Naoyuki Kurita

Comparison Between 1- and 2-Stent Strategies in Unprotected Distal Left Main Disease: The Milan and New-Tokyo Registry

Background—There are only little data available on the comparison of clinical outcomes between a 1-stent strategy (1-SS) and a 2-stent strategy (2-SS) for percutaneous coronary intervention in unprotected distal left main disease. Methods and Results—Between April 2005 and August 2011, we recruited 937 consecutive unprotected distal left main patients treated with drug-eluting stents (1-SS, 608 patients; 2-SS, 329 patients). Major adverse cardiovascular events were defined as all-cause death, myocardial infarction, or target lesion revascularization (TLR) during the median follow-up period of 1592 days. Furthermore, the individual components of major adverse cardiovascular events, cardiac death, and stent thrombosis were evaluated. More complex lesions were seen with 2-SS than with 1-SS. Cardiac death occurred more frequently with 1-SS than with 2-SS (propensity score–adjusted hazard ratio, 0.52; 95% confidence interval, 0.29–0.64; P=0.03), whereas TLR occurred more frequently with 2-SS than with 1-SS (propensity score–adjusted hazard ratio, 1.59; 95% confidence interval, 1.15–2.20; P=0.005). TLR was mainly driven by revascularizations after restenosis at the ostial left circumflex artery (propensity score–adjusted hazard ratio, 1.94; 95% confidence interval, 1.33–2.82; P=0.001). However, there were no differences in major adverse cardiovascular events, all-cause death, stent thrombosis, and myocardial infarction. Of the 139 pairs that were propensity score matched, only TLRs were significantly higher in the 2-SS group (hazard ratio, 1.59; 95% confidence interval, 1.00–2.53; P=0.05). Conclusions—The difference between 1-SS and 2-SS in percutaneous coronary intervention for unprotected distal left main disease may be summarized by the high incidence of TLR, mainly because of restenosis at the ostial left circumflex artery in the 2-SS group.

Independent predictors of in-stent restenosis after drug-eluting stent implantation for ostial right coronary artery lesions

OBJECTIVES We evaluated the angiographic patterns and predictors of in-stent restenosis (ISR) for ostial lesions of the right coronary artery (RCA) to clarify the mechanism of insoluble restenosis. BACKGROUND Although ISR of the RCA still occurs, limited data is available regarding the associated angiographic findings. METHODS Between January 2005 and September 2013, we recruited consecutive patients undergoing routine angiography 6-18months after implantation of a drug-eluting stent (DES). Multiple logistic regression analysis was used to determine the independent predictors of ISR, and the adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) were calculated. RESULTS Routine angiography revealed that 45 of 131 patients (34.3%) had RCA-ISR, which were classifiable by occlusion type into ostial (24 cases), proximal (17 cases), diffuse (3 cases), and total (1 case). By multivariable analysis, early generation DES was the only independent predictor of overall ISR (aOR, 3.54; 95% CI, 1.59-7.87; p=0.002). In a subgroup analysis of each focal ISR pattern, early generation DES (aOR, 7.76; 95% CI, 2.15-28.0; p=0.002) was associated with increased risk of ostial ISR. On the contrary, larger stent (aOR, 0.21; 95% CI, 0.05-0.84; p=0.027) was associated with decreased risk of ostial ISR. Furthermore, a ratio of the stent to post-balloon size >1.10 (aOR, 3.93; 95% CI, 1.30-11.8; p=0.002) and good left ventricular contractility (ejection fraction >60%) (aOR, 8.27; 95% CI, 1.76-39.0; p=0.008) were associated with increased risk of proximal ISR when stent fracture was observed. CONCLUSION The focal pattern of RCA-ISR was mostly observed after DES implantation, and the mechanisms of proximal and ostial ISR differed.

High prevalence of coronary artery events and non-coronary events in patients with coronary artery aneurysm in the observational group

Background Coronary artery aneurysm (CAA) is occasionally detected on a small percentage of coronary angiography or multi-detector computed tomography (MDCT). CAA itself is considered benign entity despite the potential risks of rupture, thromboembolism, and compression of surrounding structures. However, the optimal management including other vascular comorbidity has yet to be fully clarified. Objective The aim of this study was to evaluate cardiovascular events in the patients with CAA in the observational group. Methods Between January 2010 and August 2015, 48 CAAs were identified in 37 patients out of consecutive 10,010 patients (0.37%) by MDCT. Twenty-eight patients treated conservatively were included in this study. Their major adverse cardiovascular events (MACE) were evaluated retrospectively: death, non-fatal myocardial infarction (MI), revascularizations; coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), and other vascular events. Results The average age was 62.0 ± 15.5 year sold, and median follow-up period was 49.6 months (IQR 23.6 to 78.1). Mean CAA diameter was 7.5 ± 2.8 mm. Twenty-two MACE occurred in 15 patients (53.6%): 1 sudden death, 4 MI, 1 CABG for CAA, 3 PCI for CAA, 7 PCI for non-CAA lesions, and 6 other vascular treatments for aorta and cerebral and peripheral artery. Follow-up MDCT was performed for 22 CAAs in 16 patients. In 9 CAAs of them, the maximal diameter increased significantly (Δ diameter: 1.5 ± 1.1 mm). Conclusions Presence of CAA may be associated with adverse vascular events including non-coronary diseases. This study could suggest the management for CAA should include the evaluation of not only CAA itself but also other vascular diseases.

SIGNIFICANCE OF 123I-BMIPP-SCINTIGRAPHY IN THE RECOVERY OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION IN TAKOTSUBO CARDIOMYOPATHY: INSIGHT FROM THE NEW TAKOTSUBO BMIPP REGISTRY

Background: Takotsubo cardiomyopathy (TCM) is notable for reversible left ventricular (LV) systolic dysfunction in a short-term whereas it is well-known long-duration or persistent wall-motion abnormality is observed in some cases. However, its prevalence and predictor have yet to be fully-clarified

Difference in vascular response between sirolimus-eluting- and everolimus-eluting stents in ostial left circumflex artery after unprotected left main as observed by optical coherence tomography

BACKGROUND Kissing-balloon technique (KBT) is commonly performed during percutaneous coronary intervention of distal unprotected left main coronary artery (ULM) aiming at obtaining optimal opening of the side branch (left circumflex artery; LCX) ostium. Nonetheless, detailed evaluation of vascular response to stents in LCX ostium is lacking. We therefore evaluated the vascular response to different drug-eluting stents (DES) in ostial LCX after ULM by means of optical coherence tomography (OCT). METHODS We prospectively enrolled 38 consecutive patients with ULM disease, who were treated with single-stent procedure using DES, crossover the ULM-left anterior descending artery (LAD) followed by KBT. Twelve patients were treated with sirolimus-eluting stents (SES) and 26 patients were treated with everolimus-eluting stents (EES). OCT was conducted at post-PCI and 9-month follow-up. We evaluated the DES-vessel interactions and number of stent struts at the side branch (LCX) ostium (SO) at post-PCI, and compared the narrowing of ostial area at LCX between SES and EES. RESULTS Post-procedure, the number of stent struts at SO was significantly higher in SES compared to EES (median 14.47% vs 0.19%, p<0.001). The narrowing of LCX ostial area at follow-up was more pronounced in SES compared with EES (29.16% vs 2.46%, respectively, p<0.001). Linear regression analysis showed a high correlation between the number of stent struts in LCX ostium and ostial area narrowing (r=0.771, p<0.001). CONCLUSIONS OCT showed differences between EES- and SES-vessel interactions at ULM bifurcation PCI. Number of LCX ostium struts at post-PCI impacted the narrowing of ostial area at 9-month follow-up.

Impact of a combination of full coverage stenting and proximal optimization technique on long term outcome for unprotected distal left main disease

BACKGROUND There is no consensual opinion regarding the percutaneous coronary intervention (PCI) procedure for unprotected distal left main (UDLM) lesion. METHODS Between April 2005 and August 2011, 586 consecutive patients with UDLM stenosis treated with drug-eluting stents were recruited for this study to clarify the impact of combination of full-coverage stenting and proximal optimization technique (POT) for UDLM lesion. An optimal strategy of full-coverage stenting and POT was performed in 353 patients and the other 233 patients were not optimally treated. Major adverse cardiovascular events (MACEs) were defined as all-cause death, myocardial infarction, or target lesion revascularization (TLR) during follow-up period. TLRs were also evaluated for main branch (MB) restenosis. RESULTS At 1615days of follow-up, MACE occurred in 166 (28.3%) patients. The occurrence of MACE and TLR had a trend to being lower in the optimal strategy [propensity score-adjusted HR, 0.73 (95% CI, 0.53-1.01), p=0.05 and propensity score-adjusted HR, 0.69 (95% CI, 0.46-1.02), p=0.06, respectively]. TLR of the MB occurred significantly less frequently in the optimal strategy [propensity score-adjusted HR, 0.34 (95% CI, 0.15-0.76), p=0.008]. Cardiac death occurred in 28 (4.8%) patients. There was no significant difference in cardiac death between the two groups. These results were sustained after propensity-score matching. CONCLUSIONS An optimal PCI strategy of full-coverage stenting and POT might be effective for UDLM lesion to reduce the occurrence of MACE, especially driven by TLR of the MB.

IMPACT OF THE SKIN AUTOFLUORESCENCE TO CORONARY ARTERY STENOSIS PROGRESSION

Accumulation of tissue advanced glycation end products (AGEs) has been reported as a marker of cumulative glycemic and/or oxidative stress. It is reported that patients involved with coronary artery disease (CAD) with higher AGEs show worse clinical outcome. The aim of this study is to evaluate

Association of skin autofluorescence with plaque vulnerability evaluated by optical coherence tomography in patients with cardiovascular disease

BACKGROUND AND AIMS Accumulation of advanced glycation end products (AGEs) can be measured non-invasively by skin autofluorescence (SAF) whose values are elevated in patients with cardiovascular disease (CVD). Optical coherence tomography (OCT) is an intravascular imaging modality that could allow visualization of plaque composition. We aim to examine the relationship between SAF and plaque composition evaluated by frequency-domain OCT in patients with CVD. METHODS We prospectively enrolled 108 patients with CVD, who underwent OCT images during percutaneous coronary intervention (PCI). We divided the population into two groups: high SAF group (greater than or equal to 2.6) and low SAF one (less than 2.6). OCT findings were then compared between high and low SAF groups. RESULTS The high SAF group showed much more thin cap fibroatheroma (TCFA), and calcified or ruptured plaques compared to the low SAF group. In multivariable analysis, low-density lipoprotein-cholesterol (LDL) (odds ratio: 1.15; 95% confidence interval: 1.00 to 1.32; p = 0.043), TG (OR for 10 mg/dl increase: 1.04; 95% confidence interval: 1.01 to 1.13; p = 0.016), and SAF (4.28; 1.86 to 9.84; p < 0.001) were independent correlates of TCFA, whereas SAF (2.61; 1.02 to 6.70; p = 0.047), estimated glomerular filtration rate (0.68; 0.49 to 0.93; p = 0.017) and LDL (1.19; 1.01 to 1.41; p = 0.037) were independent predictors of ruptured plaques. SAF and diabetes were independently associated with calcified plaques. CONCLUSIONS High SAF were associated with plaque vulnerability in patients with CVD, thus suggesting the clinical utility of SAF measurement in identifying high-risk patients for future cardiovascular events.

Optical coherence tomography assessment of in-stent restenosis after percutaneous coronary intervention with two-stent technique in unprotected left main.

BACKGROUND Optical coherence tomography (OCT) has contributed to a better understanding of in-stent restenosis (ISR); however, studies evaluating ISR pattern after two-stent technique in unprotected left main (ULM) are lacking. We aim to evaluate the ISR pattern of proximal LAD and LCX after two-stent technique in ULM. METHODS We performed OCT in 26 patients with isolated or combined ISR (identified by angiography as >50%) after two stent implantation in the proximal LCX and LAD. Finally, 13 LAD and 22 LCX ISR lesions underwent OCT assessments. OCT analyses were undertaken in the proximal segments of the LAD and LCX. In addition, we compared OCT findings in the flow divider (FD) and lateral wall (LW). RESULTS In both the LAD and LCX, the distance from the ostium to the minimum lumen area (MLA; LAD, 2.00mm [1.00, 3.00]; LCX, 1.00mm [0.00, 1.80] distal to ostium) was short. Uncovered struts were more common on the FD side compared with the LW in the LAD (6.25% [0.00, 20.00] vs 0.00% [0.00, 0.00], respectively, p=0.016) and LCX (11.32% [0.00, 19.44] vs 0.00% [0.00, 4.55], respectively, p<0.001). Conversely, neointimal hyperplasia (NIH) was significantly thicker on the FD side compared with the LW in the LCX (0.31mm [0.19, 0.47] vs 0.15mm [0.09, 0.31], p<0.001). CONCLUSIONS While uncovered struts were more commonly found on the FD side of both arteries, NIH was significantly thicker on the FD side compared with the LW in the LCX. These unique findings might indicate inferior outcomes after two-stent techniques in ULM bifurcation lesions.

TCT-27 The Impact of Second Generation Drug-eluting Stent on Mid-term Clinical Outcome in Patients with Unprotected Left Main, Milan and New-Tokyo Registry

Niels R. Holm, Kari Kervinen, Matti J. Niemela, Andrejs Erglis, Indulis Kumsars, Terje Steigen, Evald H. Christiansen, Markku Eskola, Hannu Romppanen, Andis Dombrovskis, Ole Frobert, Lars Åberge, Pål Gunnes, Juhani Airaksinen, Anders Hervold, Sanda Jegere, Thor Trovik, Lisette Okkels Jensen, Michael Maeng, Timo Makikallio, Mikko Pietila, Iwar Sjögren, Per Thayssen, Saila Vikman, Jens F. Lassen, Leif Thuesen Aarhus University Hospital, Skejby, Aarhus N, Denmark, Oulo University Hospital, Oulo, Finland, University of Oulo, Oulo, Finland, Pauls Stradins Clinical University Hospital, Riga, Latvia, Latvian Cardiology Center, Riga, Latvia, University Hospital of Northern Norway, Tromso, Norway, Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus N, Denmark, Tampere Heart Center, Tampere, Finland, Latvian center of cardiology, Paul Stradins Clinical Hospital, Riga, Latvia, Örebro University Hospital, Örebro, Sweden, Rikshospitalet, Oslo, Norway, Feiringklinikken, Feiring, Norway, Turku University Hospital, Turku, Finland, Pauls Stradins Clinical University Hospital, Riga, Not applicable, University Hospital of Tromsoe, Tromsoe, Norway, Odense University Hospital, Odense, Denmark, Aarhus University Hospital, Aarhus, Denmark, Falun Hospital, Falun, Sweden, Department of Cardiology, Odense University Hospital, Odense, Denmark, Tampere University Hospital, Tampere, Finland, Department of Cardiology, Aarhus University Hospital, Skejby, Denmark, Aarhus, Denmark