Tomoyuki Umemoto

Adenosine triphosphate-induced atrial fibrillation: the clinical significance and relevance to spontaneous atrial fibrillation

PurposeAdenosine triphosphate (ATP) frequently triggers atrial fibrillation (AF), but the clinical significance of this phenomenon is unknown. The purpose of this study was to reveal the relevance between spontaneous AF and ATP-induced AF.MethodsIn 81 AF patients undergoing pulmonary vein isolation (PVI), we injected 20 mg of ATP before PVI, and recorded triggering sites of the AF induced. We also injected 20 mg of ATP in 44 patients receiving ablation for atrioventricular reciprocating tachycardia (AVRT).ResultsATP provoked AF in 24 (29.6 %) of the 81 PVI patients and atrial ectopic beats in a further 48 (59.3 %). The trigger site of the AF was in the PV and the right atrium in 22 (91.7 %) and 2 patients, respectively. In 14 of those 24 patients, spontaneous AF arose from the same triggering site as the ATP-induced AF. In the 48 patients with ATP-provoked ectopic beats, spontaneous AF arose from the same site in 13. Conversely, among the 34 patients demonstrating spontaneous AF initiation, AF or ectopic beats were provoked by ATP from the same site in 14 (41.2 %) and 13 patients (38.2 %), respectively. ATP provoked AF in only 2 (4.5 %) of the AVRT patients. In summary, ATP provoked AF or atrial ectopic beats in 88.9 % of PVI patients, 36.1 % of whose triggering sites matched that of the spontaneous AF, while 79.4 % of spontaneous AF trigger sites matched ATP-provoked AF or ectopic beat sites. ConclusionsATP-induced AF was strongly associated with clinical AF, and ATP is useful for identifying arrhythmogenic sites.

Optical coherence tomography assessment of newgeneration mesh-covered stents after carotid stenting

AIMS The aim of this study was to identify the findings (by optical coherence tomography [OCT]) after carotid artery stenting (CAS) with two different types of new-generation mesh-covered stent. METHODS AND RESULTS Sixteen consecutive patients undergoing CAS with mesh-covered stents and highdefinition OCT image acquisition were enrolled in the study. Cross-sectional OCT images for the presence of strut malapposition (SM) and plaque prolapse (PP) were evaluated using a proximal or distal embolic protection device (EPD). CGuard stents were used in 11 patients (68.8%) and RoadSaver stents in five (31.2%). With OCT analysis, the incidence of SM was 20.5% for CGuard vs. 26.8% for RoadSaver, p=0.26, and the incidence of PP was 10.8% for CGuard vs. 20.7% for RoadSaver, p=0.05. No neurological complications (stroke/TIA) occurred during the procedural and post-procedural periods. CONCLUSIONS The OCT findings of two different types of mesh-covered stent after CAS were obtained safely. Our work indicates that current mesh-covered carotid stents may show differences in SM and PP. The effect of stent design and implantation technique on OCT findings post CAS, and their relation to longterm clinical outcomes, require further evaluation.

Effectiveness of the proximal optimization technique for longitudinal stent elongation caused by post‐balloon dilatation

OBJECTIVES To evaluate the effectiveness of the proximal optimization technique (POT) to prevent longitudinal stent elongation. BACKGROUND The mechanism of stent elongation, which occurs after post-balloon dilation, is still unclear. METHODS A total of 103 lesions treated with optical coherence tomography guided coronary intervention between May 2013 and November 2017 were retrospectively analyzed. Lesions were divided according to the circumferential degree of malapposition at the stent edge immediately after deployment into well-apposed group (<180°) and malapposed group (≥180°). Post-dilation was performed from distal to proximal within the stent until August 2016 (non-POT cohort), and POT was applied thereafter (POT cohort). In the POT cohort, post-dilation was done at the proximal portion of the stent with sufficiently large balloon to minimize malapposition followed by distal dilatations. Stent elongation length was defined as the change in stent length from stent deployment to after post-dilatation. RESULTS In the non-POT cohort, 72 lesions, including 54 lesions in the well-apposed group and 18 in the malapposed group were analyzed. Stent elongation length was significantly longer in the malapposed group than in the well-apposed group (1.51 ± 1.34 mm vs 0.13 ± 0.84 mm, P < 0.01). In the POT cohort, 31 lesions including 21 in the well-apposed group and 10 in the malapposed group were analyzed. Stent elongation length was not significantly different between the groups (-0.09 ± 0.91 mm vs 0.30 ± 0.99 mm, P = 0.29). CONCLUSIONS Malapposition of the stent edge is responsible for longitudinal stent elongation caused by post-dilatation. POT appeared to effectively prevent longitudinal stent elongation.

Omental flap transposition for inferior vena cava filter penetration

A 40-year-old woman presented with uterine malignancy, deep vein thrombosis, and nonmassive pulmonary embolism in both lungs. Gunter-tulip filter was inserted, because she had severe genital bleeding, which is one of the contraindications to anticoagulation therapy. Total hysterectomy was conducted and anticoagulation therapy was started afterward. The thrombus worsened perioperatively, and the filter could not be retrieved. Since there was lymph node recurrence, the second time operation was performed. During operation, the struts were found to be penetrating the inferior vena cava. Omental flap was used to cover the struts, and no associated complications occurred after operation.

Difficult Cases and Complications from the Catheterization Laboratory: Case 2

Transcatheter aortic valve implantation (TAVI) is now becoming an alternative therapy to surgical aortic valve replacement (SAVR) for the patient with high surgical risk. Preprocedural complications are still frequent, and they include not only vascular but also severe life-threatening complications such as stroke, heat block, coronary obstruction, improper prosthesis positioning, cardiac perforation, mitral valve injury, and annulus or aortic root rupture. Among these severe complications, annulus and aortic root rupture will induce catastrophic outcomes [1].

Difficult Cases and Complications from the Catheterization Laboratory: Left Atrial Appendage Perforation During Percutaneous Closure

PROTECT-AF trial proved that percutaneous left atrial appendage (LAA) closure was not inferior to anticoagulant therapy in preventing stroke [1–3]. In patients with contraindication to oral anticoagulant therapy (OAT) or with stroke despite appropriate OAT, percutaneous LAA closure could be an option. Possible periprocedural complications include stroke, puncture site bleeding, and cardiac tamponade.

TCT-365 Correlation between residual anticoagulation and radial artery occlusion after transradial catheterization: preliminary results from an Italian multicenter study

TCT-363 Patient Characteristics Influencing Physician Selection of Radial vs. Femoral Access in patients presenting emergently with STElevation Myocardial Infarction Jimmy Yee, James Higgins, Vishesh Kumar, Amornpol (Song) Anuwatworn, Shenjing Li, Alexander Pham, Julia Stys, Terezia Petraskova, Paul Thompson, Adam Stys, Marian Petrasko, Tomasz Stys University of South Dakota, Sanford School of Medicine, Sioux Falls, South Dakota, United States; Interventional Cardiology, Sandro Pertini Hospital; CSI; Sanford School of Medicine of University of South Dakota, Sioux Falls, South Dakota, United States; Sioux Falls; MedStar Washington Hospital Center; Dallas VA Medical Center and UT Southwestern; UCLA, VA Greater Los Angeles Healthcare System; Dallas VA Medical Center and UT Southwestern; Sanford Cardiovascular Institute, Sioux Falls, South Dakota, United States; Sanford Cardiovascular Institute, Sioux falls, South Dakota, United States; Sanford Cardiovascular Institute, Sioux Falls, South Dakota, United States

TCT-807 An Optical Coherence Tomography Assessment of New Generation Mesh-Covered Stents after Carotid Stenting

Post procedural embolic events including transient ischemic attack (TIA) or stroke are remaining problems after carotid artery stenting (CAS). Recently, strut malappositin (SM) and plaque prolapse (PP) after the stenting have been suggested as the major causes. Now some mesh-covered stents are

Shock After Successful Primary Percutaneous Coronary Intervention for Ventricular Fibrillation

A 63-year-old man was admitted to our emergency department with an episode of sudden cardiopulmonary arrest attributable to ventricular fibrillation (Figure 1). Before admission, cardiopulmonary resuscitation by a bystander and emergency personnel with two 200-J direct-current shocks was conducted; thereafter, spontaneous circulation returned. The patient’s vital signs and level of consciousness were normal at admission. ECG at admission revealed a sinus rhythm with ST elevation in leads aVR and V1, and ST depression in leads II, III, aVF, and V3 through 6. Echocardiography …

Usefulness of Implantable Cardioverter-Defibrillators in Patients with Coronary Spasm and Inducible Ventricular Arrhythmia

Background: Coronary artery spasm is one of causes of life-threatening ventricular arrhythmia and sudden cardiac death, but indication of implantable cardioverter-defibrillators (ICDs) is controversial. Our aim is to reveal the clinical features and long term prognosis of vasospastic angina patients with ventricular arrhythmia. Methods: We investigated retrospectively 31 survivors of cardiac arrest with implantation of ICDs. All patients underwent coronary angiography, and without ischemic findings we performed acetylcholine provocation test and electrophysiological study. Results: In 5 patients (56.6±15.7 years old, 5 males) multi-vessel spasm was induced by acetylcholine injection, and in 4 patients of them ventricular fibrillation were inducted by right ventricular 3 extrastimuli, and in 1 patient ventricular tachycardia was inducted by right ventricular 2 extrastimuli. All patients were treated with calcium channel blocking agents, isosorbide and antiarrhythmic drug. During mean follow up of 37±16.9 months (between 25 to 66 months), 2 patients received appropriate ICD shocks to ventricular fibrillation respectively in 10 and 14 months after implantation. One patient had a saddle-back-type ECG abnormality, and in another patient ventricular tachycardia was easily induced by right ventricular 2 extrastimuli. Conclusion: In patients with coronary spasm and inducible ventricular arrhythmia ICDs is useful to prevent sudden cardiac death.