Tomoki Ochiai

Prehospital Transfer Pathway and Mortality in Patients Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND It is recommended that not only door-to-balloon time but also prehospital delay for primary percutaneous coronary intervention (PCI) should be improved. We investigated the effect of prehospital transfer pathway on onset-to-balloon time and prognosis in patients with ST-segment elevation myocardial infarction (STEMI) in Japan. METHODSANDRESULTS We analyzed data from 540 consecutive patients with primary PCI for STEMI. Patient clinical data and mortality were compared between patients who visited the family physician or non-PCI-capable hospitals and were then transferred to PCI-capable centers (indirect transfer patients), and those who directly visited PCI-capable centers (direct transfer patients). Onset-to-balloon time was longer in indirect transfer patients than in direct transfer patients (mean, 270 min; range, 180-480 min vs. 180 min, 120-240 min; P<0.001). In addition, patient prognosis was evaluated on Cox proportional regression analysis. Cardiac death and all-cause death were significantly higher in indirect transfer patients (odds ratios [OR], 2.17; 95% confidence intervals [95% CI]: 1.17-4.01, P=0.01; OR, 1.71; 95% CI: 1.09-2.68, P=0.02). These results were confirmed using propensity score matching for adjusted analyses. CONCLUSIONS Patients with indirect transfer to regional emergency departments of PCI centers had longer onset-to-balloon time and worse prognosis than those with direct transfer.

Renin–angiotensin system blockade therapy after transcatheter aortic valve implantation

Objective The persistence of left ventricular (LV) hypertrophy is associated with poor clinical outcomes after transcatheter aortic valve implantation (TAVI) for aortic stenosis. However, the optimal medical therapy after TAVI remains unknown. We investigated the effect of renin−angiotensin system (RAS) blockade therapy on LV hypertrophy and mortality in patients undergoing TAVI. Methods Between October 2013 and April 2016, 1215 patients undergoing TAVI were prospectively enrolled in the Optimized CathEter vAlvular iNtervention (OCEAN)-TAVI registry. This cohort was stratified according to the postoperative usage of RAS blockade therapy with angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs). Patients with at least two prescriptions dispensed 180 days apart after TAVI and at least a 6-month follow-up constituted the RAS blockade group (n=371), while those not prescribed any ACE inhibitors or ARBs after TAVI were included in the no RAS blockade group (n=189). Results At 6 months postoperatively, the RAS blockade group had significantly greater LV mass index regression than the no RAS blockade group (−9±24% vs −2±25%, p=0.024). Kaplan-Meier analysis revealed a significantly lower cumulative 2-year mortality in the RAS blockade than that in the no RAS blockade group (7.5% vs 12.5%; log-rank test, p=0.031). After adjusting for confounding factors, RAS blockade therapy was associated with significantly lower all-cause mortality (HR, 0.45; 95% CI 0.22 to 0.91; p=0.025). Conclusions Postoperative RAS blockade therapy is associated with greater LV mass index regression and reduced all-cause mortality. These data need to be confirmed by a prospective randomised controlled outcome trial.

Long-term risks for patency loss in patients with hemodialysis after bare self-expandable nitinol stent implantation to femoropopliteal artery occlusive lesions

BACKGROUND Although patients receiving hemodialysis (HD+) have significantly different backgrounds, including a history of progressive atherosclerotic disease, compared with those not receiving hemodialysis (HD-), there are no studies evaluating the risks for loss of primary patency (PP) and need for target lesion revascularization (TLR) in HD+ patients following bare self-expandable nitinol stent (BSNS) implantation to femoropopliteal (FP) artery occlusive lesions, after adjusting for differences using propensity score (PS) analysis in observed characteristics between groups. METHODS We studied 531 limbs of 432 Japanese patients (HD+, n=107; HD-, n=325) who received BSNS implantation to FP lesions between 2004 and 2014. Patients were followed-up for an average of 44.3±33.6months. We compared the long-term results between HD+ and HD- patients using the Cox-proportional hazard model with adjustment for inverse probability treatment weight (IPTW) of PS, which was calculated for covariates with HD as a dependent variable. RESULTS PP rate in HD+ vs. HD- patients at 9years after the procedure was 19.1% vs. 47.9%, with a freedom from TLR rate of 47.6% vs. 62.9%, respectively. Adjusted HRs in HD+ patients with 95% confidence intervals (CIs) were as follows: loss of PP: HR 1.64, 95% CI 1.052-2.557, P=0.03; TLR: HR 1.862, 95% CI 1.104-3.139, P=0.02. CONCLUSIONS The present study suggests that HD+ patients have an increased risk for loss of PP and need for TLR after BSNS implantation to FP lesions.

The COFFEE Trial (COmparison of Fractional Flow Reserve Measurements through 4 FrEnch versus 6 FrEnch Diagnostic Catheter)

Fractional flow reserve (FFR) measurement is a well-established pressure wire-based procedure that is used to assess the functional severity of coronary lesions [(1)][1]. Various randomized trials have demonstrated that FFR-guided revascularization improves clinical outcomes in patients with

Diagnosis and Outcomes of Transcatheter Aortic Valve Implantation in Bicuspid Aortic Valve Stenosis

Bicuspid aortic valve is the most common congenital cardiac malformation. Aortic valve replacement is often required in older patients but the surgical risk is often extremely high. As Transcatheter aortic valve implantation (TAVI) is an established therapy for intermediate and high surgical risk patients with symptomatic severe aortic valve stenosis (AS). Advances in technology and knowledge have led to TAVI being used for other pathologies and populations such as bicuspid AS. Recently, the diagnosis and classification of bicuspid aortic valve based on multidetector computed tomography (MDCT) assessment has been proposed, which may have an impact of outcomes after TAVI. This review article describes the advancements in diagnosis and outcomes of bicuspid AS.

Modified jailed balloon technique for bifurcation lesions

We propose a new systematic approach in bifurcation lesions, modified jailed balloon technique (M‐JBT), and report the first clinical experience.

IMPACT OF RENIN-ANGIOTENSIN SYSTEM BLOCKADE THERAPY AFTER TRANSCATHETER AORTIC VALVE IMPLANTATION FOR SEVERE AORTIC STENOSIS: INSIGHTS FROM THE OCEAN-TAVI MULTICENTER REGISTRY

Background: In patients who underwent surgical aortic valve replacement for severe aortic stenosis, postoperative renin-angiotensin system (RAS) blockade therapy with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) has been shown to reduce left ventricular (

Reply : Slender Sheaths Have the Potential to Expand the Use of Transradial Access for Complex CTO-PCI

We would like to thank Dr. Aminian and colleagues for their interest in our study [(1)][1] that assessed whether the transradial approach can be used to treat complex chronic total occlusion (CTO) and that attempted to determine the predictors of transradial percutaneous coronary intervention (PCI)

Diagnostic performance of 320-slice computed tomography coronary angiography for symptomatic patients in clinical practice

OBJECTIVE Multi-slice computed tomography (MSCT) coronary angiography has been reported as an effective alternative to invasive conventional coronary angiography (CCA) for the diagnosis of coronary artery disease (CAD). However, in previous reports, the diagnostic accuracy of MSCT has not been significant enough to be of benefit in symptomatic patients. The aim of this study was to identify the usefulness of 320-slice computed tomography coronary angiography (320-CTA) for symptomatic patients in terms of the diagnostic accuracy of 320-CTA and the prevalence of vasospastic angina pectoris (VSAP) within the study cohort. METHODS We retrospectively analyzed 513 consecutive symptomatic patients with suspected CAD who had undergone 320-CTA and CCA. We determined the diagnostic accuracy of 320-CTA using CCA as the reference standard. Ergonovine provocation tests were performed on patients without significant coronary artery stenosis on CCA. RESULTS Of the total cohort of 513 symptomatic patients, 39% had obstructive CAD. The patient based analysis of the accuracy of 320-CTA showed a sensitivity of 91.0%, a specificity of 71.0%, a positive predictive value of 66.5%, and a negative predictive value of 92.5%. Of the 314 symptomatic patients who did not have significant coronary artery stenosis on CCA, 58 (18%) were diagnosed with VSAP using ergonovine provocation tests. DISCUSSION The negative and positive predictive values indicate that 320-CTA cannot replace CCA for symptomatic patients. Indeed, a combination of CCA and ergonovine provocation tests should be taken into consideration for symptomatic patients.

Rapid diagnosis of prosthetic valve endocarditis from Janeway lesions in a transcatheter aortic valve implantation patient

Percutaneous transcatheter aortic valve implantation (TAVI), first introduced in 2002, is a viable solution for previously inoperable or high-risk patients with aortic stenosis, providing the benefit of valve replacement without the associated risks of surgery. When these patients develop prosthetic valve endocarditis (PVE), management is complicated, owing to their often, atypical presentations and baseline comorbidities. Moreover, it is often difficult to detect vegetations in such patients, even with transesophageal echocardiography. Here, we describe a case of post-TAVI PVE that was successfully treated medically after a rapid diagnosis was made based on physical examination. Our experience shows that physical examination continues to be important for rapid diagnosis of infective endocarditis, even in the era of structural heart disease intervention. <Learning objective: Diagnosis of endocarditis in transcatheter aortic valve implantation patients can be difficult and may be delayed, as echocardiography is often inconclusive because of the unique physiology of these patients. We should maintain a low threshold for investigation of infective endocarditis in these patients, and more emphasis should be placed on physical examination to ensure rapid diagnosis and favorable clinical outcome.>.