confidence interval, 0.47–1.89; P=0.9). The risk for the primary bleeding outcome measure (moderate or severe bleeding by Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries classification) was lower in the CABG groups than in the PCI group (cumulative incidence: 1.3% versus 2.6%; unadjusted P=0.07; adjusted hazard ratio, 0.36; 95% confidence interval, 0.12–0.87; P=0.02). There were no interactions between the timing of surgery and the types of coronary revascularization (CABG/PCI) for both ischemic and bleeding outcomes. Conclusions—Surgical procedures were performed significantly more frequently after CABG than after PCI, particularly <6 months after coronary revascularization. Surgical procedures after CABG as compared with those after PCI were associated with similar risk for ischemic events and lower risk for bleeding events, regardless of the timing after coronary revascularization.

Insights of stroke in aortic arch surgery: identification of significant risk factors and surgical implication.

PurposeAlthough the outcomes of aortic arch surgery have improved, stroke remains one of the most devastating complications. Therefore, identification of true risk factors and understanding the pathogenesis of intraoperative stroke are necessary to decrease its occurrence.MethodsFrom January 2002 to December 2010, a total of 251 consecutive patients underwent aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion in our hospital. Hemiarch replacement cases were excluded. Of the remaining patients, 190 elective cases that could be reviewed with full perioperative clinical data were analyzed. Strokes were classified into three subtypes according to their distribution on imaging studies: multiple-embolism type, hypoperfusion type, and solitary-embolism type.ResultsOperative death occurred in 1.1% of patients (2/190), and aortic arch surgery-related in-hospital death occurred in 5.3%. Among the 188 survivors, intraoperative strokes occurred in 5.9%. Multiple-embolism, hypoperfusion type, and solitary-embolism stroke occurred in 2.7%, 2.1%, and 1.6%, respectively. Multivariate analysis revealed that the risk factor for multiple-embolism stroke was high-grade atheroma in the ascending aorta [P < 0.001, odds ratio (OR) 118.0], and that for hypoperfusion type stroke was prolonged brain ischemia time over 120 min (P = 0.004, OR 31.5). No significant risk factor was found for solitary-embolism stroke.ConclusionIntraoperative strokes during elective aortic arch surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion are strongly influenced by the presence of a high-grade atheroma in the ascending aorta and prolonged brain ischemia time. The results suggest that these are key issues to reduce stroke in aortic arch surgery.

Airway stenosis associated with a mycotic pseudoaneurysm of the common carotid artery.

A 56-year-old woman was seen who had been under hemodialysis treatment. In September 2003, the patient was sent to our hospital with fever and dyspnea, and artificial respiration was initiated. Bronchoscopy detected stenosis due to compression of the bronchus. Contrast computed tomography and angiography detected a pseudoaneurysm of the right common carotid artery. We performed emergency excision of the mycotic pseudoaneurysm, which was closed with an autologous pericardial patch. We also performed median sternotomy to obtain an adequate surgical view. A perfusion tube was inserted into the internal carotid artery. The inflammatory findings and dyspnea resolved postoperatively.

GRADED EXERCISE IN THREE CASES OF HEART RUPTURE AFTER ACUTE MYOCARDIAL INFARCTION: A Brief Report

Despite advances in the study of exercise for acute myocardial infarction (AMI) patients, few studies on exercise for post-AMI heart rupture patients have been reported. We assessed three cases of heart rupture (of the left ventricular free wall in two cases and of the ventricular septum in one case) in post-AMI patients who underwent three-graded exercise. Two of the three patients were operated on, whereas one patient was managed conservatively for heart rupture. Two of the three cases had also suffered cerebral infarction post-AMI. The exercise program was composed of three grades, slow level walking (grade 1), mild reconditioning and activities of daily living (ADL) exercises (grade 2), and optional endurance training using machines below 75% of predicted maximal heart rate (grade 3). Electrocardiograms and blood pressure were monitored during all exercises. All patients had muscle weakness, poor endurance capacity, as well as low cardiac function (28-47% of left ventricular ejection fraction). Two patients underwent grades 1 and 2 exercise programs, and the other performed grades 1, 2, and 3 exercise programs over a 3- to 10-wk period. We observed improvement in the double product, work capacity, and ADL without congestive heart failure, ischemic attack, or serious arrhythmias. However, the youngest patient, who underwent the grade 3 exercise program, died from a cardiac event 10 mo after onset of AMI. We conclude that post-AMI heart rupture patients should undergo delayed, gradual, low-level graded exercise (4-6 metabolic equivalents), with monitoring of blood pressure and electrocardiograms to improve work capacity, ADL, and the quality of life. However, daily activity and exercise intensity should be promptly supervised for those with severely deteriorated cardiac functions to prevent sudden cardiac event.