Tsuyoshi Ito

Impact of epicardial fat volume on coronary artery disease in symptomatic patients with a zero calcium score

BACKGROUNDnThis study sought to evaluate the prevalence of coronary artery disease (CAD) and the impact of epicardial fat volume (EFV) on CAD in symptomatic patients with a zero calcium score (CS) using multislice computed tomography (MSCT).nnnMETHODSnIn this study, 1308 consecutive symptomatic patients who underwent 64-slice MSCT with a zero CS were evaluated. EFV was quantified with CS data sets. Presence of an obstructive plaque (diameter stenosis >50%) and a CT-derived vulnerable plaque, which was defined as a plaque with remodeling index >1.10 and mean CT density value <3 0HU, was assessed with a CT coronary angiography.nnnRESULTSnObstructive plaques were detected in 86 patients (7%) and CT-derived vulnerable plaques in 63 (5%). EFV was larger in patients with obstructive plaques than no plaque (124.3 ± 43.2 cm(3) vs. 95.1 ± 40.3 cm(3); p<0.01). Patients with CT-derived vulnerable plaques had a greater amount of EFV than no plaque (133.0 ± 40.2 cm(3) vs. 95.1 ± 40.3 cm(3); p<0.01). Multivariate analysis revealed EFV as a predictor of the presence of an obstructive and a CT-derived vulnerable plaque (per 10 cm(3); Odds ratio (OR) 1.10; 95% confidence interval (CI), 1.04-1.16; p<0.01 and OR 1.19; 95% CI, 1.12-1.27; p<0.01). The combination of EFV and Framingham risk score (FRS) resulted in an area under the receiver-operating characteristic curve for prediction of obstructive and CT-derived vulnerable plaque of 0.75 and 0.75, which was significantly higher than 0.68 and 0.64 for FRS alone (p=0.02 and p<0.01).nnnCONCLUSIONSnA zero CS doesnt exclude CAD and EFV can be a useful marker of CAD in symptomatic zero CS patients.

Relationship between fractional flow reserve and residual plaque volume and clinical outcomes after optimal drug-eluting stent implantation: Insight from intravascular ultrasound volumetric analysis

BACKGROUNDnThe underlying cause of FFR reduction and prognostic impact of FFR after optimal DES implantation remain unknown. The study aims were to use intravascular ultrasound (IVUS) to investigate the mechanism responsible for reduced fractional flow reserve (FFR) after optimal drug-eluting stent (DES) implantation and to evaluate FFR effect on clinical outcomes after optimal percutaneous coronary intervention with DES.nnnMETHODSnNinety-seven patients treated with optimal DES implantation under IVUS and pullback FFR guidance were followed clinically (median 17.8 months). Post-stenting IVUS examination and pullback FFR recording were performed, and angiographic and IVUS parameters associated with reduced FFR were evaluated. The composite of major adverse cardiac events (MACE), including cardiac death, myocardial infarction, stent thrombosis, and target vessel revascularization, was analyzed.nnnRESULTSnRegression analysis showed inverse correlations between post-stent FFR and residual plaque volume index (r=-0.40, p<0.01) and residual percent plaque volume (r=-0.68, p<0.01) in IVUS but no correlation of minimal lesion diameter with quantitative coronary angiography (r=0.07, p=0.50) or IVUS-derived minimal stent area (r=0.02, p=0.84). MACE was observed in 10 patients (10.3%), and FFR after optimal stenting was significantly lower in this group (0.86 ± 0.04 vs 0.91 ± 0.04, p<0.01). The optimal FFR threshold for predicting MACE was 0.90, identified by the receiver operating characteristic curve.nnnCONCLUSIONSnReduced FFR after optimal DES implantation was associated with residual plaque volume identified by IVUS and future adverse cardiac events.

Impact of lesion morphology on angiographic and clinical outcomes in patients with chronic total occlusion after recanalization with drug-eluting stents: a multislice computed tomography study

AbstractObjectivesThe aim of this study was to investigate the multislice computed tomography (MSCT) parameters associated with adverse outcomes after chronic total occlusion percutaneous coronary intervention (CTO-PCI) with drug-eluting stents.MethodsA total of 285 patients who underwent MSCT before CTO-PCI were analyzed. Lesion morphology was assessed with MSCT. Angiographic restenosis, reocclusion, and MACE (a composite of cardiac death, myocardial infarction, stent thrombosis, and target lesion revascularization) were analyzed.ResultsMACE was observed in 36 patients (13.6xa0%). Occlusion length was greater (39.5u2009±u200919.9xa0mm vs. 22.3u2009±u200913.7xa0mm, pu2009<u20090.01), minimal vessel area smaller (11.2u2009±u20095.7xa0mm2 vs. 14.5u2009±u20095.6xa0mm2, pu2009<u20090.01), and severe calcification more common (36xa0% vs. 12xa0%, pu2009<u20090.01) in the MACE group compared to the non-MACE group. We defined occluded length >25.4xa0mm, minimal vessel area <11.9xa0mm2, which were identified by receiver operating characteristic analysis, and severe calcification as CT-derived risk factors. Angiographic restenosis (60xa0% vs. 12xa0% vs. 7xa0%, pu2009<u20090.01), reocclusion (29xa0% vs. 2xa0% vs. 2xa0%, pu2009<u20090.01), and MACE (43xa0% vs. 6xa0% vs. 3xa0%, pu2009<u20090.01) were more common in patients with 2 or more risk factors than in those with 1 or 0.ConclusionsMSCT characteristics associated with adverse outcomes after CTO-PCI were occlusion length, minimal vessel area, and severe calcification.Key points• Percutaneous coronary intervention of chronic total occlusion remains a challenge.n • The parameters related to adverse outcomes after CTO-PCI have not been clarified.n • MSCT can provide useful information associated with adverse outcomes after CTO-PCI.

Malondialdehyde-modified low-density lipoprotein is a predictor of cardiac events in patients with stable angina on lipid-lowering therapy after percutaneous coronary intervention using drug-eluting stent

OBJECTIVEnPatients undergoing lipid-lowering therapy after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) are subject to residual risk. Malondialdehyde-modified low-density lipoprotein (MDA-LDL) is suggested as a marker of the initiation and acceleration of atherosclerosis. This study aimed to investigate the impact of MDA-LDL on clinical outcomes in patients with stable angina undergoing lipid-lowering therapy after DES implantation.nnnMETHODSnIn this study, 332 patients whose MDA-LDL was measured before PCI with DES were followed clinically (median 2.9 years). Lipid-lowering therapy was conducted, with the target LDL ≤100xa0mg/dL. We analyzed the composite of major adverse cardiac events (MACE), including cardiac death, myocardial infarction, stent thrombosis, ischemia-driven target lesion revascularization, and any revascularization.nnnRESULTSnMACE was observed in 64 patients (19.3%). MDA-LDL was significantly higher in the MACE group (139.1xa0±xa053.2U/L vs. 106.5xa0±xa038.3U/L, pxa0<xa00.01). Univariate Cox regression analysis indicated a significant relationship between MACE and hemodialysis (Hazard ratio (HR) 4.60; pxa0<xa00.01), MDA-LDL (per 10U/L, HR 1.14; pxa0<xa00.01), multivessel disease (HR 1.78; pxa0=xa00.02), and high-density lipoprotein (per 10xa0mg/dL, HR 0.79; pxa0=xa00.03). In the multivariate model, hemodialysis (HR 4.10; pxa0<xa00.01) and MDA-LDL (per 10U/L, HR 1.10; pxa0<xa00.01) remained significant predictors of MACE. The optimal MDA-LDL threshold for predicting MACE was 114.1U/L, identified by the receiver operating characteristic curve.nnnCONCLUSIONSnMDA-LDL was associated with future cardiac events in patients with stable angina that underwent lipid-lowering therapy after DES-PCI.

Impact of sirolimus-eluting stent fractures without early cardiac events on long-term clinical outcomes: a multislice computed tomography study.

AbstractObjectivesThis study sought to evaluate the impact of sirolimus-eluting stent (SES) fractures on long-term clinical outcomes using multislice computed tomography (MSCT).MethodsIn this study, 528 patients undergoing 6- to 18-month follow-up 64-slice MSCT after SES implantation without early clinical events were followed clinically (the median follow-up interval was 4.6xa0years). A CT-detected stent fracture was defined as a complete gap with Hounsfield units (HU) <300 at the site of separation. The major adverse cardiac events (MACEs), including cardiac death, stent thrombosis, and target lesion revascularisation, were compared according to the presence of stent fracture.ResultsStent fractures were observed in 39 patients (7.4xa0%). MACEs were more common in patients with CT-detected stent fractures than in those without (46xa0% vs. 7xa0%, pu2009<u20090.01). Univariate Cox regression analysis indicated a significant relationship between MACE and stent fracture [hazard ratio (HR) 7.65; pu2009<u20090.01], age (HR 1.03; pu2009=u20090.04), stent length (HR 1.03; pu2009<u20090.01), diabetes mellitus (HR 1.77; pu2009=u20090.04), and chronic total occlusion (HR 2.54; pu2009=u20090.01). In the multivariate model, stent fracture (HR 5.36; pu2009<u20090.01) and age (HR 1.03; pu2009=u20090.04) remained significant predictors of MACE.ConclusionsAn SES fracture detected by MSCT without early clinical events was associated with long-term clinical adverse events.Key points• Long-term outcomes of sirolimus-eluting stent fracture have not been fully clarified.n • MSCT could detect stent fracture with high accuracy.n • Sirolimus-eluting stent fracture detected by MSCT was associated with long-term adverse events.

Safety and utility of total percutaneous endovascular aortic repair with a single Perclose ProGlide closure device

OBJECTIVEnThis study evaluated the safety and efficacy of total percutaneous endovascular aortic aneurysm repair (PEVAR) with a single Perclose ProGlide device (Abbot Vascular, Santa Clara, Calif) compared with endovascular aortic repair with surgical cutdown (SEVAR).nnnMETHODSnThe study included 50 abdominal aortic aneurysm patients who were treated with PEVAR with a single Perclose ProGlide device and 96 patients treated with SEVAR. Technical success was defined as successful arterial closure of the common femoral artery without the need for adjunctive surgical or endovascular procedures. The rates of complications, including bleeding requiring transfusion, infection, pseudoaneurysm, paresthesia, and lymphocele, as well as the operating room time and hospital duration were compared between the PEVAR and SEVAR groups.nnnRESULTSnTechnical success was obtained in all patients in the PEVAR group. One patient in the SEVAR group needed surgical repair due to access site bleeding. Complication rates were similar between the groups (4% in the PEVAR vs 8% in the SEVAR; Pxa0= .495). The PEVAR group had significantly shorter operating room times (153xa0± 47xa0minutes vs 211xa0± 88xa0minutes, Pxa0< .001) and hospital lengths of stay (6.7xa0± 6.8xa0days vs 9.3xa0± 4.5xa0days, Pxa0< .001).nnnCONCLUSIONSnCompared with SEVAR, PEVAR with a single ProGlide device is a safe procedure with a shorter operating room time and hospital stay, without increasing access site complications.

Non-atherosclerotic spontaneous coronary artery dissection revascularized by intravascular ultrasonography-guided fenestration with cutting balloon angioplasty

A 46-year-old woman was referred to our hospital due to chest pain. Twelve-lead electrocardiogram revealed ST-segment elevation suggesting acute myocardial infarction. Emergent coronary angiography showed diffuse narrowing and occlusion in the middle to distal left anterior descending artery (LAD). To investigate the cause of occlusion, an intravascular ultrasound (IVUS) examination was performed and we diagnosed spontaneous coronary artery dissection (SCAD) as the cause of occlusion. After a cutting balloon was dilated at the distal LAD, coronary flow recovered. IVUS-guided angioplasty with cutting balloon could be a choice of treatment in SCAD patients who need revascularization.

Fractional flow reserve-guided percutaneous coronary intervention for an intermediate stenosis complicated by a coronary-to-pulmonary artery fistula

A 65-year-old man was referred to our hospital following repetitive chest pain. Invasive coronary angiography showed an intermediate stenosis of the proximal left anterior descending artery (LAD), and a coronary fistula originating distal to the stenosis draining into the main pulmonary artery. To evaluate the functional abnormality arising from the stenosis and coronary steal due to the fistula, fractional flow reserve (FFR) was measured using a pressure wire with pullback recording. The FFR value was 0.74 at the distal LAD, 0.78 distal to the fistula, 0.81 proximal to the fistula (distal to the stenosis), and abruptly increased to 1.0 proximal to the stenosis. Based on these FFR results, percutaneous coronary intervention was performed to the stenosis. After stent placement, the FFR value improved to 0.87 at the distal LAD, and no abrupt pressure gradient was observed beyond the fistula and the stent. FFR-guided intervention with pullback pressure recording could be a useful and practical method to apply in cases with coronary stenosis complicated by coronary fistula in the same vessel.

Increased circulating malondialdehyde-modified low-density lipoprotein levels in patients with ergonovine-induced coronary artery spasm

OBJECTIVEnCoronary endothelial dysfunction is thought to underlie the development of coronary artery spasms. Malondialdehyde-modified low-density lipoprotein (MDA-LDL) was suggested as a marker of endothelial damage. This study investigated the diagnostic impact of MDA-LDL on ergonovine-induced coronary spasms.nnnMETHODSnWe included 152 patients with suspected coronary spastic angina. MDA-LDL levels were measured before an ergonovine provocation test. Coronary spasm was defined as total or subtotal occlusion, compared to the relaxed state after nitroglycerin, associated with ischemic ECG changes and concurrent chest pain. Changes in vessel diameter in response to ergonovine were evaluated with quantitative coronary angiography.nnnRESULTSnCoronary spasms were observed in 41 patients (27%). MDA-LDL levels were significantly higher in patients with spasms compared to those without spasms (139.9 ± 45.9 U/L vs. 109.6 ± 36.6 U/L, p<0.01). Univariate logistic regression analyses indicated significant relationships between coronary spasms and MDA-LDL (per 10 U/L, odds ratio (OR): 1.20; p<0.01), high-density lipoprotein (per 10 mg/dL, OR: 0.76; p=0.03), smoking (OR: 3.04; p<0.01), and male gender (OR: 3.51; p<0.01). In the multivariate model, MDA-LDL (per 10 U/L, OR: 1.17; p<0.01) remained a significant predictor of coronary spasm. Regression analysis showed a positive correlation between MDA-LDL levels and coronary luminal diameter changes induced by ergonovine (r=0.57, p<0.01). The optimal MDA-LDL threshold for predicting coronary spasm was 121.3 U/L, identified with a receiver operating characteristic curve.nnnCONCLUSIONSnIncreased circulating MDA-LDL levels were associated with ergonovine-induced coronary artery spasm.

Impact of epicardial adipose tissue volume quantified by non-contrast electrocardiogram-gated computed tomography on ergonovine-induced epicardial coronary artery spasm

OBJECTIVEnEndothelial dysfunction of the coronary artery is thought to lead to the development of coronary spasms. Epicardial adipose tissue may be a marker of coronary atherosclerosis. This study investigated the diagnostic impact of epicardial fat volume (EFV), quantified with non-contrast electrocardiogram (ECG)-gated computed tomography (CT), on ergonovine-induced coronary spasms.nnnMETHODSnWe included 97 patients with suspected coronary spastic angina who underwent ECG-gated CT and an ergonovine provocation test. The EFV was measured with CT data sets using dedicated software. Coronary spasm was defined as total or subtotal occlusion (compared with the relaxed state after nitroglycerin) that was associated with ischemic ECG changes and concurrent chest pain.nnnRESULTSnCoronary spasms were observed in 27 patients (28%). The EFV was significantly higher in patients with spasms compared with those without spasms (175.0±57.8cm(3) vs. 129.7±57.8cm(3), p<0.01). Univariate logistic regression analyses indicated significant relationships between coronary spasms and EFV (per 10cm(3), odds ratio (OR): 1.13; p<0.01), male gender (OR: 3.34; p<0.01), and smoking (OR: 3.42; p<0.01). In the multivariate model, EFV (per 10cm(3), OR: 1.10; p=0.03) and male gender (OR: 5.94; p=0.02) remained significant predictors of coronary spasm. The optimal EFV threshold for predicting coronary spasm was 149.4cm(3), identified with a receiver operating characteristic curve.nnnCONCLUSIONSnIncreased EFV was associated with ergonovine-induced epicardial coronary artery spasms.