Takuya Sumi

Impact of coronary stent designs on acute stent recoil

BACKGROUND Acute stent recoil has been often observed following stent delivery balloon deflation in coronary arteries and the recoil rate varies by stent design. Accordingly, the purpose of the present study was to evaluate the impact of stent designs on acute stent recoil after new generation drug-eluting stent implantation. METHODS AND RESULTS A total of 154 lesions [56 treated with biolimus-eluting stent (BES), 46 with cobalt chromium everolimus-eluting stent (CoCr-EES), and 52 with platinum chromium everolimus-eluting stent (PtCr-EES)] were evaluated. Quantitative coronary angiography was used to measure the minimal lumen diameter (MLD). MLD1 was defined as a MLD of complete expansion of the last stent delivery balloon at the highest pressure. MLD2 was defined as a MLD immediately after the last stent delivery balloon deflation. Acute stent recoil was determined by the calculation as (MLD1-MLD2)/MLD1. Acute stent recoil was significantly higher in the CoCr-EES group versus the BES group and PtCr-EES group (10.1 ± 6.9%, 6.7 ± 5.5%, and 6.5 ± 4.8%, respectively, p = 0.01). Multivariate linear regression analysis demonstrated that the use of CoCr-EES and the number of stent delivery balloon inflations were independent predictors of acute stent recoil (r = 0.26, β = 0.21, p = 0.01 and r = -0.51, β = -0.58, p < 0.01, respectively). CONCLUSION Acute stent recoil occurred more frequently with the CoCr-EES compared with both BES and PtCr-EES. Strategies with multiple balloon inflation might be needed to overcome this recoil phenomenon.

Nutrition Status Predicts Severity of Vascular Calcification in Non-Dialyzed Chronic Kidney Disease

BACKGROUND Vascular calcification is a major complication in chronic kidney disease (CKD) that increases the risk of adverse clinical outcomes. Geriatric nutritional risk index (GNRI) is a simple nutritional assessment tool that predicts poor prognosis in elderly subjects. The purpose of the present study was to evaluate the correlation between GNRI and severity of vascular calcification in non-dialyzed CKD patients.Methods and Results:We enrolled 323 asymptomatic CKD patients. To evaluate abdominal aortic calcification (AAC), we used aortic calcification index (ACI) determined on non-contrast computed tomography. The patients were divided into three groups according to GNRI tertile. Median ACI significantly decreased with increasing GNRI tertile (15.5%, 13.6%, and 7.9%, respectively; P=0.001). On multivariate regression analysis GNRI was significantly correlated with ACI (β=-0.15, P=0.009). We also investigated the combination of GNRI and C-reactive-protein (CRP) for predicting the severity of AAC. Low GNRI and high CRP were significantly associated with severe AAC, compared with high GNRI and low CRP (OR, 4.07; P=0.004). CONCLUSIONS GNRI was significantly associated with AAC in non-dialyzed CKD patients.

Unruptured Left Coronary Sinus of Valsalva Aneurysm Causing Mitral Valve Obstruction

A 77-year-old man was admitted for congestive heart failure. He had started to have palpitations after eating supper 2 days before the admission and had experienced dyspnea on exertion since then. He visited his family physician, who referred him to the cardiology clinic of our hospital. The patient was under the family physicians care for diabetes mellitus, hypertension, and paroxysmal atrial fibrillation. He had never been diagnosed as having any organic heart disease. He was an ex-smoker and drank alcohol on social occasions. The patient was on β-blockers and Coumadin. His cardiovascular physical examination was significant for a 3/6 systolic murmur and a rapid, irregular heart beat. His ECG showed atrial fibrillation with a ventricular rate of 150 bpm. His portable chest x-ray (Figure 1A) showed bilateral pleural effusion and pulmonary edema. An emergency transthoracic echocardiogram showed normal left and right ventricular function. A large mass in the left atrium was seen that was causing functional mitral stenosis. The patient was admitted to the hospital, given digoxin, and started on intravenous diuresis. His ECG on normal sinus rhythm (Figure 1B), which was …

Impact of Geriatric Nutritional Risk Index on cardiovascular outcomes in patients with stable coronary artery disease

BACKGROUND The association between malnutrition and cardiovascular prognosis in patients with stable coronary artery disease remains unclear. The aim of this study was to evaluate the association between Geriatric Nutritional Risk Index (GNRI), a simple tool to assess nutritional risk, and long-term outcomes after elective percutaneous coronary intervention (PCI). METHODS This study consisted of 802 patients (age, 70±10 years, male, 69%) who underwent elective PCI. GNRI was calculated at baseline as follows: GNRI=[14.89×serum albumin (g/dl)+[41.7×(body weight/body weight at body mass index of 22)]]. Patients were then divided into three groups as previously reported: GNRI <92, 92 to ≤98, and >98. The endpoint of this study was the composite of cardiac death or non-fatal myocardial infarction. RESULTS During a median follow-up period of 1568 days, 56 cardiac events occurred. Using Kaplan-Meier analysis, the 4-year event-free rates were found to be 79% for GNRI <92, 90% for GNRI 92 to ≤98, and 97% for GNRI >98 (log-rank test p<0.001). GNRI <92 and GNRI 92 to ≤98 showed 6.76-fold [95% confidence interval (CI) 3.13-14.56, p<0.001] and 3.03-fold (HR 3.03, 95%CI 1.36-6.78, p=0.007) increase in the incidences of cardiac death or non-fatal myocardial infarction compared with GNRI >98 after adjusting for confounding factors. CONCLUSION GNRI significantly associated with cardiac events after elective PCI. Further studies should be performed to establish appropriate therapeutic strategies for this vulnerable patient group.

Decreased Serum Albumin Predicts Bleeding Events in Patients on Antiplatelet Therapy After Percutaneous Coronary Intervention

BACKGROUND Antiplatelet therapy (APT) after percutaneous coronary intervention (PCI) prevents ischemic events with increased risk of bleeding. Little is known about the relationship between hypoalbuminemia and bleeding risk in patients receiving APT after PCI. This study investigated the association between serum albumin level and bleeding events in this population.Methods and Results:We enrolled 438 consecutive patients who were prescribed dual APT (DAPT; aspirin and thienopyridine) beyond 1 month after successful PCI without adverse events. The patients were divided into 3 groups according to serum albumin tertile: tertile 1, ≤3.7 g/dL; tertile 2, 3.8-4.1 g/dL; and tertile 3, ≥4.2 g/dL. Adverse bleeding events were defined as Bleeding Academic Research Consortium criteria types 2, 3, and 5. During the median follow-up of 29.5 months, a total of 30 adverse bleeding events were observed. Median duration of DAPT was 14 months. The tertile 1 group had the highest risk of adverse bleeding events (event-free rate, 83.1%, 94.3% and 95.8%, respectively; P<0.001). On Cox proportional hazards modeling, serum albumin independently predicted adverse bleeding events (HR, 0.10, 95% CI: 0.027-0.39, P=0.001, for tertile 3 vs. tertile 1). CONCLUSIONS Decreased serum albumin predicted bleeding events in patients with APT after PCI.

Coronary air embolism following transbronchial lung biopsy

An 80-year-old man with IgG4-related kidney disease underwent bronchoscopy for evaluation of a right middle lobe nodule. Immediately after the transbronchial lung biopsy (TBLB) from the right lateral segment (B4), his heart rate suddenly dropped to < 20 bpm, and an electrocardiogram showed complete atrioventricular block and ST elevation in leads II, III, and aVF (Fig. 1a). Emergency coronary angiography, following temporary transvenous pacemaker insertion, revealed total occlusion at the distal portion of the left anterior descending (LAD) artery, and the right coronary artery (RCA) was filled with embolized air (Fig. 1b, c, Online Video 1). Manual aspiration was performed using a 4Fr diagnostic catheter in both the RCA and LAD, and a final angiogram showed excellent results with complete recanalization (Fig. 1d, e). Thereafter, we performed wholebody computed tomography (CT) imaging, which revealed multiple foci of air embolism observed in the ascending aorta, left ventricle, and cerebral vessels, as well as pneumothorax in the right lung and pneumomediastinum (Fig. 1f–j). Next, we attempted to evacuate as much residual air as possible in the ascending aorta using a 4Fr multi-orifice pigtail catheter. After completion of the procedure, he was hemodynamically stable with clear consciousness, demonstrating only minor neurological mobility impairment. However, we maintained the patient in a supine position under administration of oxygen until we had confirmed elimination of all residual air using a follow-up CT. Hyperbaric oxygen therapy was not used in this case to prevent further entry of gas due to positive ventilation pressure. Peak creatine kinase level was 1615 IU/l and echocardiogram showed only mild hypokinesis of inferior wall. The patient was discharged after rehabilitation following an uneventful course. Systemic air embolism following TBLB is an extremely rare complication, and only a few reports have described cerebral infarction induced by air embolism [1]. Although its mechanism has not been fully elucidated, high bronchial pressure and venous trauma induced by a biopsy can explain this complication. Mechanical tissue destruction might

Vasospastic angina in a 16-year-old female

150 J of biphasic shock. After confirming the diagnosis of vasospastic angina (VSA), we resumed the medication, and the patient had an uneventful course without recurrence of chest symptoms after discharge. VSA is mainly observed in middle-aged or older males who are at risk for atherosclerotic cardiovascular disease. VSA in premenopausal females is considered very rare due to high estrogen levels, which regulate endothelial function and prevent coronary spasm [1]. However, this 16-year-old female was diagnosed with VSA in the absence of risk factors or family history, and the attack was not related to the menstrual cycle [2]. There are few reports of VSA in females under 20 years of age, but the prevalence might be underestimated. Unexpected sudden death in young adults has been a subject of discussion for over two decades, and about 40% of cases remain unexplained [3]. Most previous reports of VSA in young females were diagnosed following serious cardiac events [4]. It is possible that VSA may account for a significant proportion of unexpected sudden deaths. Our case suggests that VSA can occur in young females in the absence of specific contributors. Further research is required to determine the true prevalence and contribution to unexpected sudden death in young patients. A 16-year-old female presented to our hospital with frequent chest tightness radiating to the left shoulder, which had persisted for several years. Her symptoms usually occurred on the way to school in the morning regardless of menstrual cycle, and disappeared after a period of rest. She had no coronary risk factors; congenital heart disease, Kawasaki disease, or menstrual disorder; or family history of sudden death, coronary artery disease, or hyperlipidemia. She and her family members had never smoked. The electrocardiogram, treadmill exercise testing, chest X-ray, laboratory data, and echocardiography were within normal limits. However, because of persistent symptoms, we decided to treat her as for angina pectoris. Her symptoms completely disappeared after starting diltiazem (200 mg/ day) and isosorbide mononitrate (40 mg/day). However, accurate diagnosis was thought necessary, and we planned additional evaluation following discontinuation of medication. Holter ECG revealed ST depression with symptoms. Coronary angiography showed no fixed stenosis. We then performed a spasm provocation test. Administration of 10 μg acetylcholine into the right coronary artery induced chest pain and significant ST changes, and the angiogram showed diffuse 90% stenosis (Fig. 1). Ventricular fibrillation occurred following ventricular premature conduction at R on T, but sinus rhythm was immediately restored with

The combination assessment of lipid pool and thrombus by optical coherence tomography can predict the filter no-reflow in primary PCI for ST elevated myocardial infarction

Abstract The usefulness of distal protection devices is still controversial. Moreover, there is no report on thrombus evaluation by using optical coherence tomography (OCT) for determining whether to use a distal protection device. The aim of the present study was to investigate the predictor of filter no-reflow (FNR) by using OCT in primary percutaneous coronary intervention (PCI) for ST-elevated acute myocardial infarction (STEMI). We performed preinterventional OCT in 25 patients with STEMI who were undergoing primary PCI with Filtrap. FNR was defined as coronary flow decreasing to TIMI flow grade 0 after mechanical dilatation. FNR was observed in 13 cases (52%). In the comparisons between cases with or without the FNR, the stent length, lipid pool length, lipid pool + thrombus length, and lipid pool + thrombus index showed significant differences. In multivariate analysis, lipid pool + thrombus length was the only independent predictor of FNR (OR 1.438, 95% CI 1.001 - 2.064, P < .05). The optimal cut-off value of lipid pool + thrombus length for predicting FNR was 13.1 mm (AUC = 0.840, sensitivity 76.9%, specificity 75.0%). Moreover, when adding the evaluation of thrombus length to that of lipid pool length, the prediction accuracy of FNR further increased (IDI 0.14: 0.019–0.25, P = .023). The longitudinal length of the lipid pool plus thrombus was an independent predictor of FNR and the prediction accuracy improved by adding the thrombus to the lipid pool. These results might be useful for making intraoperative judgment about whether filter devices should be applied in primary PCI for STEMI.

Impact of post-dilatation on longitudinal stent elongation: An in vitro study

OBJECTIVES To evaluate whether balloon inflation for post-dilatation causes longitudinal stent deformation (LSD). METHODS AND RESULTS Two stents, sized 2.5mm×28mm and 3.5mm×28mm (Nobori®, biodegradable polymer biolimus-eluting stent; Ultimaster®, biodegradable polymer sirolimus-eluting stent; Terumo Co., Tokyo, Japan), were deployed at nominal pressure in straight and tapered silicon vessel models. Then, post-dilatation was performed in two ways: dilatation from the distal (D-P group) or proximal (P-D group) side of the stent. Microscopic findings showed that the stents were elongated during every step of the procedure regardless of the post-dilatation method and type of vessel model. The D-P group showed linear elongation during each step of post-dilatation (straight model: 28.7±0.3mm vs. 29.9±0.3mm, p=0.002; tapered model: 28.0±0.1mm vs. 29.9±0.1mm, p<0.001). In contrast, in the P-D group, the most significant change was observed in the first step of post-dilatation and only slight changes were observed thereafter (straight model: 28.6±0.1mm vs. 29.5±0.1mm, p<0.001; tapered model: 28.2±0.1mm vs. 29.5±0.1mm, p<0.001). Optical frequency domain imaging analysis showed that the frequency of stent strut malapposition was positively correlated with the percentage change in stent length (r=0.74, p<0.0001). CONCLUSION LSD was observed during every step of post-dilatation in both the straight and tapered vessel models. However, some differences were observed between the D-P and P-D groups. Minimizing stent strut malapposition may reduce the risk of LSD.

Association of renal function with clinical parameters and conditions in a longitudinal population‑based epidemiological study

The aim of the present study was to examine the association of renal function with clinical parameters and conditions in the general population. Study subjects comprised 6,027 community-dwelling individuals who were recruited to the Inabe Health and Longevity Study: A longitudinal genetic epidemiological study of atherosclerotic, cardiovascular and metabolic diseases. The cutoff value, which was used to divide the subjects into those with normal and those with low estimated glomerular filtration rate (eGFR), was 60 ml/min/1.73 m2. Bonferronis correction was applied to establish the statistical significance of the association. Longitudinal analysis using the generalized linear mixed-effect model, following adjustments for age and gender, revealed that the eGFR was significantly associated (P<0.0017) with serum levels of triglycerides, low-density lipoprotein cholesterol, uric acid, blood glycosylated hemoglobin content, fasting plasma glucose and body mass index. These parameters decreased curvilinearly with increases in eGFR. Furthermore, eGFR correlated positively with serum levels of high-density lipoprotein (HDL) cholesterol. Longitudinal analysis using the generalized estimating equation following adjustment for age and gender indicated a significant association (P<0.0024) between eGFR and prevalence of hypertension, type 2 diabetes mellitus, hypo-HDL cholesterolemia, hyperuricemia and obesity. Thus, low eGFR results in detrimental effects on various clinical parameters and conditions, resulting in increased risk of hypertension, dyslipidemia, type 2 diabetes mellitus, hyperuricemia and obesity.