坂倉 建一

BACKGROUND: Since the long fluoroscopy time in primary PCI for ST-segment elevation myocardial infarction (STEMI) could be an indicator of delayed reperfusion, it should be important to recognize which types of lesions require longer fluoroscopy-time in primary PCI. The purpose of this study was to investigate the association of the long fluoroscopy-time with clinical factors in primary percutaneous coronary interventions (PCI). METHODS: A total of 539 patients who underwent primary PCI were divided into the conventional fluoroscopy-time group (Q1-Q4: n = 434) and the long fluoroscopy-time group (Q5: n = 105) according to the quintile of the total fluoroscopy time in primary PCI. Univariate and multivariate logistic regression analyses were performed to find associations between clinical variables and the long fluoroscopy-time. RESULTS: In univariate logistic regression analysis, prevalence of diabetes mellitus, hemodialysis, and previous CABG were significantly associated with the long fluoroscopy-time. In addition, complex lesion characteristics such as lesion length, lesion angle, tortuosity, and calcification were associated with the long fluoroscopy-time. In multivariable logistic regression analysis, lesion length [per 10 mm incremental: odds ratio (OR) 1.751, 95% confidence interval (CI) 1.397-2.195, P<0.001], moderate-excessive tortuosity (vs. mild tortuosity: OR 4.006, 95% CI 1.498-10.715, P = 0.006), and moderate to severe calcification (vs. none-mild calcification: OR 1.865, 95% CI 1.107-3.140, P = 0.019) were significantly associated with the long fluoroscopy-time. CONCLUSIONS: In primary PCI for STEMI, diffuse long lesion, tortuosity, and moderate-severe calcification were associated with the long fluoroscopy-time. These complex features require special attention to reduce reperfusion time in primary PCI.

Objective In primary percutaneous coronary intervention (PCI), the door-to-balloon time (DTBT) is known to be associated with in-hospital death in patients with ST-segment elevation myocardial infarction (STEMI). However, little is known regarding the association between the DTBT and the mid-term clinical outcomes in patients with STEMI. The purpose of this study was to investigate the association between the DTBT and mid-term all-cause death. Methods The study population included 309 STEMI patients, who were divided into the short DTBT (DTBT<60 minutes, n=103), intermediate DTBT (DTBT 60-120 minutes, n=174) and long DTBT (DTBT >120 minutes, n=32) groups. The median follow-up period was 287 days (interquartile range: 182-624 days). Results The incidence of all-cause death in the long DTBT group was significantly higher in comparison to the other groups (p<0.001). In the multivariate Cox regression analysis, although a short DTBT [vs. intermediate DTBT: hazard ratio (HR) 1.00, 95% confidence interval (CI) 0.39-2.55, p=0.99] was not associated with all-cause death, a long DTBT (vs. intermediate DTBT: HR 2.80, 95% CI 1.26-6.17, p=0.011) was significantly associated with all-cause death, after controlling for confounding factors such as Killip class 4, an impaired renal function, and the number of diseased vessels. Conclusion The DTBT was significantly associated with the incidence of mid-term all-cause death. Our results support the strong adherence to the DTBT in patients with STEMI.

BACKGROUND: Recently, the importance of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI) has been emphasized with greater success rates. In the antegrade wire based approach, it is generally considered that the guidewire would not advance from the subintimal space to the intimal space without dissection re-entry device. However, it is sometimes observed by intravascular ultrasound (IVUS) that the guidewire within the subintimal space advanced into the distal true lumen. The purpose of this study was to investigate specific conditions or characteristics which were associated with "antegrade true-sub-true" phenomenon in CTO-PCI. METHODS: We retrospectively reviewed consecutive 320 CTO lesions that underwent CTO-PCI in our institution. Among them, 16 lesions in which the IVUS confirmed the "antegrade true-sub-true" phenomenon were categorized as the true-sub-true group, whereas 27 lesions that resulted in unsuccessful CTO-PCI were categorized as the unsuccessful group. We compared the clinical, lesion, and procedural characteristics between the true-sub-true group and the unsuccessful group. RESULTS: The prevalence of bifurcation with abrupt type in CTO exit-sites was significantly higher in the true-sub-true group in comparison to the unsuccessful group (75.0% vs. 25.9%, p = 0.002). The multivariate logistic regression analysis revealed that bifurcation with abrupt type in CTO exit-site (OR 8.017; 95%CI: 1.484-43.304; p = 0.016) was independent predictor of the antegrade true-sub-true phenomenon. CONCLUSIONS: In CTO-PCI, the antegrade true-sub-true phenomenon is rare, but can be a last chance for successful PCI. Bifurcation with abrupt type in CTO exit-site was significantly associated with the antegrade true-sub-true phenomenon.

A reverse guidewire technique along with double lumen catheter has become a standard technique for extremely angulated bifurcation lesions. A-72-year-old male underwent coronary angiography, which revealed a severe stenosis of the left anterior descending artery with an extremely angulated diagonal branch. We introduced the Crusade (Kaneka, Osaka, Japan) accompanied with the reversed guidewire to the lesion, but the Crusade with the reversed guidewire could not cross the lesion. We kept the Crusade at the just proximal to the stenosis, and advanced the only reversed guidewire to the lesion. The reversed guidewire successfully crossed the lesion, and then we pulled back the reversed guidewire to lead the reversed guidewire's tip into the diagonal branch retrogradely. In this modified reverse guidewire technique, the Crusade does not need to cross the lesion, but needs to bring the reversed guidewire at the just proximal of the lesion. Because the profile of the reversed guidewire alone is smaller than that of the Crusade accompanied with the reversed guidewire, the reversed guidewire alone has greater chance to cross the severe stenosis. Our modification may increase the success rate of the reverse guidewire technique, and expand the indication of this technique. <Learning objective: In a reverse guidewire technique, if there is a severe stenosis at just proximal of the bifurcation lesion, it may be difficult to cross the double lumen catheter with a reversed guidewire beyond the bifurcation lesion, because the profile of the double lumen catheter accompanied with a reversed guidewire is much larger than the double lumen catheter or the reversed guidewire alone. We modified reverse guidewire technique, which may increase the success rate of the reverse guidewire technique.>.

Vascular toxicity is one of serious complications following cisplatin-based chemotherapy. This case suggests that cisplatin has a potential risk of delayed occurrence of vasospastic angina. It is important to perform careful history taking including discontinued drugs for differential diagnosis of chest pain.

BACKGROUND: Skin radiation injuries, especially radiation ulcers, are serious side effects caused by ionizing radiation during percutaneous coronary interventions (PCI). Because skin radiation injuries are closely associated with the peak skin dose, it is important to minimize the peak skin dose. The aim of the present study was to investigate the determinants of greater peak skin dose in current PCI. METHODS: We included 707 consecutive coronary artery lesions, and divided them into an excess radiation group (n = 26; defined as peak skin dose ≥2 Gy) and a standard radiation group (n = 681; defined as peak skin dose <2 Gy). Clinical, lesion, and procedural characteristics were compared between the 2 groups. Univariate and multivariate logistic regression analyses were performed to identify determinants of the excess radiation group. RESULTS: A multivariate logistic regression analysis revealed that body surface area (BSA) [0.1 m2 increase: odds ratio (OR) 1.39, 95% confidence interval (CI) 1.13-1.71, P < 0.01], PCI to a right coronary artery (RCA) (OR 3.11, 95% CI 1.35-7.17, P < 0.01), and PCI to a chronic total occlusion (CTO) (OR 6.69, 95% CI 2.65-16.87, P < 0.01) were significantly associated with the excess radiation group. CONCLUSIONS: Greater BSA, PCI to RCA lesions, and PCI to CTO lesions were significantly associated with excess radiation dose. The first step in the prevention of radiation injuries in current PCI will be to recognize these risk factors.

Persistent severe left ventricular (LV) systolic dysfunction after acute myocardial infarction (AMI) is associated with increased morbidity and mortality, whereas mid-term recovery of LV systolic function after AMI is associated with better long-term outcomes. The purpose of this study was to investigate the determinants of mid-term improvement of LV ejection fraction (EF) in AMI patients. We included 210 AMI patients who had modified Simpson EF both at the index admission and mid-term follow up. The difference of EF between the index admission and mid-term follow-up was calculated in all study patients. The EF improvement group was defined as mid-term ≥ 10% EF increase compared with the index admission EF. Of 210 AMI patients, 46 (21.9%) were allocated to the EF improvement group and 164 (78.1%) to the non-EF improvement group. Brain natriuretic peptide (BNP) at the timing of admission was significantly greater in the EF improvement group (735.8 ± 1077.6 pg/mL) than in the non-EF improvement group (239.0 ± 419.8 pg/mL) (P < 0.001). Multivariate logistic regression analysis revealed that log10 BNP at the timing of admission (OR 3.36, 95% CI 1.69-6.66, P < 0.001) and left main trunk-left anterior descending artery (LM-LAD) as the infarct-related artery (OR 3.34, 95% CI 1.59-7.02, P = 0.001) were significantly associated with EF improvement. In conclusion, elevated BNP at the timing of admission and LM-LAD as the infarct-related artery were significantly associated with mid-term LVEF recovery. Our results support aggressive acute treatment for those severe AMI, because the possibility of mid-term LVEF recovery is greater compared with other AMI.

Transcatheter aortic valve implantation (TAVI) has been recognized as a standard therapy for severe aortic valve stenosis. However, since some patients who receive TAVI have poor outcomes, the predictors of clinical outcomes after TAVI are important. The aim of this study was to investigate the association between appetite and long-term clinical outcomes.We screened consecutive cases who received TAVI at our medical center between July 2014 and October 2018. A total of 139 patients who received transfemoral TAVI were included as the final study population. They were divided into a good appetite group (n = 105) and a less appetite group (n = 34) according to their dietary intake rate (> 90%: good appetite group, ≤ 90%: less appetite group). We defined the intake rate as the average for breakfast, lunch, and dinner on the day just before discharge. We defined two-year major adverse cardiovascular and cerebrovascular events (MACCE) as a composite of cardiovascular death, myocardial infarction, any coronary revascularization, history of hospitalization due to heart failure, and disabling acute cerebral infarction. Kaplan-Meier analyses and multivariate Cox regression analysis were performed.The median duration of the follow-up period was 372 (189-720) days. Kaplan-Meier curves showed that the less appetite group got MACCE more frequently (event free rate of the less appetite group: 76.5% versus the good appetite group: 94.3%, Log Rank P = 0.01). In multivariate Cox regression analysis, having less appetite was a significant predictor of two-year MACCE (HR 5.26, 95%CI 1.66-16.71, P < 0.01).In conclusion, among the patients who received transfemoral TAVI, appetite status just before discharge was significantly associated with long-term outcome.

Postcatheterization pseudoaneurysm is a serious complication following diagnostic or therapeutic catheterization. Because radial access is unsuitable in some situations, there is still a need to use femoral or brachial access for arterial catheterization. The aim of this study was to compare the incidence and clinical characteristics of pseudoaneurysm between brachial and femoral access. We identified patients who underwent arterial catheterization from our cardiac catheter records. A total of 5,990 cardiac catheter records and discharge summaries were reviewed, and 23 pseudoaneurysm cases were identified. Those pseudoaneurysm cases were divided into a brachial pseudoaneurysm group (n = 9) and a femoral pseudoaneurysm group (n = 14). The incidence of pseudoaneurysm was significantly higher in brachial access than in femoral access (odds ratio: 4.16, 95% confidence interval: 1.80-9.65; P < 0.001). Successful manual compression was frequently achieved in both the brachial (77.8%) and the femoral (92.9%) pseudoaneurysm groups (P = 0.295). Surgical intervention was more frequently performed in the brachial pseudoaneurysm group (22.2%) than in the femoral pseudoaneurysm group (0%) without reaching statistical significance (P = 0.07). Moreover, neurological disorders were observed only in the brachial pseudoaneurysm group (22.2%). In conclusion, the incidence of pseudoaneurysm was significantly higher in brachial access than in femoral access, indicating the potential risk of brachial access. Successful manual compression was frequently achieved in both groups, but neurological disorders were observed only in brachial access, suggesting the greater risk of brachial pseudoaneurysms.

Right ventricular infarction (RVI) is a complication following inferior ST-elevation myocardial infarction (STEMI). The aim of the present study was to investigate the clinical outcomes of RVI in the contemporary primary percutaneous coronary intervention (PCI) era. The primary endpoint was in-hospital death, and the secondary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiovascular death, re-hospitalization for heart failure, and non-fatal acute myocardial infarction (AMI). Event-free survival curves for MACE were constructed using the Kaplan-Meier method, and statistical differences between curves were assessed using the log-lank test. A total of 1354 patients with AMI were screened from January 2010 to December 2016. The final study population involved 315 patients with STEMI whose infarct related artery (IRA) was the right coronary artery (RCA). We categorized these 315 patients into the RVI group (n = 85) and the non-RVI group (n = 230). Median follow-up duration was 358 (IQR: 208-987) days. In-hospital deaths were more frequently observed in the RVI group (9.4%) than in the non-RVI group (3.0%) (P = 0.018). However, the incidence of MACE was not different between the groups (P = 0.537). In conclusion, in-hospital clinical outcomes were poorer in the RVI group than in the non-RVI group. However, mid-term MACE was not different between the two groups, suggesting the importance of aggressive acute treatment for STEMI patients with RVI.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited myocardial disease characterized by fibrofatty replacement and ventricular arrhythmias. ARVC is believed to be a disease of the young, with most cases being diagnosed before the age of 40 years. We report here a case of newly diagnosed ARVC in an octogenarian associated with a pathogenic variant in the plakophilin 2 gene (PKP2). CASE PRESENTATION: An 80-year-old Japanese man was referred for sustained ventricular tachycardia. His baseline electrocardiogram showed negative T waves in V1-V4. Right ventriculography showed right ventricular aneurysm. Because this case met three major criteria, ARVC was diagnosed. He was successfully treated with radiofrequency ablation and oral amiodarone. Genetic analysis identified an insertion mutation in exon 8 of PKP2 (1725_1728dupGATG), which caused a frameshift and premature termination of translation (R577DfsX5). CONCLUSIONS: To the best of our knowledge, this is the first report of newly diagnosed ARVC in an octogenarian associated with a loss-of-function PKP2 pathogenic variant. Although the late clinical presentation of ARVC is rare, it should be included in the differential diagnosis when treating older patients with ventricular tachyarrhythmias.

Introduction: Transcatheter aortic valve implantation (TAVI) has grown to be an alternative treatment for severe symptomatic aortic valve stenosis (AS) in elderly patients. Although TAVI is a less invasive surgery than surgical aortic valve replacement, some patients may require prolonged hospitalization. Aim: To find the determinants of prolonged hospitalization in patients who underwent trans-femoral TAVI. Material and methods: A total of 94 AS patients who underwent trans-femoral TAVI were included as the final study population, and divided into the conventional hospitalization group (≤ 21 days) (n = 74) and prolonged hospitalization group (> 21 days) (n = 20). We compared clinical characteristics between the two groups, and multivariate logistic regression analysis was performed to find the determinants of prolonged hospitalization. Results: In multivariate logistic regression analysis, moderate or severe mitral regurgitation (OR = 4.49, 95% CI: 1.16-17.47, p = 0.03), taking statins or angiotensin converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB) on admission (statins: OR = 0.13, 95% CI: 0.02-0.71, p = 0.02, ACE inhibitors/ARB: OR = 0.25, 95% CI: 0.06-0.96, p = 0.04), estimated glomerular filtration rate (eGFR) (per 15 ml/min/1.73 m2 incremental) (OR = 0.49, 95% CI: 0.26-0.90, p = 0.02) and current chopsticks user (OR = 0.05, 95% CI: 0.01-0.41, p < 0.01) were significantly associated with prolonged hospitalization. Conclusions: Moderate or severe mitral regurgitation was significantly associated with prolonged hospitalization, while current chopsticks user, eGFR (per 15 ml/min/1.73 m2 incremental), taking ACE inhibitors/ARB or statins before the procedure were inversely associated with prolonged hospitalization in patients who underwent trans-femoral TAVI.

In-hospital outcomes of acute myocardial infarction (AMI) with cardiogenic shock (CS) were still not satisfactory even in the primary percutaneous coronary intervention (PCI) era. The aim of this study was to compare in-hospital outcomes of AMI with CS caused by right coronary artery (RCA) occlusion vs. left coronary artery (LCA) occlusion. Consecutive 894 AMI patients from January 2010 to March 2015 were screened for inclusion. A total of 114 AMI patients with CS were included as the final study population, and were divided into the RCA group (n = 56) and LCA group (n = 58). The patient characteristics were compared between the two groups. Multivariate logistic regression analysis was performed to show whether the RCA group was associated with better outcomes even after controlling confounding factors. In-hospital mortality was significantly lower in the RCA group (8.9%) than in the LCA group (46.6%) (P < 0.001). The RCA group (vs. the LCA group) was inversely associated with in-hospital death (OR 0.08, 95% CI 0.02-0.21, P < 0.001) after controlling covariates. Aspartate transaminase value (per 50 U/L incremental: OR 1.22, 95% CI 1.03-1.45, P = 0.02), aging (per 10-year-old incremental: OR 2.14, 95% CI 1.26-3.63, P = 0.01) and using VA-ECMO (OR 22.13, 95% CI 5.22-93.90, P < 0.001) were also significantly associated with in-hospital death. In conclusion, among AMI patients with CS, IRA of RCA was significantly associated with the better in-hospital outcome.

Acute myocardial infarction (AMI) is more frequently observed in patients with chronic kidney disease (CKD) than in patients without CKD. Initial treatment strategy for AMI includes primary percutaneous coronary intervention (PCI), which requires substantial amount of contrast media. We hypothesized that the clinical outcomes are comparable or worse in patients with AMI and advanced CKD off chronic hemodialysis as compared to patients with AMI and advanced CKD on chronic hemodialysis. The purpose of this study was to compare the clinical outcomes of patients with AMI and advanced CKD on hemodialysis versus off hemodialysis. A total of 148 patients with estimated glomerular filtration rate &amp lt  30 ml/min/1.73 m2 on admission were included and were divided into the HD group (n = 68) and non-HD group (n = 80). The length of hospitalization was significantly less in the HD group (15.7 ± 14.8 days) than in the non-HD group (22.4 ± 21.3 days) (P = 0.01). In-hospital death was significantly less in the HD group (10.3%) than in the non-HD group (25.0%) (P = 0.02). While the non-HD group was not significantly associated with in-hospital death after controlling clinical covariates, the non-HD group (odd ratio 2.89, 95% confidence interval 1.03–8.12, P = 0.04) was significantly associated with long hospitalization even after controlling clinical covariates. In conclusion, as compared to advanced CKD on chronic hemodialysis, advanced CKD off hemodialysis had higher morbidity and mortality in patients with AMI. Advanced CKD off hemodialysis was closely associated with long hospitalization even after controlling clinical factors.

Primary percutaneous coronary interventions (PCI) have been developed to improve clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). In primary PCI, the door-to-balloon time (DTBT) is closely associated with mortality and morbidity. The purpose of this study was to find determinants of short and long DTBT. From our hospital record, we included 214 STEMI patients, and divided into the short DTBT group (DTBT &lt  60 min, n = 60), the intermediate DTBT group (60 min ≤ DTBT ≤ 120 min, n = 121) and the long DTBT group (DTBT &gt  120 min, n = 33). In-hospital mortality was highest in the long DTBT group (24.2%), followed by the intermediate DTBT group (5.8%), and lowest in the short DTBT group (0%) (&lt  0.001). Transfers from local clinics or hospitals (OR 3.43, 95% CI 1.72–6.83, P &lt  0.001) were significantly associated with short DTBT, whereas Killip class 3 or 4 (vs. Killip class 1 or 2: OR 0.20, 95% CI 0.06–0.64, P = 0.007) was inversely associated with short DTBT in multivariate analysis. In conclusion, transfer from local clinics/hospitals was associated with short DTBT. Our results may suggest the current limitation of ambulance system, which does not include pre-hospital ECG system, in Japan. The development of pre-hospital ECG system would be needed for better management in STEMI.

Bleeding complications following percutaneous coronary interventions (PCI) have been closely associated with morbidity and mortality. Although radial arteries have been widely used in current PCI, including primary PCI, transfemoral PCI remains necessary for complex PCI. The purpose of this study was to compare the incidence of complications following elective transfemoral PCI between manual compression with and without protamine. We identified 249 consecutive patients who underwent elective transfemoral PCI from hospital records, and divided them into two groups: patients who used protamine for manual compression (the protamine group n = 205) and patients who did not (the non-protamine group, n = 44). Complications including acute thrombosis, bleeding requiring blood transfusion, transient hypotension, skin rash, and death within 30 days were compared between groups. The baseline clinical and procedural characteristics were comparable between the protamine and non-protamine groups. The incidences of all complications were not different between the protamine (5.9%) and the non-protamine groups (9.1%) (P = 0.43). While more than 90% of the patients received drug-eluting stent implantation, there was no acute thrombus in either group. The incidence of bleeding requiring blood transfusion was significantly lower in the protamine group (0.5%) than in the non-protamine group (6.8%) (P = 0.002). Multivariate logistic regression analysis revealed the inverse association between protamine use and bleeding requiring blood transfusion (odds ratio 0.08, 95% confidence interval 0.01-0.84, P = 0.04). In conclusion, the use of protamine for manual compression following elective transfemoral PCI was safe and was associated with less bleeding complications.

Intravascular ultrasound (IVUS) is mainly used in PCI to treat complex lesions, such as left main bifurcation, chronic total occlusion and calcified lesions. Although IVUS yields useful information such as the presence of napkin-ring calcification, the role of IVUS in rotational atherectomy (RA) is not fully appreciated. Recently, since the deliverability and crossability of IVUS catheters have improved, IVUS should be attempted before RA. Even if the IVUS catheter cannot cross the lesion, IVUS provides information just proximal to the target lesion, which would be useful in the selection of the appropriate guidewire and burr size. IVUS can be repeated following RA, which may influence the decision to continue RA with larger burrs. Circumferential calcification is a good indication for RA, since RA can create a calcium crack that facilitates balloon dilatation. However, if the distribution of calcification is not circumferential, the indication for RA can more safely be determined based on IVUS images than angiographic information alone. Because RA burrs usually follow the route taken by the IVUS catheter, the positional relationship between the IVUS imaging core and calcification would be similar to that between the RA burrs and calcification. The relationship between the RA burrs and distribution of calcification is discussed in this review.

A 32-year-old man with a history of bronchial asthma was referred for low back pain and bilateral femur pain. Vascular sonography revealed bilateral deep vein thrombosis (DVT) from the femoral veins to the popliteal veins. Computed tomography revealed hypoplasia of the inferior vena cava (IVC) and dilated lumbar veins, ascending lumbar veins, and azygos vein as collaterals. There was no evidence of malignant neoplasm. The results of the thrombophilia tests were within normal limits. Hypoplasia of the IVC is a rare cause of DVT. This anomaly should be considered as a cause of bilateral and proximal DVT, in particular, in young patients without major risk factors.

Slow flow is a serious complication in primary percutaneous coronary intervention (PCI) and is associated with poor clinical outcomes. Intravascular ultrasound (IVUS)-guided PCI may improve clinical outcomes after drug-eluting stent implantation. The purpose of this study was to seek the factors of slow flow following stent implantation, including factors related to IVUS-guided primary PCI. The study population consisted of 339 ST-elevation myocardial infarction patients, who underwent stent deployment with IVUS. During PCI, 56 patients (16.5%) had transient or permanent slow flow. Multivariate logistic regression analysis showed age (OR 1.04, 95% CI 1.01–1.07, P = 0.01), low attenuation plaque on IVUS (OR 3.38, 95% CI 1.70–6.72, P = 0.001), initial Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 (vs. TIMI 0: OR 0.44, 95% CI 0.20–0.99, P = 0.046), and the ratio of stent diameter to vessel diameter (per 0.1 increase: OR 2.63, 95% CI 1.84–3.77, P &lt  0.001) were significantly associated with slow flow. A ratio of stent diameter to vessel diameter of 0.71 had an 80.4% sensitivity and 56.9% specificity to predict slow flow. There was no significant difference in ischemic-driven target vessel revascularization between the modest stent expansion (ratio of stent diameter to vessel diameter &lt 0.71) and aggressive stent expansion (ratio of stent diameter to vessel diameter ≥0.71) strategies. Unlike other variables, the ratio of stent diameter to vessel diameter was the only modifiable factor. The modest stent expansion strategy should be considered to prevent slow flow following stent implantation in IVUS-guided primary PCI.

Background - Ablation lesion depth caused by radiofrequency-based renal denervation (RDN) was limited to &lt 4 mm in previous animal studies, suggesting that radiofrequency-RDN cannot ablate a substantial percentage of renal sympathetic nerves. We aimed to define the true lesion depth achieved with radiofrequency-RDN using a fine sectioning method and to investigate biophysical parameters that could predict lesion depth. Methods and Results - Radiofrequency was delivered to 87 sites in 14 renal arteries from 9 farm pigs at various ablation settings: 2, 4, 6, and 9 W for 60 seconds and 6 W for 120 seconds. Electric impedance and electrode temperature were recorded during ablation. At 7 days, 2470 histological sections were obtained from the treated arteries. Maximum lesion depth increased at 2 to 6 W, peaking at 6.53 (95% confidence interval, 4.27-8.78) mm under the 6 W/60 s condition. It was not augmented by greater power (9 W) or longer duration (120 seconds). There were statistically significant tendencies at 6 and 9 W, with higher injury scores in the media, nerves, arterioles, and fat. Maximum lesion depth was positively correlated with impedance reduction and peak electrode temperature (Pearson correlation coefficients were 0.59 and 0.53, respectively). Conclusions - Lesion depth was 6.5 mm for radiofrequency-RDN at 6 W/60 s. The impedance reduction and peak electrode temperature during ablation were closely associated with lesion depth. Hence, these biophysical parameters could provide prompt feedback during radiofrequency-RDN procedures in the clinical setting.

Overall mortality and neurologic outcome of patients treated by veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was still not satisfactory. The aim of this study was to clarify the determinants of survival and favorable neurologic outcomes in patients with ischemic heart disease (IHD) treated by V-A ECMO. We identified IHD patients who received V-A ECMO, and divided those patients into the survived and the in-hospital death group. Multivariate logistic regression analysis was performed to identify the determinants of survival and favorable neurologic outcomes. Fifty-eight patients were divided into the in-hospital death group (n = 35) and the survived group (n = 23). Cardiogenic arrest for the reason for V-A ECMO introduction (vs. non-cardiac arrest: OR 0.34, 95% CI 0.002–0.65, P = 0.03) and final thrombolysis in myocardial infarction (TIMI-3) flow grade (vs. TIMI ≤2 flow grade: OR 17.44, 95% CI 1.65–184.04, P = 0.02) were determinants of in-hospital survival. Time from collapse to initiation of V-A ECMO was inversely associated with favorable neurologic function (10 min increase OR 0.49, 95% CI 0.28–0.89, P = 0.02), while final TIMI-3 flow grade was not associated with favorable neurologic function. In conclusion, the rapid establishment of V-A ECMO system as well as obtaining TIMI-3 flow grade should be sought for better survival with maintaining neurological function in IHD patients who requires V-A ECMO.

Percutaneous coronary interventions to ostial left anterior descending artery (LAD)-acute myocardial infarction (AMI) were challenging, especially in crossover stenting from left main trunk (LMT) to LAD. The clinical outcomes of ostial LAD-AMI that needed crossover stenting were not well investigated. The objective of this study was to compare the clinical outcomes of LMT crossover stenting with those of ostial LAD just proximal (jp) stenting. Between January 2009 and March 2016, 1499 patients were diagnosed as AMI in our institution. Among them, 76 ostial LAD-AMIs were included in this study, and divided into 30 LMT crossover stenting (the crossover group) and 46 jp stenting (the jp stenting group). The primary endpoint was major cardiovascular events (MACE) defined as the composite of cardiac death, acute myocardial infarction (AMI), stent thrombosis (ST), target lesion revascularization (TLR) and target vessel revascularization (TVR). The frequency of MACE was comparable between the 2 groups (16.7% in the crossover group and 21.7% in the jp stenting group, P = 0.587). Similarly, the frequency of cardiac death was comparable between the 2 groups (6.7% in the crossover group and 13.0% in the jp stenting group, P = 0.376). The frequencies of TLR (6.7% in the crossover group and 6.5% in the jp stenting group, P = 0.980) and TVR (10.0% in the crossover group and 8.7% in the jp stenting group, P = 0.848) were not significantly different between the 2 groups. In conclusion, the clinical outcomes of the crossover stenting were comparable to the jp stenting in the stenting strategy for ostial LAD-AMI. LMT-LAD crossover stenting would be the acceptable strategy for ostial LAD-AMI.

Background: Percutaneous coronary intervention for heavily calcified lesions requires rotational atherectomy (RA). Long-term clinical outcomes after drug-eluting stent (DES) implantation following (RA) for heavily calcified lesions remain unclear. We assessed 5-year clinical outcomes after DES implantation following RA. Methods and Results: Between March 2006 and September 2011, 219 consecutive patients with 219 lesions treated with DES following RA, were retrospectively enrolled. The cumulative 5-year incidence of target-lesion revascularization (TLR) and definite stent thrombosis (ST) were assessed. The cumulative incidence of TLR within (≤) the first year was 18.6%. Late TLR beyond (&gt ) 1 year continued to occur at 1.9% per year without a decrease in the rate (5-year incidence, 26.0%). The cumulative incidence of definite ST at 30 days, 1 and 5 years was 0.9%, 2.3% and 2.9%, respectively. The annual rate of definite ST beyond 1 year was 0.15%. On multivariate analysis, the significant predictor of TLR within 1 year was use of first-generation DES (hazard ratio [HR], 2.09 95% CI: 1.10–4.03, P=0.02) and that of TLR beyond 1 year was hemodialysis (HR, 3.29 95% CI: 1.06–10.55, P=0.04). Conclusions: Late TLR beyond 1 year continued to occur up to 5 years at a constant annual incidence, whereas very late ST was rare. Careful long-term clinical follow-up is continually needed in patients who have already received DES following RA for heavily calcified lesions.