Toshiki Kuno

Impact of coronary dominance on in-hospital outcomes after percutaneous coronary intervention in patients with acute coronary syndrome.

Objective This study evaluated the manner in which coronary dominance affects in-hospital outcomes of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Background Previous studies have shown that left dominant coronary anatomies are associated with worse prognoses in patients with coronary artery disease. Methods Data were analyzed from 4873 ACS patients undergoing PCI between September 2008 and April 2013 at 14 hospitals participating in the Japanese Cardiovascular Database Registry. The patients were grouped based on diagnostic coronary angiograms performed prior to PCI; those with right- or co-dominant anatomy (RD group) and those with left-dominant anatomy (LD group). Results The average patient age was 67.6±11.8 years and both patient groups had similar ages, coronary risk factors, comorbidities, and prior histories. The numbers of patients presenting with symptoms of heart failure, cardiogenic shock, or cardiopulmonary arrest were significantly higher in the LD group than in the RD group (heart failure: 650 RD patients [14.7%] vs. 87 LD patients [18.8%], P = 0.025; cardiogenic shock: 322 RD patients [7.3%] vs. 48 LD patients [10.3%], P = 0.021; and cardiopulmonary arrest: 197 RD patients [4.5%] vs. 36 LD patients [7.8%], P = 0.003). In-hospital mortality was significantly higher among LD patients than among RD patients (182 RD patients [4.1%] vs. 36 LD patients [7.8%], P = 0.001). Multivariate logistic regression analysis revealed that LD anatomy was an independent predictor for in-hospital mortality (odds ratio, 1.75; 95% confidence interval, 1.06–2.89; P = 0.030). Conclusion Among ACS patients who underwent PCI, LD patients had significantly worse in-hospital outcomes compared with RD patients, and LD anatomy was an independent predictor of in-hospital mortality.

Location of the culprit coronary lesion and its association with delay in door-to-balloon time (from a multicenter registry of primary percutaneous coronary intervention)

Current guidelines recommend shorter door-to-balloon times (DBTs) (<90 minutes) for patients with ST-elevation myocardial infarction (STEMI). Clinical factors, including patient or hospital characteristics, associated with prolonged DBT have been identified, but angiographic variables such as culprit lesion location have not been thoroughly investigated. We aimed to evaluate the effect of culprit artery location on DBT of patients with STEMI who underwent percutaneous coronary intervention (PCI). Data were analyzed from 1,725 patients with STEMI who underwent PCI from August 2008 to March 2014 at 16 Japanese hospitals. Patients were divided into 3 groups according to culprit artery location, right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LC), and associations with DBT were assessed. The LC group had a trend toward a longer DBT among the 3 groups (97.1 [RCA] vs 98.1 [LAD] vs 105.1 [LC] minutes; p = 0.058). In-hospital mortality was also significantly higher in patients with a left coronary artery lesion (3.5% [RCA] vs 6.3% [LAD] vs 5.4% [LC]; p = 0.041). In-hospital mortality for patients with DBT >90 minutes was significantly higher compared with patients with DBT ≤90 minutes (6.5% vs 3.6%; p = 0.006). Multivariate logistic regression analysis revealed that the LC location was an independent predictor for DBT >90 minutes (odds ratio, 1.45; 95% confidence interval, 1.04 to 2.01; p = 0.028). In conclusion, LC location was an independent predictor of longer DBT. The difficulties in diagnosing LC-related STEMI need further evaluation.

Use of the GuideLiner catheter for aspiration thrombectomy in a patient with ST-elevation myocardial infarction with a large intracoronary thrombus

We report a 67-year-old man with ST-elevation myocardial infarction with a large intracoronary thrombus who was successfully treated with percutaneous thrombectomy using the GuideLiner catheter. This catheter is designed for the “Mother and Child” technique with a rapid exchange system and it has a larger internal diameter than conventional aspiration devices. When aspiration thrombectomy using a conventional aspiration catheter is not feasible or fails, use of the GuideLiner catheter for aspiration of thrombus is a reasonable alternative for primary percutaneous coronary intervention in patients with acute myocardial infarction.

Clinical History and Colliquative Myocytolysis Are Keys to the Diagnosis of Shoshin Beriberi

Cardiovascular beriberi presents as either the fulminant (Shoshin beriberi) or chronic form. Shoshin beriberi is a rare disease that may lead to a fatal outcome if the patient does not receive appropriate treatment. In the present report, we describe the case of a 66-year-old man presenting with leg edema and dyspnea at rest. Clinical presentations were nonalcoholic Shoshin beriberi and lactate accumulation; however, clinical improvement was observed after the administration of thiamine. His pretherapy thiamine level (2.1 μg/dL) was consistent with a diagnosis of beriberi. Based on the findings of the present case, we believe that a diagnosis can be made in patients with a clinical history that is consistent with that of Shoshin beriberi, combined with low thiamine levels, lactate accumulation, and colliquative myocytolysis. Learning Objective. Shoshin beriberi is often misdiagnosed because of its rarity; a detailed clinical history and characteristic myocardial histopathology changes may be useful for making a definite diagnosis.

Successful percutaneous coronary intervention of a chronic totally occluded left anterior descending artery via an ipsilateral intraseptal channel using intravascular ultrasound-guided retrograde wire-crossing technique

We herein report a 59-year-old man with a chronic totally occluded left anterior descending artery treated by percutaneous coronary intervention via an ipsilateral intraseptal channel using an intravascular ultrasound-guided retrograde wire-crossing technique. When an antegrade approach is not feasible or fails, a retrograde approach to a chronic totally occluded lesion is reasonable. However, a retrograde approach from the contralateral coronary artery is not always feasible. We herein report that an ipsilateral intraseptal channel can serve as one route by which to perform a retrograde approach to chronic totally occluded lesions of the left anterior descending artery.

Percutaneous Coronary Intervention for the Anomalous Left Coronary Artery Originating from the Noncoronary Cusp

Percutaneous coronary intervention (PCI) for anomalous left coronary artery (LCA) originating from the noncoronary cusp (NCC) is challenging, as it poses difficulties with the engagement of the guiding catheter and the establishment of backup support. This report examines the case of a 69-year-old woman with unstable angina of anomalous LCA origin. The computed tomography showed a diffuse plaque in the middle of the left anterior descending (LAD) artery and an anomalous LCA originating from the NCC. After successful engagement of a straightened Judkins-Left diagnostic catheter, the angiography revealed a diffuse plaque in the middle of the LAD artery. We then engaged a Judkins-Right guiding catheter. Due to the weak backup support of the guiding catheter, we used another wire to stabilize it, and the stent was then implanted successfully. To our knowledge, this is the first case report of PCI for an anomalous LCA originating from the NCC.

Successful percutaneous thrombectomy in an elderly patient with massive pulmonary embolism with cardiogenic shock

We report on an 80-year-old woman with cardiogenic shock due to massive pulmonary embolism who was successfully treated with percutaneous thrombectomy using a conventional angiographic guide wire and catheters combined with systemic thrombolysis. We successfully treated the patient without a ventilator or extracorporeal life support. We report that percutaneous thrombectomy can provide rapid improvement of hemodynamic instability and can be used as an effective adjuvant therapy for systemic thrombolysis in patients with massive pulmonary embolism. Percutaneous thrombectomy is a less invasive and reasonable alternative to surgical embolectomy for patients with massive pulmonary embolism with cardiogenic shock.

Recurrent right atrial thrombosis due to Behçet disease.

Behçet disease is a rare condition sometimes associated with chronic cardiac inflammation followed by myocardial dysfunction and vascular inflammation. We report a case of recurrent right atrial thrombus due to Behçet disease despite continued anticoagulation therapy. The thrombus disappeared after the initiation of immunosuppressive therapy. To avoid a progression to thrombus or cardiac dysfunction in this recurrent case, the early identification of cardiac involvement of Behçet disease using echocardiography and/or cardiac magnetic resonance imaging might be important. Combined immunosuppressive therapy with prednisone and cyclophosphamide might be needed to treat recurrent thrombosis due to Behçet disease.

A rare adult case of left main coronary artery atresia

We report a 65-year-old woman with congenital left main coronary artery atresia detected by coronary angiography and 320-slice multidetector computed tomography. The patient was hospitalized with congestive heart failure and treated by medical therapy conservatively. Surgical revascularization of the left coronary artery was not performed since stress myocardial perfusion scintigraphy revealed no clear evidence of myocardial ischemia. Recently, there are many patients with congenital coronary artery anomalies detected by multidetector computed tomography. However, the adult case of left main coronary artery atresia is extremely rare. In this case, 320-slice multidetector computed tomography played a pivotal role in the diagnosis of the extremely rare coronary artery anomaly.

Three-dimensional optical frequency domain imaging of a true bifurcation lesion after stent implantation using the jailed semi-inflated balloon technique

Objective: Percutaneous coronary intervention for coronary bifurcation lesion is very challenging, especially for true bifurcation lesions. Although the jailed semi-inflated balloon technique is one of the established methods for treatment of coronary bifurcation lesions, little is known regarding the configuration of the side branch orifice after stent implantation using this technique. Methods: We report a 73-year-old male patient with angina pectoris who was successfully treated with percutaneous coronary stent implantation for a true bifurcation lesion of the right coronary artery with an obtuse angle using the jailed semi-inflated balloon technique. Results: Three-dimensional optical frequency domain imaging clearly showed that there were no signs of plaque or carina shift into the side branch after stent implantation using this technique. Conclusions: This case report highlights that the jailed semi-inflated balloon technique is a safe and useful treatment for coronary true bifurcation lesions with an obtuse angle.