Takashi Kajiya

Everolimus-eluting bioresorbable vascular scaffold (BVS) implantation in patients with ST-segment elevation myocardial infarction (STEMI).

AIMS Recent studies have demonstrated favourable clinical outcomes for the everolimus-eluting bioresorbable vascular scaffold (BVS) ABSORB™ in patients with stable coronary artery disease. There are currently no data on its use in patients with ST-segment elevation myocardial infarction (STEMI). We assessed the safety and impact of BVS in the setting of primary percutaneous coronary intervention (PCI) in patients presenting with STEMI to our institution. METHODS AND RESULTS A total of 11 patients who underwent primary PCI with intent for BVS implantation between October 2012 and April 2013 at our institution were included. Median follow-up period was 53.0 ± 45.9 days. One patient presented to the hospital with cardiogenic shock and subsequently died. The other 10 patients did not have any major adverse cardiac events (MACE). There were no acute or subacute stent thromboses at short-term follow-up. CONCLUSIONS These are the first real-world data using BVS in patients with STEMI. The ABSORB™ BVS may be safely used in patients with STEMI undergoing primary PCI with favourable short-term outcome.

Intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism in a patient with Behçet's disease: a case report and literature review

A 26-year-old woman with intermittent fever was admitted to our hospital, and gradually developed facial edema. Examinations including computed tomography, transesophageal echocardiography, digital subtraction angiography, and pulmonary perfusion scintigraphy revealed intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism. Clinical findings and laboratory data led us to make a diagnosis of Behçets disease. Combination of intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism are rare complications in Behçets disease. Behçets disease should be considered in the differential diagnosis of intracardiac mass of the right heart, and early diagnosis and treatment are essential for the management of Behçets disease especially with large-vessel manifestations. In addition to a case report, we review the literature and report the characteristics of intracardiac thrombus in Behçets disease.

Initial experience in the clinical use of everolimus-eluting bioresorbable vascular scaffold (BVS) in a single institution

We read with great interest the recent review article on bioresorbable vascular scaffolds by Bourantas et al. and wish to share our institutions experience with the use of the ABSORB bioresorbable vascular scaffold (BVS; Abbott Vascular, Santa Clara, California) [1]. There is currently limited published data on the use of BVS in routine clinical practice andwehaveundertaken a prospective evaluation of this novel device in our institution. All consecutive patients who underwent percutaneous coronary intervention (PCI) with intent for BVS implantation between July 2011 and September 2012were included in the analysis. All patients received dual anti-platelet therapyprior to PCI and this therapywascontinued for at least a year after implantation. This study fulfilled local ethical requirements and written informed consent was obtained from all patients. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. Once a suitable lesion was identified, the pre-procedural reference vessel diameter (RVD) was assessed by quantitative coronary analysis (QCA) using the Pie Medical CAAS QCA (quantitative coronary analysis) package in our Xcelera Workstations (Philips Medical Systems, Veenpluis, The Netherlands). Alternative vessel sizing was via the use of commercially available intravascular ultrasound (IVUS) or optical coherence tomography (OCT). A RVD of 2.0 to 3.8 mm and a lesion length of less than 28 mm were considered suitable for BVS (single or overlapping). The availableABSORBBVSwere2.5×18 mm,2.5×28 mm, 3.0×18 mm, 3.0×28 mm, 3.5×12 mm, 3.5×18 mm, or 3.5×28 mm in size. 6 Fr vascular access was used in all patients with a predominant radial access (77.1%). Mandatory predilation with balloon angioplasty using a balloon with a diameter of 0.5 mm smaller or equivalent to the intended BVS size was performed prior to BVS implantation. Device deployment was performed at a rate of ≤2 atm per 5 s up to 16 atm (rated burst pressure). Postdilation was with a non-compliant balloon with diameter≤0.25 mm beyond the implanted BVS if necessary to avoid scaffold damage. For longer lesions or edge dissections, overlapping scaffolds were used. A total of 35 consecutive patients with 41 lesions underwent attempted ABSORB BVS implantation during the study period. Baseline emographics, indications, procedure and quantitative coronary angiography details are summarized in Table 1. The mean age is 54.7± 11.2 years (range 36–86 years) and 85.7% of the patients (n=30) were male. Diabetes mellitus (type I or II) was present in 17.1% (n=6) of the study population. 51.4% of patients presented with an acute coronary syndrome including unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). Overall, 45 BVS were successfully implanted in 33 (93.3%) patients (1.4 BVS/patient). Of the 41 lesions treated, the success rate was 100% (22/22) for the left anterior descending artery (LAD), 100% (11/11) for the right coronary artery (RCA), and 75% (6/8) for the left circumflex artery (LCX). Two patients had circumflex (LCX) stenosis not crossable by the BVS despite aggressive lesion preparation with multiple balloon predilations. An equivalent metallic drug eluting stent crossed without difficulty in both cases. The majority, 31 (75.6%), of lesions treated were complex (B2 or C). Pre-procedure RVD was assessed by QCA in 28 patients (80.0%), IVUS in 4 patients (11.4%), andOCT in 3 patients (8.6%). Themeanpre-procedural RVDwas 2.7±0.4 mm, diameter stenosiswas 77.7±13.0%, and lesion lengthwas 17.2±6.7 mm. Post-procedural RVD was 3.0±0.3 mmwith residual diameter stenosis of 2.4±2.0%.

Noninvasive Evaluation of Coronary Reperfusion by CT Angiography in Patients With STEMI

OBJECTIVES The aim of this study was to determine whether 64-slice multidetector computed tomography (MDCT) can differentiate coronary reperfusion with Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 from TIMI flow grade ≤ 2 after ST-segment elevation myocardial infarction (STEMI). BACKGROUND Multidetector computed tomography has become a popular modality for noninvasive coronary artery imaging. Recently, 64-slice MDCT has been applied to evaluate coronary arteries in acute coronary artery disease. METHODS The presence or absence of distal reperfusion in infarct-related arteries (IRA) was visualized with 64-slice MDCT during the acute phase in 87 non-high-risk patients after STEMI. To differentiate TIMI flow grade 3 from TIMI flow grade 2, we calculated the computed tomography (CT) number ratio by dividing the CT number of the contrast-enhanced coronary lumen at the most distal IRA by that at the proximal site to the culprit lesion in patients with reperfusion on MDCT. The MDCT findings were compared with TIMI flow grade with invasive coronary angiography (ICA) performed 20 ± 5 min later. RESULTS According to ICA, 58 patients had TIMI flow grade 0 or 1, 17 had TIMI flow grade 2, and 12 had TIMI flow grade 3, whereas distal reperfusion was evident on MDCT in 28 of the 29 patients with TIMI flow grade ≥ 2 and absent in 55 of the 58 with TIMI flow grade ≤ 1. The CT number ratio was significantly higher in TIMI flow grade 3 than in TIMI flow grade ≤ 2 (0.64 ± 0.11 vs. 0.37 ± 0.12; p < 0.0001). The sensitivity, specificity, and accuracy of a diagnosis of TIMI flow grade 3 on the basis of a CT number ratio of ≥ 0.54 that was an optimal cutoff value determined by receiver-operator characteristic curve analysis were 92%, 97%, and 97%, respectively. CONCLUSIONS Visualization of the IRA by 64-slice MDCT enables noninvasive differentiation of angiographic TIMI flow grade 3 from TIMI flow grade ≤ 2 coronary reperfusion during the acute phase in patients with STEMI.

Comparison of a new slender 6 Fr sheath with a standard 5 Fr sheath for transradial coronary angiography and intervention: RAP and BEAT (Radial Artery Patency and Bleeding, Efficacy, Adverse evenT), a randomised multicentre trial

AIMS The 6 Fr Glidesheath Slender (GSS6Fr) is a recently developed thin-walled radial sheath with an outer diameter (OD) that is smaller than the OD of standard 6 Fr sheaths. The purpose of this trial was to clarify whether the use of this new slender sheath would result in similar rates of RAO to a standard 5 Fr sheath in unselected patients undergoing transradial (TR) coronary angiography and/or intervention, and to assess the relative importance of sheath size and haemostasis protocol on the rate of RAO. METHODS AND RESULTS We conducted a randomised, multicentre, non-inferiority trial comparing the GSS6Fr against the standard GS5Fr in patients undergoing TR coronary angiography and/or intervention. Patients in each group were subsequently randomised to undergo patent haemostasis or the institutional haemostasis protocol. The primary endpoint was the occurrence of RAO at discharge. A total of 1,926 patients were randomised in 12 centres. The incidence of RAO was 3.47% with GSS6Fr compared with 1.74% with GS5Fr (risk difference 1.73%, 95% CI: 0.51-2.95%; pnon-inferiority=0.150). Patients randomised to patent haemostasis had a similar rate of RAO compared with institutional haemostasis (2.61% vs. 2.61%, p=1). There was no difference with regard to all secondary endpoints, including vascular access-site complications, local bleeding and spasm. CONCLUSIONS In this large multicentre randomised trial, the GSS6Fr was associated with a low event rate for the primary endpoint (RAO), although non-inferiority to the GS5Fr was not met, due to a lower than expected rate of RAO in the GS5Fr group. As compared to institutional haemostasis, the use of patent haemostasis was not associated with a reduced rate of RAO.

A single-center experience of transitioning from a routine transfemoral to a transradial intervention approach in ST-elevation myocardial infarction: Impact on door-to-balloon time and clinical outcomes

BACKGROUND In the emergent setting of ST-elevation myocardial infarction (STEMI), transradial intervention (TRI) is less frequently employed than transfemoral intervention (TFI). Because of the greater technical complexity of TRI, a potential compromise in door-to-balloon (DTB) time remains a major concern of centers adopting TRI for STEMI. METHODS We performed a propensity-matched analysis, with 1:1 matching of TRI and TFI patients comparing DTB time, 30-day major adverse cardiac event (MACE), and bleeding outcomes of 1052 consecutive STEMI patients managed at our center during a 2-year transition program from routine TFI to TRI access for STEMI. RESULTS From January 2008 to April 2010, 359 (34.1%) STEMI patients underwent TRI and the remaining 693 (65.9%) STEMI patients underwent TFI. In 283 propensity score matched pairs of TRI and TFI patients, TRI was associated with shorter DTB time (63.6min vs 69.4min, p=0.027) and more patients having DTB time<90min (88.3% vs 82.3%, p=0.043). Thirty-day MACE occurred in 1.0% in the TRI group and 3.0% in the TFI group (p=0.129). There was no significant difference in major (p=0.313) or minor bleeding (p=0.714) between the TRI and TFI groups. There was a twofold greater use of glycoprotein (GP) IIb/IIIa inhibitor in the TRI group (68.5%) compared with the TFI group (36.4%) (p<0.001). CONCLUSION Compared with TFI, TRI was not associated with longer DTB time during our centers transition from routine TFI to TRI in STEMI. Our experience suggests that the transition to TRI in STEMI can be safely achieved with DTB times that are comparable and possibly better than propensity-matched TFI cases.

Impact of sheath size and hemostasis time on radial artery patency after transradial coronary angiography and intervention in Japanese and non-Japanese patients: A substudy from RAP and BEAT (Radial Artery Patency and Bleeding, Efficacy, Adverse evenT) ra

During transradial (TR) access, it remains unclear whether differences in baseline patients characteristics and hemostasis care impact the rate of radial artery occlusion (RAO). We sought to compare the rate of RAO after TR access with the 6 French(Fr) Glidesheath Slender (GSS6Fr, Terumo, Japan) or a standard 5 Fr sheath in Japanese and non‐Japanese patients.

In-stent restenosis assessed by frequency-domain optical coherence tomography shows smooth coronary arterial healing process in second-generation drug-eluting stents

INTRODUCTION The pathophysiology and mechanism of in-stent restenosis (ISR) after implantation of second-generation drug-eluting stents (DESs) are not fully clear. We compared the morphological characteristics of ISR between first- and second-generation DESs using frequency domain optical coherence tomography (OCT). METHODS Patients who underwent follow-up coronary angiography (CAG) after first-generation (CYPHER™ and TAXUS™) and second-generation (Nobori®, PROMUS Element™, Resolute Integrity and XIENCE) DES implantations were examined. ISR was defined as lesions of over 50% diameter stenosis at follow-up CAG. Frequency domain OCT was performed at the time of revascularisation of ISR. Tissue morphology was assessed at minimum lumen area. OCT images of DESs at both early (≤ 1 year) and late (> 1 year) phase follow-up were compared. RESULTS On qualitative OCT assessment, the ratios of homogeneous, layered, heterogeneous without-attenuation and heterogeneous with-attenuation morphologies were 57.1%, 17.1%, 20.0% and 5.7%, respectively, for second-generation DES ISR (n = 35), and 16.7%, 25.0%, 25.0% and 33.3%, respectively, for first-generation DES ISR (n = 36). At late phase follow-up, homogeneous morphology was significantly more common for second-generation DES ISR compared to first-generation DES ISR (first-generation: 8.0% vs. second-generation: 50.0%; p < 0.01) while heterogeneous with-attenuation morphology was significantly more common for first-generation DES ISR (first-generation: 44.0% vs. second-generation: 5.6%; p < 0.01). CONCLUSION Homogeneous tissue morphology was more frequently found for second-generation than first-generation DES ISR, especially in the late phase. This suggested that neointimal hyperplasia was the main mechanism in second-generation DES ISR, and that the neointima was stabilised, much like in bare metal stent implantation.

High-grade culprit lesions are a common cause of ST-segment elevation myocardial infarction.

INTRODUCTION Conventional knowledge holds that the majority of ruptured atherosclerotic plaques causing ST-segment elevation myocardial infarction (STEMI) are found in moderate stenoses that produce < 50% loss of arterial diameter. This study aimed to analyse the culprit lesions in patients who presented with STEMI and underwent primary percutaneous coronary intervention (PPCI) at our institution. METHODS Patients who underwent PPCI between June 2008 and August 2010 at our institution were included in the analysis. Quantitative coronary angiography was performed for the culprit lesions immediately after antegrade flow was restored by thrombectomy, low-profile balloon predilatation or guidewire crossing. RESULTS A total of 1,021 patients were included in the study. The mean age was 57 ± 12 years and 85.2% were male. Lesion measurement was done after coronary flow was restored by thrombectomy (73.1%), balloon dilatation (24.1%) and following guidewire passage across the lesion (2.8%). Mean minimal luminal diameter was 1.1 ± 0.5 mm, mean reference vessel diameter was 2.8 ± 0.6 mm, mean diameter stenosis was 61 ± 16% and mean lesion length was 16 ± 6 mm. Most (80.2%) of the culprit lesions had diameter stenoses > 50% (p < 0.01). Although balloon angioplasty was performed in 24.1% of the patients, the majority (64.2%) still had diameter stenoses > 50%. High-grade stenoses (> 50%) were more frequently observed in male patients (p = 0.04). CONCLUSION Contrary to the existing paradigm, we found that most of the patients with STEMI in our institution had culprit lesions with diameter stenosis > 50%.

Heart failure caused by atrial fibrillation in a patient with isolated adrenocorticotropic hormone deficiency and hashimoto's thyroiditis

We report the case of a 75-year-old female patient with a history of Hashimoto′s thyroiditis who presented with congestive heart failure caused by atrial fibrillation associated with isolated adrenocorticotropic hormone (ACTH) deficiency. This is the first case of the combination of these complex conditions. Clinical conditions in a patient with isolated ACTH deficiency and Hashimoto′s thyroiditis can be variable. Thus, it is sometimes difficult to establish a diagnosis. The mechanism underlying heart failure may be complex in some cases. Various conditions can affect patients simultaneously. Therefore, making a proper diagnosis is necessary to improve the patient′s prognosis.