Sho Hashimoto

Prognostic impact of systolic blood pressure at admission on in-hospital outcome after primary percutaneous coronary intervention for acute myocardial infarction

BACKGROUND Data regarding the relationship between systolic blood pressure (SBP) at admission and in-hospital outcome in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) are still lacking in Japan. METHODS AND RESULTS A total of 1475 primary PCI-treated AMI patients were classified into quintiles based on admission SBP (<105 mmHg, n=300; 105-125 mmHg, n=294; 126-140 mmHg, n=306; 141-158 mmHg, n=286; and ≥159 mmHg n=289). The patients with SBP<105 mmHg tended to have higher age, previous myocardial infarction, chronic kidney disease (CKD), Killip class≥3 at admission, right coronary artery, left main trunk (LMT), or multivessels as culprit lesions, larger number of diseased vessels, lower Thrombolysis In Myocardial Infarction (TIMI) grade in the infarct-related artery before primary PCI, and higher value of peak creatine phosphokinase concentration. Patients with SBP<105 mmHg had a significantly higher mortality, while mortality was not significantly different among the other quintiles: 24.3% (<105 mmHg), 4.8% (105-125 mmHg), 4.9% (126-140 mmHg), 2.8% (141-158 mmHg), and 5.2% (≥159 mmHg) (p<0.001). On multivariate analysis, Killip class≥3 at admission, LMT or multivessels as culprit lesions, admission SBP<105 mmHg, CKD, and age were the independent positive predictors of in-hospital mortality, whereas admission SBP 141-158 mmHg and TIMI 3 flow after PCI were the negative ones, but admission SBP 105-125 mmHg, admission SBP 126-140 mmHg, and admission SBP≥159 mmHg were not. CONCLUSIONS These results suggest that admission SBP 141-158 mmHg might be correlated with better in-hospital prognosis, whereas admission SBP<105 mmHg was associated with in-hospital death in Japanese AMI patients undergoing primary PCI.

Prognostic impact of pulse pressure at admission on in-hospital outcome after primary percutaneous coronary intervention for acute myocardial infarction

Data regarding relationship between pulse pressure (PP) at admission and in-hospital outcome in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) are still lacking. A total of 1413 primary PCI-treated AMI patients were classified into quintiles based on admission PP (<40, n = 280; 40–48, n = 276; 49–57, n = 288; 58–70, n = 288; and ≥71 mmHg, n = 281). The patients with PP < 40 mmHg tended to have higher prevalence of male, smoking, and Killip class ≥3 at admission; right coronary artery, left main trunk (LMT), or multivessels as culprit lesions; larger number of diseased vessels; lower Thrombolysis in Myocardial Infarction (TIMI) grade in the infarct-related artery before/after primary PCI; and higher value of peak creatine phosphokinase concentration. Patients with PP < 40 mmHg had highest mortality, while patients with PP 49–57 mmHg had the lowest: 11.8 % (<40), 7.2 % (40–48), 2.8 % (49–57), 5.9 % (58–70), and 6.0 % (≥71 mmHg). On multivariate analysis, Killip class ≥3 at admission, LMT or multivessels as culprit lesions, chronic kidney disease, and age were the independent positive predictors of the in-hospital mortality, whereas admission PP 49–57 mmHg, hypercholesterolemia, and TIMI 3 flow before/after PCI were the negative ones, but admission PP < 40 mmHg was not. These results suggest that admission PP 49–57 mmHg might be correlated with better in-hospital prognosis in Japanese AMI patients undergoing primary PCI.

Primary percutaneous coronary intervention and intravascular ultrasound imaging for coronary thrombosis after cisplatin-based chemotherapy

Although cisplatin is indispensable for the chemotherapy treatment of many malignancies, cisplatin-associated thrombosis is attracting increasing attention. However, experience of primary percutaneous coronary intervention (PCI) and intravascular ultrasound imaging (IVUS) for coronary thrombosis, possibly due to cisplatin-based chemotherapy, has been limited. Case 1 with postoperative gastric cancer developed acute myocardial infarction (AMI) on the sixth day of the second chemotherapy course with conventional doses of cisplatin and tegafur gimeracil oteracil potassium. Emergency coronary angiography (CAG) showed a filling defect in the proximal left anterior descending coronary artery (LAD) concomitant with no reflow in the distal LAD. Case 2 with advanced lung cancer and brain metastasis suffered AMI on the fifth day of the first chemotherapy course with conventional doses of cisplatin and gemcitabine. Emergency CAG delineated a total occlusion in the proximal right coronary artery. In both cases, thrombectomy using aspiration catheter alone obtained optimal angiographic results and subsequent IVUS revealed no definite atherosclerotic plaque, while slow flow still remained even after selective intra-coronary infusion of vasodilator in the case 1. These cases suggest that primary PCI using thrombus-aspiration catheter might be safe and effective for coronary thrombosis due to cisplatin-based chemotherapy.

Percutaneous coronary intervention for nonagenarian patients with ST-segment elevation myocardial infarction: Experience of a single Japanese center

BACKGROUND Old age is a prognostic risk factor for patients with ST elevation acute myocardial infarction (STEMI); however, few data exist describing STEMI patients aged over 90 years. METHODS We retrospectively evaluated the clinical indices and outcomes of 282 consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) in our hospital between January 2008 and December 2012. Patients with acute myocardial infarction complicated by out-of-hospital cardiopulmonary arrest, patients with a left main trunk culprit lesion, and patients diagnosed more than 24h after symptom onset were excluded. RESULTS Of the patients treated during the study period, 11 (3.8%) were >90 years old. The mean door-to-balloon time was significantly longer for nonagenarians than younger patients (66.2 vs. 44.0minutes; p<0.001). This was mainly attributed to delays in decision-making regarding invasive treatment by both the doctors and families. Nonagenarians had multiple coronary artery stenoses more frequently (36.4% vs. 15.0%; p<0.05) and required intra-aortic balloon pumping more often (36.4% vs. 18.9%; p=0.15) compared with patients aged ≤89 years. However, the peak creatinine kinase levels and the left ventricular ejection fractions were similar between the groups. Moreover, the in-hospital and 30-day mortality rates were similar (9.1% vs. 4.6%, p=0.50; 9.1% vs. 3.6%, p=0.34, respectively) between the groups. The two-year survival rate was 81.8% in nonagenarians. CONCLUSIONS Despite the longer door-to-balloon time, higher use of intra-aortic balloon pumping, and larger number of diseased vessels, the 30-day and 2-year survival rates of nonagenarians with STEMI were comparable to those of younger patients.

Impact of the Presence of Chronic Total Occlusion in a Non-Infarct-Related Coronary Artery in Acute Myocardial Infarction Patients.

Chronic total occlusion (CTO) in a non-infarcted-related artery was reported to worsen immediate clinical outcome in acute myocardial infarction (AMI) patients. However, the prognosis of such patients with preserved left ventricular function after successful primary percutaneous coronary intervention (PCI) has not yet been clarified. The aim of the present study was to evaluate whether the presence of CTO contributes to a worse prognosis even in patients with preserved left ventricular function after primary PCI.We retrospectively analyzed 353 consecutive patients with acute myocardial infarction, whose left ventricular ejection fraction (LVEF) was not less than 40% in the echocardiography performed 1 day after primary PCI. We divided the patients into two groups according to the presence (n = 25) or absence (n = 328) of CTO in the non-infarct-related coronary artery, and compared the clinical outcome of patients between the two groups.The LVEF estimated by echocardiography after primary PCI was similar between patients with and without CTO (55.1 ± 8.6% versus 58.0 ± 9.4%; P = 0.07). The peak creatine kinase value was also similar between the two groups (1539 versus 1921 U/L; P = 0.33); however, CTO patients were significantly more likely to undergo intra-aortic balloon pumping (56.0% versus 12.5%; P < 0.001) during primary PCI, and 30-day mortality was significantly higher in CTO patients (12.0% versus 0.9%; P < 0.001). By multivariate analysis, cardiogenic shock at arrival was significantly correlated with 30-day mortality.Even though the LVEF of AMI patients with CTO was preserved after successful PCI, a high mortality rate was observed.

Severe catheter kinking and entrapment during transbrachial angiography: percutaneous retrieval with a slender approach

A 74-year-old man previously treated with bilateral femoro-popliteal bypass was referred to our hospital for the treatment of a severely tangled 4-Fr diagnostic catheter in the right brachial artery. We inserted a 5-Fr sheath introducer from the proximal right femoral artery and advanced a 5-Fr JR catheter to the right brachial artery. A Sion coronary guidewire was then advanced for the tip of the tangled catheter, and a 4-mm gooseneck snare catheter was inserted through the guidewire. The tip of the catheter was caught and successfully removed after clockwise untwisting. The patient was discharged the next day without any complications.

Usefulness of the Twin Guidewire Method During Retrieval of the Broken Tip of a Microcatheter Entrapped in a Heavily Calcified Coronary Artery

During percutaneous coronary intervention performed for a stenotic lesion with heavy calcification in the left coronary artery, the microcatheter tip became transected in the vessel. The fragment was successfully retrieved using the twin guidewire method after negotiating to cross a chronic total occlusion-dedicated guidewire outside the retained tip.

Spontaneous rotation of the monorail-type guide extension support catheter during advancement of a curved guiding catheter: the potential hazard of twisting with the coronary guidewire

The extension support guiding catheter has been used to perform complex percutaneous coronary intervention to increase back-up support for the guiding catheter or to ensure deep intubation for device delivery. However, because of its monorail design, advancement of the stent into the distal extension tubing segment is sometimes problematic. Although this problem is considered due to simple collision of the stent, operators have observed tangling between a monorail extension catheter and coronary guidewire in some patients. To examine movement of the collar of the extension guide catheter during advancement of the guiding catheter, we set up an in vitro model in which the guiding catheter had two curves. Rotation of the extension guide catheter was examined by both fluoroscopic imaging and movement of the hub of the proximal end of the catheter. During advancement in the first curve, the collar moved toward the outer side of the curve of the guiding catheter as the operator pushed the shaft of the extension guiding catheter, which overrode the guidewire. After crossing the first curve, the collar moved again to the outer side of the second curve (the inner side of the first curve) of the mother catheter, and then, another clockwise rotation was observed in the proximal hub. Consequently, the collar and tubing portion of the extension guide catheter rotated 360° around the coronary guidewire, and the monorail extension catheter and guidewire became tangled. There is a potential risk of unintentional twisting with the guidewire during advancement into the curved guiding catheter because of its monorail design.

CRT-100.85 Excimer Laser Coronary Angioplasty for In-stent Restenosis: Impact of Tissue Characteristics Assessed by Optical Coherence Tomography on Acute and Mid-term RESULTS

The effect of excimer laser coronary angioplasty (ELCA) for in-stent restenosis (ISR) in bare-metal stent has been proved to be ineffective when conducted under angiography or intravascular ultrasound guidance. We sought to evaluate the clinical significance of tissue characteristics assessed by

Examination of the appropriate timing of reperfusion therapy for recent myocardial infarction: a Japanese single-center retrospective study

Background The various guidelines clearly mention the treatment strategies for in patient of acute myocardial infarction (MI) presenting more than 24 h from symptom onset (recent myocardial infarction, RMI). However, the appropriate timing of reperfusion for RMI is unclear. Methods We retrospectively evaluated 525 consecutive MI patients who underwent percutaneous coronary intervention (PCI) in our hospital between January 2008 and December 2012. Results Sixty RMI patients were more frequently associated with cardiac complications such as myocardial rupture (3.3% vs. 0%; p < 0.01), ventricular septal rupture (3.3% vs. 0.4%; p < 0.05), and congestive heart failure (15% vs. 2.6%; p < 0.001) than 272 consecutive ST-elevation myocardial infarction (STEMI) patients. Of the 60 RMI patients, 33 (55.0%) underwent PCI within 7 days (early-PCI group) and 27 (45.0%) underwent PCI after 7 days (late-PCI group). Left ventricular ejection fraction measured by echocardiography at second hospital day was similar between the groups. The early-PCI group was more significantly associated with cardiogenic shock and heart failure and more frequently required intra-aortic balloon pumping (24.2% vs. 3.7%; p < 0.05) than the late-PCI group. There were no significant differences in 30-day mortality, cardiac complications, and major cardiac events during long-term follow-up (12–36 months) between the groups. Conclusion RMI patients had a higher incidence of cardiac complications than AMI patients. Clinical outcomes were similar between patients undergoing early revascularization and those undergoing late revascularization, although the former group included a higher proportion of patients with severe cardiac failure.