Xuejun Ren

Impact of diabetes mellitus on patients with unprotected left main coronary artery lesion disease treated with either percutaneous coronary intervention or coronary-artery bypass grafting.

ObjectiveThis study was conducted to evaluate the impact of diabetes on patients with unprotected left main coronary artery (LMCA) disease treated with either percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG). BackgroundThe optimal coronary revascularization strategy in diabetic patients with unprotected LMCA disease remains uncertain. MethodsA total of 823 consecutive patients having unprotected LMCA disease, who received drug-eluting stent (DES) (n=331) implantation or underwent CABG (n=492), were retrospectively analyzed. We compared the effects of these two treatments on clinical outcomes [death, cardiac death, myocardial infarction (MI), stroke, target vessel revascularization, and the composite of death, MI, or stroke], according to the patients’ diabetic status. ResultsAfter multivariable adjustment, the risk of death [hazard ratio (HR): 1.096, 95% confidence interval (CI): 0.541–2.222; P=0.799] and that of the composite of death, MI, or stroke (HR: 0.769, 95% CI: 0.446–1.328; P=0.346) were similar in the DES and CABG groups. However, the rate of target vessel revascularization was significantly higher in the DES group (HR: 0.169, 95% CI: 0.079–0.358; P<0.001). Incidence of MI (HR: 1.314, 95% CI: 0.238–7.254; P=0.754) and that of the composite of death, MI, or stroke (HR: 1.497, 95% CI: 0.682–3.289; P=0.315) were similar between DES and CABG in the nondiabetic group; however, in the diabetic population incidence of the composite of death, MI, or stroke (HR: 0.31, 95% CI: 0.126–0.761; P=0.011) was significantly higher in the DES compared with the CABG group, driven mainly by the significantly higher rate of MI in the DES group (HR: 0.114, 95% CI: 0.022–0.593; P=0.01). Rate of repeat revascularization was higher with DES compared with CABG in both diabetic and nondiabetic groups. ConclusionThere was a prognostic impact of diabetes mellitus on treatment effects in patients with unprotected LMCA lesions who underwent DES or CABG. For patients with unprotected LMCA lesions, PCI with DES was an acceptable alternative to CABG at risk for higher repeat revascularization in the nondiabetic cohort, whereas in the diabetic cohort PCI with DES was inferior to CABG in terms of both safety and efficacy.

Duration of dual antiplatelet therapy after implantation of the first-generation and second-generation drug-eluting stents.

ObjectiveThis study was carried out to determine the effect of the use of dual antiplatelet therapy (DAPT) for more than 12 months on long-term clinical outcomes in patients who had undergone a percutaneous coronary intervention with the first and second generations of drug-eluting stents (DES). BackgroundThe potential benefits of the use of DAPT beyond a 12-month period in patients receiving DES have not been established clearly. Moreover, it is also unclear whether the optimal duration of DAPT is similar for all DES types. MethodsA total of 2141 patients with coronary artery disease treated exclusively with Cypher sirolimus-eluting stents (SES) or Endeavor zotarolimus-eluting stents (ZES) were considered for retrospective analysis. The primary endpoint [a composite of all-cause mortality, nonfatal myocardial infarction (MI), and stroke] was compared between the 12-month DAPT and the >12-month DAPT group. ResultsA total of 1870 event-free patients on DAPT at 12 months were identified. The average follow-up was 28.2±7.4 months. The primary outcomes were similar between the two groups (4.1% 12-month DAPT vs. 1.9% >12-month DAPT; P=0.090). Incidences of death, MI, stroke, and target vessel revascularization did not differ significantly between the two groups. Subgroup analysis showed that in the patients with hypertension, >12-month DAPT significantly reduced the occurrence of death/MI/stroke compared with that in the 12-month DAPT group (P=0.04). In patients implanted with SES, the primary outcome was significantly lower with the >12-month DAPT group (5.2% 12-month DAPT vs. 1.6% >12-month DAPT; P=0.016), whereas in patients with ZES, the primary outcome was comparable between the two groups (2.3% 12-month DAPT vs. 2.0% >12-month DAPT; P=0.99). ConclusionIn our study, for all patients, >12-month DAPT in patients who had received DES was not significantly more effective than 12-month DAPT in reducing the rate of death/MI/stroke. Our findings, that patients who received SES benefit from >12-month DAPT whereas extended use of DAPT was not significantly more effective in those implanted with ZES, implied that the optimal duration of DAPT was different depending on different types of DES.

Circulating endothelial microparticles and miR-92a in acute myocardial infarction

Microparticles (MPs) and miRNAs have been shown to play important roles in coronary artery disease (CAD) by monitoring endothelial dysfunction. The present study aims to investigate the diagnostic value of endothelial MPs (EMPs) and miRNAs (miR-92a or miR-23a) as biomarkers in distinguishing patients with acute myocardial infarction (AMI) from those with CAD. Plasma samples from 37 patients with AMI, 42 patients with stable CAD (SCAD), and 35 healthy adults were collected for investigation in the present study. The numbers of CD31+/CD42b− MPs, CD31+/CD42b+ MPs, and CD31−/CD42b− MPs were measured by flow cytometry and the levels of miR-92a and miR-23a were analyzed using reverse transcription-quantitative PCR. Moreover, cardiac troponin I (cTnI) expression was detected by ELISA to serve as a routine diagnostic parameter. The number of CD31+/CD42b− was higher in AMI group than those in SCAD and healthy groups. Besides, the expression of miR-92a was higher in AMI group compared with two other groups. Furthermore, evidence showed that there was a positive correlation between the levels of CD31+/CD42b− MPs and miR-92a. Finally, the receiver operating characteristic (ROC) curve revealed that the area value under the curve of CD31+/CD42b− MPs, miR-92a and cTnI was 0.893, 0.888, and 0.912 respectively. CD31+/CD42b− MPs and miR-92a might have great potential to provide diagnostic value for AMI and could probably regulate the endothelial dysfunction in AMI patients.

Focal atrial tachycardia originating from the septal mitral annulus: electrocardiographic and electrophysiological characteristics and radiofrequency ablation

AIMS This study sought to investigate electrocardiographic characteristics, electrophysiological features, and radiofrequency ablation in patients with focal atrial tachycardia (AT) originating from the septal mitral annulus. METHODS AND RESULTS In 13 patients with AT originating from the septal mitral annulus, activation mapping was performed to identify the earliest activation site. Successful ablation was performed through either a transseptal (n = 12) or a retrograde aortic approach (n = 1). As confirmed by electrogram recordings, fluoroscopy, and three-dimensional (3D) mapping, successful ablation sites were located in the anterior paraseptal, mid- to anteroseptal, and posterior septal mitral annulus in eight, three, and two patients, respectively. Foci for all locations demonstrated a negative/positive appearance in lead V1. Mapping in the right atrium demonstrated that the earliest right atrial activation was near the septum (His-bundle region or proximal coronary sinus). The electrograms at the successful ablation sites were fractionated in 9 patients, and presented with an atrial:ventricular ratio of <1 in all 13 patients. There were no complications in any patients and long-term success was achieved in 12 of 13 patients during the 23 ± 6 months following ablation. CONCLUSION The area surrounding the septal mitral annulus, most commonly the anterior paraseptal, is an unusual, but important site of origin for focal AT, which is associated with a distinctive P-wave morphology and atrial endocardial activation sequence. Radiofrequency ablation of AT originating from the septal mitral annulus, through either a transseptal or a retrograde aortic approach appears to be safe and effective.

Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease

Background:There are limited data on longer-term outcomes (>5 years) for patients with unprotected left main coronary artery (ULMCA) disease who underwent percutaneous coronary intervention (PCI) in the drug-eluting stents (DES) era. This study aimed at comparing the long-term (>5 years) outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting (CABG) and the predictors of adverse events. Methods:All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups. Results:Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses (DES = 465 vs. CABG = 457). During the median follow-up of 7.1 years (interquartile range 5.3–8.2 years), no difference was found between PCI and CABG in the occurrence of death (P = 0.282) and the composite endpoint of cardiac death, myocardial infarction (MI) and stroke (P = 0.294). Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group (P = 0.014) in large part because of the significantly higher rate of repeat revascularization (P < 0.001). PCI was correlated with the lower occurrence of stroke (P = 0.004). Multivariate analysis showed ejection fraction (EF) (P = 0.012), creatinine (P = 0.016), and prior stroke (P = 0.031) were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age (P = 0.026) and EF (P = 0.002) were independent predictors in the CABG group. Conclusions:During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.

Idiopathic ventricular arrhythmias originating from the right coronary sinus: Prevalence, electrocardiographic and electrophysiological characteristics, and catheter ablation

BACKGROUND Ventricular arrhythmias (VAs) of the right coronary cusp (RCC) are not fully characterized. OBJECTIVES To investigate the electrocardiographic and electrophysiological characteristics, mapping and ablation of RCC-VAs. METHODS Among 256 consecutive patients undergoing electrophysiological evaluation and ablation of VAs of ventricular outflow tract origin, data were compared among 27 RCC-VAs, 50 VAs of the septal aspect of right ventricular outflow tract (RVOT), including from pulmonary artery, and 9 VAs of left coronary cusp (LCC). RESULTS The only electrocardiographic characteristic that differentiated VAs originating from the RCC and RVOT was the amplitude of the R wave in lead I. During VAs of the RCC, the earliest activation site (EAS) in the right ventricle was localized in the middle-posterior septal region of the RVOT. The distance between the His bundle and the EAS in the RVOT in the RCC group was shorter than that in the RVOT and LCC group; the distance ≤ 29.4 mm, which rules out an RVOT and LCC origin, had 92.6% sensitivity and 100% specificity for RCC-origin speculation. Double or complex potentials were recorded in RVOT middle-posterior septal area surrounding the EAS in 20 of 27 RCC-VA patients (70%). Most of the successful ablation sites (24/27) were located in the anterior and upper margin of the RCC, close to the middle-posterior septal region of the RVOT. The prepotential (P1) amplitude and the P1-to-QRS complex interval may be indicators of successful RCC-VA ablation sites. CONCLUSIONS RCC-VAs are not uncommon and have unique electrocardiographic and electrophysiological characteristics that distinguish an RCC origin of VA from RVOT and LCC origins. Most RCC-VAs were ablated successfully in the anterior and upper aspects of the RCC.

Impact of chronic kidney disease on patients with unprotected left main coronary artery disease treated with coronary artery bypass grafting or drug-eluting stents.

ObjectivesThis study aimed to evaluate clinical outcomes after percutaneous coronary intervention with drug-eluting stents (DESs) or coronary artery bypass grafting (CABG) in unprotected left main coronary artery (ULMCA) disease patients with and without chronic kidney disease. BackgroundThe optimal coronary revascularization strategy for ULMCA disease patients with chronic kidney disease remains uncertain. MethodsThe sample included 818 ULMCA disease patients who received DESs (n=358) or underwent CABG (n=460). We retrospectively compared clinical parameters and outcomes between different endogenous creatinine clearance rates [estimated glomerular filtration rates (eGFRs), ml/min×1.73 m2]. ResultsThe incidences of major adverse cardiocerebral events, all-cause death, cardiac death, and stroke were not significantly different between the DES and the CABG groups. The DES group had significantly higher risks of myocardial infarction (MI) and target vessel revascularization than the CABG group. Compared with the CABG group, the hazard ratios for target vessel revascularization were 3.965 [95% confidence interval (CI): 1.743–9.023, P=0.001] in the eGFR of at least 60 group and 46.463 (95% CI: 4.558–473.639, P=0.001) in the eGFR 45–59 group. The rate of MI was higher in patients treated with DESs in the eGFR of less than 45 group (hazard ratio: 14.098, 95% CI: 1.123–176.988, P=0.040). ConclusionFor patients with ULMCA disease at risk of higher repeat revascularization with normal renal function or eGFR of at least 45 ml/min×1.73 m2, DESs are a safe alternative to CABG. However, for patients with severely reduced kidney function (eGFR<45 ml/min×1.73 m2), DESs should be selected after careful evaluation of MI risk.

The relationship between revascularization extent and the long-term prognosis of patients with stable angina pectoris and three-vessel disease treated by percutaneous coronary intervention in the era of drug-eluting stents.

The effects of revascularization extent (RE) on the long‐term prognosis of patients with stable angina pectoris and 3‐vessel disease who underwent percutaneous coronary intervention were unknown.

Catheter ablation of ventricular arrhythmias with QRS morphology resembling that of aortic sinus cusp arrhythmias: Significance of mapping the left pulmonary sinus cusp

There is a close anatomical relationship between aortic sinus cusp (ASC) and the left pulmonary sinus cusp (LPSC).

Mapping and ablation of RVOT-type arrhythmias: comparison between the conventional and reversed U curve methods

PurposeWe assessed conventional and reversed U curve methods for mapping and ablation of RVOT-type VAs.MethodsSingle-center data were reviewed from consecutive cases of symptomatic VAs of RVOT-type origin that were mapped and ablated successfully using conventional method in RVOT (pulmonary artery might be included) from January 2014 to December 2015 (cohort 1, n = 75) or conventional method in RVOT and reversed U curve in PSC (for first ablation attempt) from January 2016 to March 2017 (cohort 2, n = 60).ResultsAt least 90% of RVOT-VAs could be eliminated using conventional method in RVOT or reversed U curve in PSC. For RVOT-VAs, if the earliest activation site was in midposterior free wall, midposterior septal side of RVOT, or anterior free wall/septal side of RVOT with conventional method, it was likely eliminated in right, left, and anterior PSC with reversed U curve method, respectively. Nearly the same earliest potential in almost the same region could be recorded by both methods. Compared with conventional method, the reversed U curve method showed better catheter stability and contact force during mapping and ablation, and showed distinctive features in presystolic potential recording, unipolar mapping, and ablation response.ConclusionsMost of RVOT-VAs could be eliminated using conventional method in RVOT or reversed U curve in PSC. However, the reversed U curve method has superiority in catheter stability and contact force, especially for VAs form free wall of RVOT.