Noriyuki Kinoshita

Assessment of Takotsubo cardiomyopathy (transient left ventricular apical ballooning) using 99mTc-tetrofosmin, 123I-BMIPP, 123I-MIBG and 99mTc-PYP myocardial SPECT.

We compared Takotsubo cardiomyopathy (transient left ventricular apical ballooning) with acute myocardial infarction (AMI) using two-dimensional echocardiography,99mTc-tetrofosmin,99mTc-PYP,123I-BMIPP and123I-MIBG myocardial SPECT.Methods: We examined 7 patients with Takotsubo cardiomyopathy and 7 with AMI at the time of emergency admission (acute phase), and 2-14 days (subacute phase), one month (chronic phase), and 3 months (chronic II phase) after the attack. The left ventricle was divided into nine regions on echocardiograms and SPECT images, and the degree of abnormalities in each region was scored according to five grades from normal (0) to severely abnormal (4).Results: Coronary angiography showed the absence of stenotic regions in patients with Takotsubo cardiomyopathy, and severely stenotic and/or occlusive lesions in patients with AMI. The total ST segment elevation on electrocardiograms (mm) was 7.8 ± 3.7 in those with Takotsubo cardiomyopathy, and 7.3 ± 3.9 in patients with AMI. Abnormal wall motion scores on echocardiograms were 14.2 ± 4.6, 4.7 ± 4.0, 1.7 ± 2.0 and 0.5 ± 0.4 during the acute, subacute, chronic and chronic II phases, respectively, in patients with Takotsubo cardiomyopathy, and 14.0 ± 4.3, 11.4 ± 3.9, 8.8 ± 3.6 and 5.2 ± 4.8 in those with AMI. Abnormal myocardial perfusion scores on99mTc-tetrofosmin images were 11.8 ± 3.5, 3.2 ± 3.0, 0.5 ± 1.2 and 0.2 ± 0.4 during the acute, subacute, chronic and chronic II phases, in patients with Takotsubo cardiomyopathy, and 16.2 ± 4.3, 13.9 ± 4.6, 7.9 ± 4.6 and 5.0 ± 4.5, respectively, in those with AMI. Abnormal myocardial fatty acid scores on123I-BMIPP images were 12.6 ± 3.7, 6.8 ± 3.2 and 0.4 ± 0.6 during the subacute, chronic and chronic II phases, respectively, in patients with Takotsubo cardiomyopathy, and 16.5 ±5.1,14.7 ± 4.8 and 7.5 ± 4.5 in those with AMI. Abnormal myocardial sympathetic nerve function scores on123I-MIBG images were 14.8 ± 4.0, 8.8 ± 4.0 and 0.4 ± 0.6 during the subacute, chronic, chronic II phases, respectively, in patients with Takotsubo cardiomyopathy, and 18.6 ± 6.5, 16.8± 6.8 and 12.9 ± 5.2 in those with AMI. Myocardial99mTc-PYP uptake was abnormal not only in patients with AMI but also in those with Takotsubo cardiomyopathy during the acute phase.Conclusions: Takotsubo cardiomyopathy might represent a stunned myocardium caused by a disturbance of the coronary microcirculation.

Indications and outcomes of excimer laser coronary atherectomy: Efficacy and safety for thrombotic lesions—The ULTRAMAN registry

BACKGROUND Excimer laser coronary atherectomy (ELCA) recently became available in Japan, but ELCAs effectiveness and safety are not clear. METHODS AND RESULTS We enrolled consecutive patients who underwent ELCA and were registered in the Utility of Laser for Transcatheter Atherectomy-Multicenter Analysis around Naniwa (ULTRAMAN) registry comprising six Japanese medical centers around Naniwa in Japan with patients registered from April 2006 to June 2015. We evaluated the catheter sizes used and compared the success rate, thrombolysis in myocardial infarction (TIMI) flow, blush score, and complications between the rich-thrombus (RT) group [acute coronary syndrome (ACS) and saphenous vein graft (SVG)] and the poor-thrombus (PT) group [in-stent restenosis (ISR), chronic total occlusion (CTO), calcification, and long or bifurcation (L&B) lesions]. Of the 328 patients, 6 (1.8%) were treated for an SVG, 175 (53.4%) were treated for ACS, 18 (5.5%) for CTO, 106 (32.4%) for ISR, 8 (2.4%) for calcification, and 15 for L&B lesions (4.6%). A 1.7-mm (concentric)-diameter ELCA catheter was used most frequently (59.4%). High success rates were achieved in both the RT and PT groups, but the TIMI flow grade and blush score were significantly lower and the complications rate was significantly higher in the RT group (n=181). CONCLUSIONS In Japan, the major indications for ELCA have been ACS and ISR. ELCA can provide a safe and effective treatment even for RT lesions.

A successful treatment for a lesion of chronic total occlusion using guiding catheter lock technique

excimer laser coronary atherectomy using a 0.9-mm X80 catheter (Vitesse RX, Spectranetics, Federal Drive, Colorado Springs, CO, USA) and stent deployment using GC lock technique (Fig. 1b). We performed manual infusion of the lactate ringer solution for flashing. Although there was some resistance of infusion, the flashing was sufficiently possible using 5F guiding catheter. This technique is the method of increasing the GC back-up force. The GC inserted into RCA was fixed by balloon dilatation (Trek Rx Abbott CO., Ltd. Tokyo, Japan: 2.5 × 15 mm 12 atm) at in-stent of ostium RCA via contralateral GC. When the ostium part is intact, it is necessary to pay attention to balloon size and inflation pressure of locking balloon to prevent balloon injuries. There are ischemia by wedge position and coronary dissection as possible complications during this technique; therefore, we must perform a careful procedure. As for the adequate size of a balloon or pressure, it is necessary to choose the balloon size and the outer diameter of GC, so that it is the same size as the vessel diameter. Regarding the indication of this technique, we consider a case where the stent is placed or the stent is scheduled to be placed in the ostial part with two arterial access site. When using greater than 0.9-mm excimer laser catheter or 1.5-mm rota burr with 5F GC, we consider that this technique is a contraindication. The patient’s clinical course was uneventful, and he was discharged the day after the PCI without any complication. In recent years, with the spread of transradial coronary intervention (TRI) and use of small-diameter catheters, percutaneous coronary intervention (PCI) has been showing a tendency to less invasive. Yoshimachi et al. showed PCI with the 5F guiding catheter (GC) system was safe and feasible, and radial artery occlusion and major bleeding complications were extremely low [1]. However, since back-up force of 5F GC is weaker than 6F or 7F, various ideas are needed to strengthen back-up force for complex lesion. We describe the successful treatment of chronic total occlusion (CTO) lesion using new technique of strengthening GC back-up force. A 59-year-old man was admitted due to effort-related chest squeezing for 3 months. In 2009, the patient was treated at ostial lesion of right coronary artery (RCA) due to unstable angina pectoris with sirolimus-eluting stent. Coronary angiogram showed a total occlusion of the midRCA with collateral vessels from left coronary artery (LCA) (Fig. 1a). The 5Fr sheathless GC WORKS JR4 (Medkit CO., Ltd. Tokyo, Japan) was engaged into the RCA via right brachial artery because his radial artery was very spastic. The 5Fr Heartrail II IL3.5 (Terumo CO., Ltd. Tokyo, Japan) was inserted into LCA via left brachial artery for simultaneous contralateral angiography. The Ikari left was originally designed for the left coronary artery, but its shape is also good for the right coronary artery. The XT-R (ASAHI INTECC CO., Ltd. Nagoya, Japan) guide wire was advanced to the distal of the occluded lesion. However, microcatheter could not pass the lesion. Therefore, we performed

A successful treatment for a lesion of chronic total occlusion with contralateral angiography in a single radial access.

A 50-year-old man was admitted due to effort chest pain. Coronary angiogram showed a total occlusion of LAD. The 5-French JL 3.5 was engaged into the left coronary artery. The XT-A guidewire was advanced to the distal of the occluded lesion. Contralateral angiography was performed using JL 3.5. The guiding catheter was pullback from the left coronary orifice leaving the guidewire at LAD, and the catheter tip was rotated clockwise to right coronary cusp for right coronary angiography. We could confirm that the guidewire was in the true lumen vessel.