Yuji Sakanoue

A Prospective, Multicenter, Randomized Trial to Assess Efficacy of Pioglitazone on In-Stent Neointimal Suppression in Type 2 Diabetes : POPPS (Prevention of In-Stent Neointimal Proliferation by Pioglitazone Study)

OBJECTIVES The aim of this study was to clarify whether pioglitazone suppresses in-stent neointimal proliferation and reduces restenosis and target lesion revascularization (TLR) after percutaneous coronary intervention (PCI). BACKGROUND Previous single-center studies have demonstrated the anti-restenotic effect of a peroxisome proliferator-activated receptor gamma agonist, pioglitazone, after PCI. METHODS A total of 97 patients with type 2 diabetes mellitus (T2DM) undergoing PCI (bare-metal stents only) were enrolled. After PCI, patients were randomly assigned to either the pioglitazone group (n = 48) or the control group (n = 49). Angiographical and intravascular ultrasound (IVUS) imaging were performed at baseline and repeated at 6-month follow-up. Primary end points included angiographical restenosis and TLR at 6 months follow-up. Secondary end point was in-stent neointimal volume by IVUS. RESULTS Baseline glucose level and glycosylated hemoglobin (HbA1c) level were similar between the pioglitazone group and the control group. Angiographical restenosis rate was 17% in the pioglitazone group and 35% in control group (p = 0.06). The TLR was significantly lower in pioglitazone group than in control group (12.5% vs. 29.8%, p = 0.04). By IVUS (n = 56), in-stent neointimal volume at 6 months showed a trend toward smaller in the pioglitazone group than in the control group (48.0 +/- 30.2 mm(3) vs. 62.7 +/- 29.0 mm(3), p = 0.07). Neointimal index (neointimal volume/stent volume x 100) was significantly smaller in the pioglitazone group than in the control group (31.1 +/- 14.3% vs. 40.5 +/- 12.9%, p = 0.01). CONCLUSIONS Pioglitazone treatment might suppress in-stent neointimal proliferation and reduce incidence of TLR after PCI in patients with T2DM.

Assessment of myocardial viability using coronary zero flow pressure after successful angioplasty in patients with acute anterior myocardial infarction

Objectives: To investigate the relation between coronary flow reserve (CFR), coronary zero flow pressure (Pzf), and residual myocardial viability in patients with acute myocardial infarction. Designs: Prospective study. Setting: Primary care hospital. Patients: 27 consecutive patients with acute anterior myocardial infarction. Main outcome measures:18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) was used in 27 patients who underwent successful intervention within 12 hours of onset of a first acute anterior myocardial infarction. Within three days before discharge they had < 25% stenosis in the culprit lesion as determined by angiography 24 (3) days after acute myocardial infarction. Pzf and the slope index of the flow-pressure relation (SIFP) were calculated from the simultaneously recorded aortic pressure and coronary flow velocity signals at peak hyperaemia.%FDG was quantified by comparing FDG uptake in the infarct myocardium with FDG uptake in the normal myocardium. Results: There was a correlation between %FDG and CFR, where y = −1.477x + 62.517, r = −0.072 (NS). There was also a correlation between %FDG and SIFP, where y = −0.975x + 60.542, r = −0.045 (NS), and a significant correlation between %FDG and Pzf, where y = −0.98x + 85.108, r = −0.696 (p < 0.001). Conclusions: CFR does not correlate with FDG-PET at the time of postreperfusion evaluation of residual myocardial viability. The parameter that correlates best with residual myocardial viability is Pzf and this may be a useful index for predicting patient prognosis.

Outcomes of everolimus-eluting stent incomplete stent apposition: a serial optical coherence tomography analysis.

AIM The aim of the present study was to evaluate the natural course of acute incomplete stent apposition (ISA) after second-generation everolimus-eluting stent (EES) when compared with first-generation sirolimus-eluting stent (SES) by using optical coherence tomography (OCT). METHODS AND RESULTS From the OCT substudy of the RESET trial, we identified 77 patients (EES = 38 and SES = 39) who successfully underwent serial OCT examination at post-stenting and 8-12-month follow-up. The presence of ISA was assessed in the OCT images, and ISA distance was measured from the centre of the strut blooming to the adjacent lumen border. Incomplete stent apposition was observed in all EES and SES at post-stenting, and it was persistent in 26% of EES and 38% of SES at 8-12-month follow-up. Maximum ISA distance was significantly decreased during the follow-up period in both EES (315 ± 94-110 ± 165 μm, P < 0.001) and SES (308 ± 119-143 ± 195 μm, P < 0.001). Receiver-operating curve analysis identified that the best cut-off value of OCT-estimated ISA distance at post-stenting for predicting late-persistent ISA at 8-12-month follow-up in EES and SES was >355 and >285 μm, respectively. CONCLUSIONS The second-generation EES showed better healing of acute ISA in comparison with the first-generation SES. Optical coherence tomography can predict late-persistent ISA after DES implantation and provide useful information to optimize PCI.

Intravenous myocardial contrast echocardiography predicts regional and global left ventricular remodelling after acute myocardial infarction: comparison with low-dose dobutamine stress echocardiography

Objective: To assess the role of intravenous myocardial contrast echocardiography (MCE) in predicting functional recovery and regional or global left ventricular (LV) remodelling after acute myocardial infarction (AMI) compared with low dose dobutamine stress echocardiography (LDSE). Methods: 21 patients with anterior AMI and successful primary angioplasty underwent MCE and LDSE during the subacute stage (2–4 weeks after AMI). Myocardial perfusion and contractile reserve were assessed in each segment (12 segment model) with MCE and LDSE. The 118 dyssynergic segments in the subacute stage were classified as recovered, unchanged, or remodelled according to wall motion at six months’ follow up. Percentage increase in LV end diastolic volume (%ΔEDV) was also calculated. Results: The presence of perfusion was less accurate than the presence of contractile reserve in predicting regional recovery (55% v 81%, p < 0.0001). However, the absence of perfusion was more accurate than the absence of contractile reserve in predicting regional remodelling (83% v 48%, p < 0.0001). The number of segments without perfusion was an independent predictor of %ΔEDV, whereas the number of segments without contractile reserve was not. The area under the receiver operating characteristic curve showed that the number of segments without perfusion predicted substantial LV dilatation (%ΔEDV > 20%) more accurately than did the number of segments without contractile reserve (0.88 v 0.72). Conclusion: In successfully revascularised patients with AMI, myocardial perfusion assessed by MCE is predictive of regional and global LV remodelling rather than of functional recovery, whereas contractile reserve assessed by LDSE is predictive of functional recovery rather than of LV remodelling.

Detection of restenosis after percutaneous coronary intervention in three major coronary arteries by transthoracic Doppler echocardiography.

BACKGROUND The aim of this study was to evaluate the diagnostic potential of coronary flow velocity reserve (CFR) measurement by transthoracic Doppler echocardiography (TTDE) to detect restenosis in the 3 major coronary arteries: the left anterior descending coronary artery, right coronary artery, and left circumflex coronary artery. METHODS The lesions of 175 patients who were scheduled for follow-up coronary angiography and TTDE 6 months after undergoing stents implantation were studied. CFR was assessed by TTDE in the targeted arteries into which stents had been implanted. RESULTS Coronary stents were implanted in a total of 238 angiographic lesions in 175 patients. Doppler recordings of coronary flow in the 3 major arterial lesions were obtained in 211 of the 238 angiographic lesions (89% feasibility). CFR was significantly lower in lesions with restenosis than those without restenosis (1.70 +/- 0.32 vs 2.65 +/- 0.66, P < .01). A CFR value < 2.0 was 89% sensitive and 91% specific for detecting restenosis in the 3 major coronary arteries. Sensitivity and specificity were 86% and 91%, respectively, in the left anterior descending coronary artery (95% feasibility); 92% and 92%, respectively, in the right coronary artery (85% feasibility); and 91% and 92%, respectively, in the left circumflex coronary artery (81% feasibility). CONCLUSION CFR assessment by TTDE is an accurate method for monitoring restenosis, not only in the left anterior descending but also in the right and left circumflex coronary arteries in patients previously subjected to percutaneous coronary intervention.

Plaque Rupture Causing Spontaneous Coronary Artery Dissection in a Patient With Acute Myocardial Infarction

A 68-year-old man was admitted to the hospital because of chest oppression. ECGs on admission revealed ST-segment elevation in leads II, III, and aVF. Urgent coronary angiography showed …

Dobutamine-stress electrocardiographically gated positron emission tomography for detection of viable but dysfunctional myocardium

PurposeThis study was performed to determine whether low-dose dobutamine stress electrocardiography (ECG)-gated fluorine-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET) can assess wall motion and identify myocardium without contractile reserve despite preserved FDG uptake.MethodsFifty-three patients with myocardial infarction and normal sinus rhythm underwent ECG-gated FDG-PET and transthoracic echocardiography. Wall motion of 10 segments of the left ventricle was graded as normal, hypokinetic, or akinetic/dyskinetic.ResultsIn 365 (76%) of 480 segments, assessment of wall motion was concordant between the 2 modalities. In 30 patients dobutamine-stress ECG-gated FDG-PET was performed. In 13 (50%) of 26 dysfunctional segments with normal FDG uptake, 16 (36%) of 44 dysfunctional segments with mildly reduced FDG uptake and 12 (25%) of 48 dysfunctional segments with moderately reduced FDG uptake, wall motion was improved by dobutamine infusion.ConclusionAssessment of left ventricular wall motion with ECG-gated FDG-PET is feasible, and dobutamine stress ECG-gated FDG-PET can simultaneously identify metabolic viability and contractile reserve.

Percutaneous Transcatheter Balloon Valvuloplasty for Bioprosthetic Tricuspid Valve Stenosis

A 59-year-old woman was admitted to our hospital because of exertional dyspnea, abdominal distension, and leg edema over the past 2 weeks. She had a history of rheumatic fever at the age of 12 years. In 1983, at the age of 37, she had undergone tricuspid valve replacement with a Carpentier-Edwards bioprosthesis for tricuspid stenosis and mitral valve replacement with a mechanical valve for mitral stenosis. The physical examination on admission revealed marked edema in both legs. There was also presystolic pulsation of the liver, which was palpable 4 cm below the right costal margin. A Levine grade III/VI, rough, diastolic rumble at the lower left sternal border was accentuated during inspiration. Echocardiography revealed severe tricuspid stenosis and a large amount of ascites. The leaflets were thickened, …

Hereditary Hemorrhagic Telangiectasia With Pulmonary Arteriovenous Fistulas

A 65-year-old woman presented with exertional dyspnea and general fatigue that began 1 week ago. She had a family history of hereditary hemorrhagic telangiectasia manifesting as telangiectasia of gastrointestinal (GI) tract and nasal mucosa and of pulmonary arteriovenous fistulas (PAVFs). Her first PAVF was diagnosed in 1999 but was untreated at that time. Her medical history was significant for multiple GI bleeds, mild to moderate nosebleeds, and a minor cerebral stroke probably due …

Usefulness of newly designed pigtail catheter with multiple side holes by reducing incidence of ventricular ectopy

This study was designed to determine whether a newly designed 5 Fr pigtail catheter of Jet Balance with multiple side holes reduces the incidence of ventricular ectopy during left ventriculography. To examine the catheter movement in vitro, we injected a colored glycerin solution by an injector through 5 Fr Jet Balance catheter and 6 Fr conventional pigtail catheter suspended in a water filled, glass container. A recoil of the catheter caused by injection was observed for a 6 Fr conventional catheter; however, no catheter movement was observed when a 5 Fr Jet Balance was used. To evaluate clinical usefulness of the 5 Fr Jet Balance, we compared the number of incidence of ventricular ectopy during left ventriculography between 5 Fr Jet Balance and 6 Fr conventional pigtail catheters. In 104 consecutive patients who underwent left ventriculography, a 5 Fr Jet Balance was used in 55 patients (5 Fr Jet Balance group), and a 6 Fr conventional pigtail in 49 patients (6 Fr conventional pigtail group). The 5 Fr Jet Balance group had a significantly lower incidence of VPB (21.8% vs. 42.9%, P = 0.02), ventricular tachycardia (1.9% vs. 14.3%, P = 0.02), and multiple VPB (9.0% vs. 34.7%, P = 0.001), respectively, than the 6 Fr conventional pigtail group. In conclusion, a 5 Fr Jet Balance pigtail catheter is useful and safe as regard to the incidence of ventricular ectopy during left ventriculography. Cathet. Cardiovasc. Intervent. 48:220–225, 1999.