Nehiro Kuriyama

Usefulness of rotational atherectomy in preventing polymer damage of everolimus-eluting stent in calcified coronary artery.

A 78-year-old woman with an 80% stenosis with moderate calcification in the mid left circumflex artery ([Figs. 1][1]A and [1][1]B) was referred for coronary angioplasty. Delivery of a 28-mm everolimus-eluting stent (EES) was initially attempted. However, it would not advance to the lesion ([Fig. 1][

Intimal hyperplasia regression from 6 to 12 months after stenting

death in hibernating human myocardium. J Am Coll Cardiol 1996;27:1577–1585. 11. Shivalkar B, Maes A, Borgers M, Ausma J, Scheys I, Nuyts J, Mortelmans L, Flameng W. Only hibernating myocardium invariably shows early recovery after coronary revascularization. Circulation 1996;94:308–315. 12. Elsasser A, Schlepper M, Kl‘vekorn WP, Cai W, Zimmermann R, Muller KD, Strasser R, Kostin S, Gagel C, Munkel B, Schaper W, Schaper J. Hibernating myocardium: an incomplete adaptation to ischemia. Circulation 1997;96:2920– 2931. 13. Dakik HA, Howell JF, Lawrie GM, Espada R, Weilbaecher DG, He Z-X, Mahmarian JJ, Verani M. Assessment of myocardial viability with 99mTCsectamibi tomography before coronary bypass graft surgery: correlation with histopathology and postoperative improvement in cardiac function. Circulation 1997;96:2892–2898. 14. Maes A, Borgers M, Flameng W, Nuyts JL, Werf F, Ausma JJ, Serseant P, Mortelmans LA. Assessment of myocardial viability in chronic coronary artery disease using technetium-99 sestamibi SPECT; correlation with histologic and positron emission tomographic studies and functional follow-up. J Am Coll Cardiol 1997;29:62–68. 15. Schwarz ER, Schoendube FA, Kostin S, Schmiedtke N, Schulz G, Buell U, Messmer BJ, Morrison J, Hanrath P, Dahl J. Prolonged myocardial hibernation exacerbates cardiomyocyte degeneration and impairs recovery of function after revascularization. J Am Coll Cardiol 1998;31:1018–1026. 16. Nagueh SF, Mikati I, Weilbaecher D, Reardon MJ, Al-Zaghrini GJ, Cacela D, He Z-X, Letsou G, Noon G, Zoghbi WA. Relation of the contractile reserve of hibernating myocardium to myocardial structure in humans. Circulation 1999; 100:490–496. 17. Shirani J, Lee J, Quigg RJ, Pick R, Bacharach SL, Dilsizian V. Relation of thallium uptake to morphologic features of chronic ischemic heart disease: evidence for myocardial remodeling in non-infarct myocardium. J Am Coll Cardiol 2001;38:84–90. 18. Shirani J, Pick R, Roberts WC, Maron BJ. Morphology and significance of the left ventricular collagen network in young patients with hypertrophic cardiomyopathy and sudden cardiac death. J Am Coll Cardiol 2000;35:36–44. 19. Dilsizian V, Rocco TP, Freedman NM, Leon MB, Bonow RO. Enhanced detection of ischemic but viable myocardium by the reinjection of thallium after stress-redistribution imaging. N Engl J Med 1990;323:141–146. 20. Dilsizan V, Freedman NMT, Bacharach SL, Perrone-Filardi P, Bonow RO. Regional thallium uptake in irreversible defects; Magnitude of change in thallium activity after reinjection distinguishes viable from nonviable myocardium. Circulation 1992;85:627–634.

Late Restenosis Following Sirolimus-Eluting Stent Implantation

OBJECTIVES This serial angiographic study evaluated the incidence and predictors of late restenosis after sirolimus-eluting stent (SES) implantation. BACKGROUND Previous studies showed late restenosis (i.e., late catch-up phenomenon) after implantation of 7-hexanoyltaxol-eluting stents and nonpolymeric, paclitaxel-eluting stents. METHODS Between August 2004 and December 2006, SES implantation was performed in 1,393 patients with 2,008 lesions, in whom 8-month and 2-year follow-up coronary angiography were planned. RESULTS Of 2,008 lesions, 1,659 (83%) underwent 8-month follow-up angiography (8.3 ± 2.2 months). Restenosis was observed in 122 lesions (7.4%). Coronary angiography 2 years (1.9 ± 0.4 years) after SES deployment was performed in 1,168 lesions (74% of lesions without restenosis at 8-month follow-up angiography). Late restenosis was observed in 83 lesions (7.1%). There was significant decrease in minimum luminal diameter (MLD) between 8-month and 2-year follow-up (2.56 ± 0.56 mm vs. 2.35 ± 0.71 mm, p < 0.001). Multivariate analysis showed in-stent restenosis before SES implantation and MLD at 8-month follow-up as independent predictors of late restenosis. CONCLUSIONS Between 8-month and 2-year follow-up after SES implantation, MLD decreases, which results in late restenosis in some lesions. In-stent restenosis before SES implantation and MLD at 8-month follow-up are independent predictors of late restenosis.

Damage to Polymer of a Sirolimus-Eluting Stent

A 75-year-old man with a history of bare-metal stent implantation in the right coronary artery was admitted for unstable angina. Coronary angiography revealed in-stent restenoses of 90% severity in the mid-right coronary artery and the right posterolateral coronary artery (Figure 1A). Attempts to pass a 33-mm sirolimus-eluting stent (Cypher, Cordis, a Johnson & Johnson Company, Miami Lakes, Fla) premounted on a 3.0-mm balloon catheter after predilatation with a 3.0-mm balloon catheter inflated at 16 atm …

Clinical Implications of Additional Pedal Artery Angioplasty in Critical Limb Ischemia Patients With Infrapopliteal and Pedal Artery Disease.

Purpose: To evaluate the clinical implications of additional pedal artery angioplasty (PAA) for patients with critical limb ischemia (CLI). Methods: Twenty-nine patients (mean age 77.8±8.6 years; 21 men) with CLI (32 limbs) presenting with de novo infrapopliteal and pedal artery (Kawarada type 2/3) disease were reviewed. The need for PAA was based on the existence of sufficient wound blush (WB) around the target wounds after conventional above-the-ankle revascularization. Fourteen patients with insufficient WB in 14 limbs received additional PAA, while 15 patients with sufficient WB in 18 limbs did not. The groups were compared for overall survival, limb salvage, and amputation-free survival within 1 year after the procedure. The wound healing rate, time to wound healing, and freedom from reintervention rate were also evaluated. Result: The success rate of additional PAA was 93% (13/14). All limbs with successful PAA achieved sufficient WB (13/13). Despite insufficient WB before the additional PAA, overall survival (86% vs 73%, p=0.350), limb salvage (93% vs 83%, p=0.400), amputation-free survival (79% vs 53%, p=0.102), and freedom from reintervention (64% vs 73%, p=0.668) rates were similar in both groups. Furthermore, the wound healing rate (93% vs 60%, p=0.05) was higher and time to wound healing (86.0±18.7 vs 152.0±60.2 days, p=0.05) was shorter in the patients who received PAA. Conclusion: Additional PAA might improve the WB and clinical outcomes (especially speed and extent of wound healing) in patients with CLI attributed to infrapopliteal and pedal artery disease.

Presence of older thrombus in patients with late and very late drug-eluting stent thrombosis

BACKGROUND Although drug-eluting stents (DES) have considerably reduced the incidence of in-stent restenosis, late and very late stent thrombosis (ST) after DES implantation have emerged as major safety concerns. We morphologically investigated the age of DES thrombi aspirated during percutaneous coronary intervention (PCI) from patients with either late or very late ST that resulted in acute myocardial infarction (AMI). METHODS AND RESULTS We obtained DES thrombi during PCI from 16 consecutive patients with ST (late and very late ST, n=4 and n=12, respectively), who presented with AMI within 24 h of the onset of anginal symptoms. Thrombi were morphologically classified as fresh, lytic, and organized. Fresh thrombus was identified in 5 (31%) of the 16 patients and lytic thrombus was found in 3 (19%). Organized thrombus was notably found in 8 (50%) patients, of whom 5 (31%) had only the organized type and 3 (19%) had both fresh and organized thrombi. The frequency of fresh thrombus tended to be higher in patients with stent failure such as stent malapposition and fracture, but the difference did not reach significance (p=0.06). CONCLUSIONS Although the study group is small, about two-thirds of DES thrombi in late and very late ST were days or weeks old. These findings suggest an important discrepancy between the time of onset of the intra-stent thrombotic process and the occurrence of acute clinical symptoms, and provide further information about another potential mechanism of DES thrombosis.

The Course of Ischemic Mitral Regurgitation in Acute Myocardial Infarction After Primary Percutaneous Coronary Intervention From Emergency Room to Long-Term Follow-Up

Background—Previously published evidence on ischemic mitral regurgitation (IMR) and its adverse prognosis after myocardial infarction has been based on the severity of IMR in the subacute or chronic period of myocardial infarction. However, the state of IMR can vary from the early stage to the chronic stage as a result of various responses of myocardium after primary percutaneous coronary intervention (PCI). Methods and Results—Standard echocardiography was serially performed in 546 consecutive patients with first-onset acute myocardial infarction (1) immediately after their arrival (pre-PCI), (2) before discharge (early post-PCI), and (3) 6 to 8 months after PCI (late post-PCI). The course of IMR after primary PCI and the prognostic impact of the IMR in each phase were investigated. IMR was found in 193/546 (35%) patients at the emergency room. In the acute phase after PCI, IMR improved in 63 patients. IMR worsened in 78 patients despite successful PCI. Shorter onset-to-reperfusion time and nontotal occlusion before PCI were the independent predictors of early improvement of IMR. In the chronic phase, IMR improved in 79 patients and worsened in 36 patients. Lower peak creatine kinase–myocardial band was an independent predictor of late improvement of IMR. IMR before PCI worsened 30-day prognosis (P=0.02), and persistent IMR in the chronic phase worsened long-term prognosis (P=0.04) after primary PCI. Conclusions—Degrees of IMR changed in the early and chronic phase after primary PCI for acute myocardial infarction. IMR on arrival and persistent IMR in the chronic phase worsened short-term and long-term prognosis after acute myocardial infarction, respectively.

Acute Versus Chronic Ischemic Mitral Regurgitation: An Echocardiographic Study of Anatomy and Physiology

Background: Little is known on the mechanism of acute ischemic mitral regurgitation (IMR) caused by sudden-onset left ventricular dysfunction in acute myocardial infarction (MI). We sought to investigate the mitral valve (MV) complex geometry in acute IMR in comparison with chronic IMR by 2-dimensional and 3-dimensional transthoracic echocardiography. Methods and Results: Forty-four first-onset acute MI and 36 previous MI with ≥moderate IMR were examined by 2-dimensional/3-dimensional transthoracic echocardiography. MV morphology was quantitatively analyzed and compared between the 2 groups. Left ventricular end-diastolic volume and left ventricular end-systolic volume were significantly smaller in acute IMR than in chronic IMR (40.8 [33.1–48.3] versus 88.8 [66.5–108.8] mL/m2; P<0.001, 17.8 [17.0–30.1] versus 49.5 [34.2–73.7] mL/m2; P<0.001). MV tenting volume and annular area were significantly smaller in acute IMR compared with chronic IMR (0.98 [0.66–1.68] versus 1.88 [1.16–2.65] cm3/m2; P=0.008, 5.17 [4.80–5.86] versus 5.81 [5.47–8.22] cm2/m2; P=0.008). Leaflet surface area was significantly smaller in acute IMR than in chronic IMR (5.78 [5.16–6.32] versus 7.56 [6.89–11.32] cm2/m2; P<0.001). The ratio of MV leaflet surface area and MV annular area was significantly smaller in acute IMR than in chronic IMR (1.08 [1.01–1.14] versus 1.28 [1.24–1.37]; P=0.001). Conclusions: Sudden-onset left ventricular dysfunction in acute MI may cause loss of coaptation of the MV even with a relatively mild degree of valve tethering. Compared with previously studied chronic IMR, a smaller leaflet area without leaflet adaptation and a larger hemodynamic burden at the acute onset of MI could result in clinically significant IMR despite relatively small leaflet tethering.

Predictors of Recurrent In-Stent Restenosis After Paclitaxel-Coated Balloon Angioplasty

BACKGROUND Although paclitaxel-coated balloon (PCB) angioplasty is an effective procedure for in-stent restenosis (ISR) after coronary stenting, recurrent ISR after PCB angioplasty still occurs. The aim of this study was to evaluate the predictors of recurrent ISR after PCB angioplasty for ISR.Methods and Results:A total of 157 ISR lesions treated with PCB angioplasty from January 2014 to May 2015 were retrospectively examined. Recurrent ISR was judged on 6-month follow-up angiography. Clinical, angiographic and procedural parameters were evaluated as possible predictors of recurrent ISR. Recurrent ISR occurred in 13.9% of lesions after PCB angioplasty. On multivariate analysis the following independent predictors of recurrent ISR were identified: (1) smaller acute gain after initial ballooning (OR, 3.06; 95% CI: 1.08-8.71; P=0.04); (2) geographic mismatch between PCB position and initial ballooning (OR, 5.59; 95% CI: 1.64-19.1; P=0.006); and (3) use of percutaneous transluminal coronary rotational atherectomy (PTCRA) at primary percutaneous coronary intervention (PCI; OR, 5.53; 95% CI: 1.89-16.2; P=0.002). CONCLUSIONS Optimal expansion at initial ballooning before PCB angioplasty and careful positioning of PCB are important technical tips to prevent recurrent ISR after PCB angioplasty. Recurrent ISR occurred more frequently in severely calcified lesions that required PTCRA at primary PCI.

The impact of three-dimensional optical coherence tomography and kissing-balloon inflation for stent implantation to bifurcation lesions

The rates of restenosis and stent thrombosis after the therapeutic stent deployment for bifurcation lesions are still comparably high after the introduction of the new-generation drug-eluting stents (DESs), because of the various factors including their morphology. We experienced a case of a successful percutaneous coronary intervention using three-dimensional optical coherence tomography (3D OCT) with a single stent deployment to a bifurcation lesion of the left anterior descending artery (LAD) and left circumflex artery (LCx) with a following kissing-balloon inflation (KBI). The 3D OCT, after the inflation of the jailed ostium of the LCx following the stent deployment to the LAD crossing the LCx, could clearly demonstrate a stent deformation and incomplete apposition at an opposite site of the LCx, which may cause high rates of restenosis and stent thrombosis. These stent abnormalities were steadily corrected by a subsequent KBI of the LAD and LCx. Furthermore, the 3D OCT images were the same findings as those of the experiments from both an in vitro phantom coronary bifurcation model and macroscopic images of the stent. <Learning objective: In view of this case report, these modalities with three-dimensional optical coherence tomography and the techniques for the following kissing-balloon inflation may be one of the useful and effective therapeutic strategies to reduce the rates of restenosis and stent thrombosis of the percutaneous coronary intervention for bifurcation lesions.>.