Toshijiro Aoki

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.

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.

Temporary immobile leaflet following transcatheter aortic valve replacement of a SAPIEN-XT valve

An 84-year-old man with carotid artery stenosis and prior history of lower limb amputation was admitted with symptomatic aortic stenosis. Echocardiogram showed an aortic valve area of 0.83 cm2 with a preserved left ventricular ejection fraction of 67%. Computed tomography (CT) demonstrated an aortic annulus area of 437 mm2, a porcelain aorta, and heavily calcified stenotic lesions of the bilateral iliac arteries. Due to high surgical risk and poor femoral access, we decided to perform transapical transcatheter aortic valve replacement (TAVR). A 26-mm Edwards SAPIENXTTM valve (Edwards Lifesciences, Irvine, California) was implanted after aortographic and transesophageal echocardiographic (TEE) confirmation of appropriate valve position. However, his blood pressure did not recover even with inotropic medications after aortic valve deployment. Aortography and TEE revealed severe intravalvular aortic regurgitation (Fig. 1a, b), and confirmed that while one leaflet was mobile and functioning, another was immobile. While preparing for a second valve implantation, removal of the guidewire and post-dilation were tried, but were ineffective. Hypotension was observed to worsen, and he then developed ventricular tachycardia. Defibrillation successfully restored sinus rhythm, and his hemodynamic parameters recovered rapidly. TEE and aortography revealed adequate functioning of all valve leaflets with only a mild paravalvular leak (Fig. 1c, d). Finally, the procedure was successful without requiring a second valve implantation. Postoperative CT showed a mass of calcification located adjacent to the commissure between the two leaflets of the implanted valve. The patient was discharged home on postoperative day 18 without any sequelae. The development of an immobile leaflet following TAVR is a rare complication. Only a few reports have described the successful management of this complication using valvein-valve implantation [1, 2]. To our knowledge, ours is the first report to describe a temporary immobile leaflet, which was restored accidentally without requiring a second valve implantation. To date, the mechanism of leaflet malfunction remains unclear. In this patient, calcification was noted adjacent to the temporary immobile leaflet of the implanted valve. The SAPIEN-XTTM valve shows a shorter stent height than the leaflet height; therefore, calcification might cause anchoring of the leaflets, resulting in leaflet failure. Furthermore, we concluded that the impact caused by defibrillation accidentally restored the normal function of the fixed/immobile leaflet, suggesting that this complication can occur unexpectedly even without any inherent valve-related

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.

Impact of Coronary Stent Fracture on Restenotic Neointimal Tissue Characterization After Drug-Eluting Stent Implantation: An Integrated Backscatter Intravascular Ultrasound Study

Although drug-eluting stents (DESs) reduce the rates of in-stent restenosis (ISR) and subsequent target lesion revascularization, stent fracture (SF) after DES implantation has become an important concern because of its potential association with restenosis and stent thrombosis. We aimed to assess the pathogenic impact of SF on in-stent restenotic neointimal tissue components after DES implantation. We analyzed 43 consecutive patients (14 with SF and 29 without SF) with ISR requiring revascularization after DES implantation between January 2008 and March 2014. For evaluation of in-stent tissue components, integrated backscatter intravascular ultrasound (IB-IVUS) was performed. SF was defined as complete or partial separation of stent segments observed using plain fluoroscopy or intravascular ultrasound. On volumetric IB-IVUS analyses, patients with SF had a significantly higher percentage of lipid tissue volume within the neointima and a significantly lower percentage of fibrous tissue volume than those without (37.3 ± 18.9% versus 24.9 ± 12.4%, P = 0.02, and 61.2 ± 18.3 versus 72.6 ± 12.1%, P = 0.04, respectively). Moreover, SF was positively correlated with the percentage of lipid volume on multiple linear regression analysis after adjustment for confounding factors (β = 0.36, P = 0.03). The interval from stent implantation was similar in both groups (47.0 ± 28.7 versus 37.7 ± 33.3 months; P = 0.39). In conclusion, SF is associated with larger lipid tissue volume within the neointima after DES placement, suggesting a contribution to the development of neoatherosclerosis and vulnerable neointima. Thus SF might lead to future adverse coronary events.