坂倉 建一

Introduction: In percutaneous coronary intervention (PCI) to atherosclerotic lesions in the right coronary artery (RCA), coronary artery dissection in the ostium of the RCA is a rare but fatal complication. Stent implantation to the ostium of RCA may be selected for the prevention of aorto-ostial dissection. Aim: To find factors associated with aorto-ostial stent coverage to mild to moderate ostial stenosis during the treatment of severely narrowed non-ostial RCA lesions. Material and methods: The primary interest was to find factors associated with ostial stent coverage using multivariate regression analysis. We included 236 patients who underwent intravascular ultrasound (IVUS)-guided PCI to severely narrowed RCA lesions with mild to moderate ostial stenosis, and divided those into the ostial-coverage group (n = 52) and the non-coverage group (n = 184). Results: The prevalence of continuous ostial plaque detected by intravascular ultrasound (IVUS) was significantly greater in the ostial-coverage group (84.6%) than in the non-coverage group (52.9%) (p < 0.001). Multivariate logistic regression analysis revealed that continuous ostial plaque detected by IVUS (OR = 5.398, 95% CI: 2.322-12.553, p < 0.001) was significantly associated with ostial stent coverage after controlling confounding factors. Ischaemia-driven target vessel revascularization was less frequently observed in the ostial-coverage group than in the non-coverage group, without reaching statistical significance (p = 0.069). Conclusions: Continuous ostial plaque detected by IVUS was significantly associated with ostial stent coverage to the mild to moderate stenosis when PCI to non-ostial, severely narrowed RCA lesions was performed. The use of IVUS may enhance the safety but may increase the total stent length in PCI to RCA.

The rapid introduction of dual antiplatelet therapy (DAPT) is important for patients with acute myocardial infarction (AMI). The risks and benefits of reduced-dose prasugrel (20 mg loading and 3.75 mg maintenance) over clopidogrel have not been fully discussed. The purpose of this study was to compare the 90-days clinical outcomes of AMI between prasugrel-based DAPT and clopidogrel-based DAPT. We included 534 AMI patients and divided them into the clopidogrel group (n = 330) and the prasugrel group (n = 204). The primary endpoint was the total ischemic events and total bleeding events. In all, 52 ischemic events and 35 bleeding events were observed during the study period. The total ischemic events were similar between the clopidogrel and the prasugrel groups (P = 0.385). The total bleeding events were similar between the clopidogrel and the prasugrel groups (P = 0.125). The multivariate Cox hazard analysis showed that prasugrel was not associated with the total ischemic events (hazard ratio (HR) 0.955, 95% confidence interval (CI) 0.499-1.829, P = 0.890) and was not associated with the total bleeding events after controlling confounding factors (HR 0.972, 95% CI 0.528-1.790, P = 0.927). In conclusion, as compared to clopidogrel, the reduced dose of prasugrel was not associated with the excess risk of bleeding or the excess risk of ischemic events. Our real-world data support the current regimen of prasugrel for AMI patients who underwent primary percutaneous coronary intervention.

Complications such as slow flow are frequently observed in percutaneous coronary intervention (PCI) with rotational atherectomy (RA). However, it remains unclear whether the high incidence of slow flow results in the high incidence of periprocedural myocardial infarction (PMI), reflecting real myocardial damage. The aim of this study was to compare the incidence of PMI between PCI with versus without RA using propensity score-matching. We included 1350 elective PCI cases, which were divided into the RA group (n = 203) and the non-RA group (n = 1147). After propensity score matching, the matched RA group (n = 190) and the matched non-RA group (n = 190) were generated. The primary interest was to compare the incidence of PMI between the matched RA and non-RA groups. Before propensity score matching, the incidence of slow flow and PMI was greater in the RA group than in the non-RA group. After matching, the incidence of slow flow was still greater in the matched RA group than in the matched non-RA group (16.8% vs. 9.5%, p = 0.048). However, the incidence of PMI was similar between the matched RA and matched non-RA group (7.4% vs. 5.3%, p = 0.528, standardized difference: 0.086). In conclusion, although use of RA was associated with greater risk of slow flow, use of RA was not associated with PMI after a propensity score-matched analysis. The fact that RA did not increase the risk of myocardial damage in complex lesions would have an impact on revascularization strategy for severely calcified coronary lesions.

Percutaneous coronary intervention (PCI) is a standard strategy for non-ST-segment elevation myocardial infarction (NSTEMI) as well as for ST-segment elevation myocardial infarction (STEMI). The device cost for PCI may be more expensive in NSTEMI, because the culprit lesion morphology may be more complex in NSTEMI. This study aimed to compare the total device cost of PCI between STEMI and NSTEMI. We included 504 patients with acute myocardial infraction (AMI) who underwent PCI, and divided those into a STEMI group (n = 286) and a NSTEMI group (n = 218). We compared the total device cost, the number of used devices, and procedure cost between the 2 groups. The total device cost was significantly higher in the NSTEMI group [\371,300 (\320,700-503,350)] than in the STEMI group [\341,200 (\314,200-410,475)] (p = 0.001), whereas the procedure cost was significantly higher in the STEMI group [\343,800 (\243,800-343,800)] than in the NSTEMI group [\220,000 (\216,800-243,800)] (p < 0.001). Drug eluting stent (85.3% vs. 76.1%, p = 0.029) and aspiration catheter (16.8% vs. 2.3%, p < 0.001) were more frequently used in the STEMI group, whereas rotablator (0.7% vs. 8.3%, p < 0.001) were more frequently used in the NSTEMI group. The multivariate logistic regression analysis revealed that NSTEMI was significantly associated with the high device cost (odds ratio 1.899, 95% confidence interval 1.166-3.093, p = 0.01). In conclusion, the total device cost for PCI was significantly higher in the culprit lesions of NSTEMI than in those of STEMI, whereas the procedure cost was significantly higher in the culprit lesions of STEMI than in those of NSTEMI.

BACKGROUND: Calcified nodule (CN) has a unique plaque morphology, in which an area of nodular calcification causes disruption of the fibrous cap with overlying luminal thrombus. CN is reported to be the least frequent cause of acute coronary thrombosis, and the pathogenesis of CN has not been well studied. OBJECTIVES: The purpose of this study is to provide a comprehensive morphologic assessment of the CN in addition to providing an evolutionary perspective as to how CN causes acute coronary thrombosis in patients with acute coronary syndromes. METHODS: A total of 26 consecutive CN lesions from 25 subjects from our autopsy registry were evaluated. Detailed morphometric analysis was performed to understand the plaque characteristics of CN and nodular calcification. RESULTS: The mean age was 70 years, with a high prevalence of diabetes and chronic kidney disease. CNs were equally distributed between men and women, with 61.5% of CNs found in the right coronary artery (n = 16), mainly within its mid-portion (56%). All CNs demonstrated surface nonocclusive luminal thrombus, consisting of multiple nodular fragments of calcification, protruding and disrupting the overlying fibrous cap, with evidence of endothelial cell loss. The degree of circumferential sheet calcification was significantly less in the culprit section (89° [interquartile range: 54° to 177°]) than in the adjacent proximal (206° [interquartile range: 157° to 269°], p = 0.0034) and distal (240° [interquartile range: 178° to 333°], p = 0.0004) sections. Polarized picrosirius red staining showed the presence of necrotic core calcium at culprit sites of CNs, whereas collagen calcium was more prevalent at the proximal and distal regions of CNs. CONCLUSIONS: Our study suggests that fibrous cap disruption in CN with overlying thrombosis is initiated through the fragmentation of necrotic core calcifications, which is flanked-proximally and distally-by hard, collagen-rich calcification in coronary arteries, which are susceptible to mechanical stress.

Radial access is recommended for primary percutaneous coronary intervention (PCI), because it has fewer bleeding complications than trans-femoral PCI. However, even if trans-radial PCI is chosen, patients with ST-elevation myocardial infarction (STEMI) presenting with anemia on admission might have poor clinical outcomes. The aim of this retrospective study was to investigate whether anemia on admission was associated with mid-term clinical outcomes in patients who underwent trans-radial primary PCI. The primary endpoint was a composite of all-cause death, recurrent acute myocardial infarction, and readmission for heart failure. A total of 288 consecutive patients with STEMI who underwent trans-radial primary PCI were divided into an anemia group (n = 79) and a non-anemia group (n = 209). The median follow-up duration was 301 days. The anemia group was significantly older than the non-anemia group (77.3 ± 11.9 versus 64.4 ± 12.7 years, respectively; P < 0.001). There were significantly more females in the anemia group than in the non-anemia group (36.7% versus 14.4%, respectively; P < 0.001). Kaplan-Meier analysis revealed that the composite outcome-free survival was significantly worse in the anemia group than in the non-anemia group (P < 0.001). Multivariate Cox hazard model analysis revealed that hemoglobin levels on admission were significantly associated with the composite outcome (per 1 g/dL increase: hazard ratio 0.76, 95% confidence interval 0.66-0.88, P < 0.001) after controlling for confounding factors. In conclusion, baseline anemia was significantly associated with poor clinical outcomes. Patients with STEMI presenting with anemia should be managed carefully, even if trans-radial primary PCI is chosen.

The clinical outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI) were comparable or even worse than those with ST-segment elevation myocardial infarction (STEMI). Although successful percutaneous coronary intervention (PCI) to the culprit lesions of NSTEMI would improve the clinical outcomes, some PCI require long fluoroscopy time, reflecting the difficulty of PCI. This study aims to find clinical factors associated with long fluoroscopy time in PCI to the culprit lesion of NSTEMI. We included 374 patients and divided those into the conventional fluoroscopy time (n = 302) and long fluoroscopy time (n = 72) groups according to the quintiles of fluoroscopy time. Clinical and angiographic parameters were compared between the two groups. Calcification and tortuosity were significantly more severe in the long fluoroscopy time group than in the conventional fluoroscopy time group. The prevalence of previous coronary artery bypass grafting (CABG) and bifurcation lesions was significantly greater in the long fluoroscopy time group than in the conventional fluoroscopy time group. In the multivariate stepwise logistic regression analysis, previous CABG (odds ratio [OR], 3.368; 95% confidence interval [CI], 1.407-8.064; P = 0.006), bifurcation lesion (OR, 2.407; 95% CI, 1.285-4.506; P = 0.006), excessive tortuosity (versus mild to moderate tortuosity; OR, 4.095; 95% CI, 1.159-14.476; P = 0.029), and moderate to severe calcification (versus none to mild; OR, 5.792; 95% CI, 3.254-10.310; P < 0.001) were significantly associated with long fluoroscopy time. In conclusion, previous CABG, bifurcation, excessive tortuosity, and moderate to severe calcification were associated with long fluoroscopy time. Our study provided a reference for PCI operators to identify the difficulties in PCI to the culprit lesion of NSTEMI.

A method to manage ST-segment elevated myocardial infarction (STEMI) caused by very late stent thrombosis (VLST) has yet to be established. In this case series, we present several cases of STEMI caused by VLST, which were successfully revascularized using a perfusion balloon. Since the perfusion balloon (Ryusei: Kaneka Medix Corporation, Osaka, Japan) has the unique advantage of maintaining blood flow during balloon inflation, we can keep dilating the target lesion for more than several minutes. Extended inflation might work to prevent acute recoil, and to achieve optimal expansion without an additional stent. Our case series may provide a reasonable option for the treatment of VLST.

Objective Since patients with thoracic aortic aneurysm (TAA)/abdominal aortic aneurysm (AAA) are often complicated with coronary artery disease, it is common for those patients to undergo percutaneous coronary intervention (PCI). The ankle brachial index (ABI) is usually measured in patients with TAA/AAA to screen the presence of peripheral arterial disease. The present study investigated the association between the ABI and clinical outcomes following PCI in patients with TAA/AAA. Methods and Material We divided 200 TAA/AAA patients who underwent PCI into a normal ABI group (n=137) and an abnormal ABI group (n=63) according to the ABI cut-off level of 1.00. The primary endpoint was one-year major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, non-fetal myocardial infarction, stroke, target vessel revascularization, and hospitalization for heart failure. Results Mean ABIs in the normal and abnormal ABI groups were 1.12±0.09 and 0.86±0.11, respectively (p<0.01). Kaplan-Meier curves showed MACE were more frequent in the abnormal ABI group than in the normal ABI group (p=0.01). A multivariate Cox hazard analysis revealed that an abnormal ABI was significantly associated with 1-year MACE (vs. ABI ≥1.0: HR 3.02, 95% confidence interval 1.00-9.08, p=0.049). Conclusion Among patients with TAA/AAA who underwent PCI, abnormal ABI was significantly associated with 1-year MACE, suggesting the utility of the ABI measurement in this high-risk population.

Left ventricular remodeling (LVR) after ST-elevation myocardial infarction (STEMI) is generally thought to be an adaptive but compromising phenomenon particularly in patients with diabetes mellitus (DM). However, whether the extent of LVR is associated with poor prognostic outcome with or without DM after STEMI in the modern era of reperfusion therapy has not been elucidated. This was a single-center retrospective observational study. Altogether, 243 patients who were diagnosed as having STEMI between January 2016 and March 2019, and examined with echocardiography at baseline (at the time of index admission) and mid-term (from 6 to 11 months after index admission) follow-up were included and divided into the DM (n = 98) and non-DM groups (n = 145). The primary outcome was major adverse cardiovascular events (MACEs) defined as the composite of all-cause death, heart failure (HF) hospitalization, and non-fatal myocardial infarction. The median follow-up duration was 621 days (interquartile range: 304-963 days). The DM group was significantly increased the rate of MACEs (P = 0.020) and HF hospitalization (P = 0.037) compared with the non-DM group, despite of less LVR. Multivariate Cox regression analyses revealed that the patients with DM after STEMI were significantly associated with MACEs (Hazard ratio [HR] 2.79, 95% confidence interval [CI] 1.20-6.47, P = 0.017) and HF hospitalization (HR 3.62, 95% CI 1.19-11.02, P = 0.023) after controlling known clinical risk factors. LVR were also significantly associated with MACEs (HR 2.44, 95% CI 1.03-5.78, P = 0.044) and HF hospitalization (HR 3.76, 95% CI 1.15-12.32, P = 0.029). The patients with both DM and LVR had worse clinical outcomes including MACEs and HF hospitalization, suggesting that it is particularly critical to minimize LVR after STEMI in patients with DM.

Percutaneous coronary intervention (PCI) is sometimes considered as an alternative therapeutic strategy to surgical revascularization in patients with coronary artery disease (CAD) and reduced left ventricular ejection fraction (LVEF). However, the types or conditions of patients that receive the clinical benefit of left ventricular reverse remodelling (LVRR) remain unknown. The purpose of this study was to investigate the determinants of LVRR following PCI in CAD patients with reduced LVEF. From 4394 consecutive patients who underwent PCI, a total of 286 patients with reduced LV systolic function (LVEF < 50% at initial left ventriculography) were included in the analysis. LVRR was defined as LV end-systolic volume reduction ≥ 15% and improvement of LVEF ≥ 10% at 6 months follow-up left ventriculography. Patients were divided into LVRR (n = 63) and non-LVRR (n = 223) groups. Multivariate logistic regression analysis revealed that unprotected left main coronary artery (LMCA) intervention was significantly associated with LVRR (P = 0.007, odds ratios [OR] 4.70, 95% confidence interval [CI] 1.54-14.38), while prior PCI (P = 0.001, OR 0.35, 95% CI 0.19-0.66), presence of in-stent restenosis (P = 0.016, OR 0.32, 95% CI 0.12-0.81), and presence of de-novo stenosis (P = 0.038, OR 0.36, 95% CI 0.14-0.95) were negatively associated with LVRR. These data suggest the potential prognostic benefit of unprotected LMCA intervention for LVRR and importance of angiographic follow-up in patients with CAD and LV systolic dysfunction.

BACKGROUND: Stent edge dissection (SED) is a well-known predictor of worse clinical outcomes. However, impact of SED after current-generation drug-eluting stent (DES) implantation remains unknown since there was no study using only current-generation DES to assess impact of SED. This study aimed to investigate a relationship between SED detected by optical coherence tomography (OCT) and clinical outcomes after current-generation DES implantation. METHODS: This study enrolled 175 patients receiving OCT after current-generation DES implantation. The SED group was compared with the non-SED group in terms of the primary study endpoints which was the cumulative incidence of major adverse cardiac event (MACE) composed of cardiac death, target vessel myocardial infarction (TV-MI), and clinically-driven target lesion revascularization (CD-TLR). RESULTS: Of 175 patients, SED detected by OCT was observed in 32 patients, while 143 patients did not show SED. In the crude population, the SED group showed a significantly higher incidence of CD-TLR, definite stent thrombosis, TV-MI and cardiac death relative to the non-SED group. After adjustment by an inverse probability weighted methods, the SED group showed a significantly higher incidence of MACE compared with the non-SED group (hazard ratio 3.43, 95% confidence interval 1.09-10.81, p = 0.035). Fibrocalcific or lipidic plaques, greater lumen eccentricity, and stent-oversizing were the predictors of SED. CONCLUSIONS: SED detected by OCT after the current-generation DES implantation led to unfavorable outcomes. Aggressive post-dilatation around the stent edge might worse clinical outcomes due to SED, although achievement of optimal stent expansion is strongly encouraged to improve clinical outcomes.

BACKGROUND: The role of cardiac index (CI) and right atrial pressure (RAP) for predicting long-term outcomes of heart failure has not been well established. The aim of this study was to investigate long-term cardiac outcomes in patients with heart failure having various combinations of CI and RAP. METHODS: A total of 787 heart failure patients who underwent right-heart catheterization were retrospectively categorized into the following four groups: Preserved CI (≥2.5 L/min/m2) and Low RAP (<8 mmHg) (PRE-CI/L-RAP; n = 285); Preserved CI (≥2.5 L/min/m2) and High RAP (≥8 mmHg) (PRE-CI/H-RAP; n = 242); Reduced CI (<2.5 L/min/m2) and Low RAP (<8 mmHg) (RED-CI/L-RAP; n = 123); and Reduced CI (<2.5 L/min/m2) and High RAP (≥8 mmHg) (RED-CI/H-RAP; n = 137). Survival analysis was applied to investigate which groups were associated with major adverse cardiovascular events (MACE). RESULTS: The RED-CI/L-RAP and RED-CI/H-RAP groups were significantly associated with MACE as compared with the PRE-CI/L-RAP and PRE-CI/H-RAP groups after adjustment for confounding factors (RED-CI/L-RAP vs. PRE-CI/L-RAP: HR 2.11 [95% CI 1.33-3.37], p = 0.002; RED-CI/H-RAP vs. PRE-CI/L-RAP: HR 2.18 [95% CI 1.37-3.49], p = 0.001; RED-CI/L-RAP vs. PRE-CI/H-RAP: HR 1.86 [95% CI 1.16-3.00], p = 0.01; RED-CI/H-RAP vs. PRE-CI/H-RAP: HR 1.92 [95% CI 1.26-2.92], p = 0.002), whereas the difference between the RED-CI/H-RAP and RED-CI/L-RAP groups was not significant (HR 1.03 [95% CI 0.64-1.66], p = 0.89). CONCLUSIONS: The hemodynamic severity categorized by CI and RAP levels provided clear risk stratification in patients with symptomatic heart failure. Low CI was an independent predictor of long-term cardiac outcomes.

BACKGROUND: The prognostic implications of combined pre- and post-capillary pulmonary hypertension (Cpc-PH) in patients with pulmonary hypertension due to left heart disease (PH-LHD) remain controversial. The aim of this retrospective study was to evaluate the new PH-LHD criteria, recommended by the 6th World Symposium on Pulmonary Hypertension and to determine the prognostic value of Cpc-PH. METHODS: A total of 701 patients with symptomatic heart failure who had undergone right-heart catheterization were divided into the following four groups: (i) Isolated post-capillary PH (Ipc-PH) group; mean pulmonary artery pressure (mPAP) >20 mmHg, pulmonary artery wedge pressure (PAWP) >15 mmHg, and pulmonary vascular resistance (PVR) <3 Wood units (WU) (ii) Cpc-PH group; mPAP >20 mmHg, PAWP >15 mmHg, and PVR ≥3 WU (iii) borderline-PH group; mPAP >20 mmHg and PAWP ≤15 mmHg (iv) non-PH group; mPAP ≤20 mmHg. Multivariate Cox hazard analysis was used to investigate whether Cpc-PH was associated with cardiac outcomes. RESULTS: The study subjects were allocated into the Ipc-PH (n = 268), Cpc-PH (n = 54), borderline-PH (n = 112), or non-PH (n = 267) groups. The Cpc-PH group was associated significantly with adverse cardiac events even after adjustment for clinically relevant confounding factors for heart failure prognosis (vs. non-PH group: HR 2.98 [95% CI 1.81-4.90], P <0.001; vs. Ipc-PH group: HR: 1.92 [95% CI 1.19-3.08], P = 0.007). CONCLUSIONS: The new definitions of PH-LHD stratified patients into 4 categories. Long-term clinical outcomes were significantly different between the four categories, with Cpc-PH having the worst cardiac outcomes.

BACKGROUND: Although several groups reported the risk factors for slow flow during rotational atherectomy (RA), they did not clearly distinguish modifiable factors, such as burr-to-artery ratio from unmodifiable ones, such as lesion length. The aim of this retrospective study was to investigate the modifiable and unmodifiable factors that were associated with slow flow. METHODS: We included 513 lesions treated with RA, which were classified into a slow flow group (n = 97) and a non-slow flow group (n = 416) according to the presence or absence of slow flow just after RA. The multivariate logistic regression analysis was performed to find factors associated with slow flow. RESULTS: Slow flow was inversely associated with reference diameter [Odds ratio (OR) 0.351, 95% confidence interval (CI) 0.205-0.600, p<0.001], primary RA strategy (OR 0.224, 95% CI 0.097-0.513, p<0.001), short single run (≤15 seconds) (OR 0.458, 95% CI 0.271-0.776, p = 0.004), and systolic blood pressure (BP) ≥ 140 mmHg (OR 0.501, 95% CI 0.297-0.843, p = 0.009). Lesion length (every 5 mm increase: OR 1.193, 95% CI 1.093-1.301, p<0.001), angulation (OR 2.054, 95% CI 1.171-3.601, p = 0.012), halfway RA (OR 2.027, 95% CI 1.130-3.635, p = 0.018), initial burr-to-artery ratio (OR 1.451, 95% CI 1.212-1.737, p<0.001), and use of beta blockers (OR 1.894, 95% CI 1.004-3.573, p = 0.049) were significantly associated with slow flow. CONCLUSIONS: Slow flow was positively associated with several unmodifiable factors including lesion length and angulation, and inversely associated with reference diameter. In addition, slow flow was positively associated with several modifiable factors including initial burr-to-artery ratio and use of beta blockers, and inversely associated with primary RA strategy, short single run, and systolic blood pressure just before RA. Application of this information could help to improve RA procedures.

BACKGROUND: High-degree atrioventricular block (HAVB) is a prognostic factor for survival in patients with inferior ST-segment elevation myocardial infarction (STEMI). However, there is little information about factors associated with temporary pacing (TP). The aim of this study was to find factors associated with TP in patients with inferior STEMI. METHODS: We included 232 inferior STEMI patients, and divided those into the TP group (n = 46) and the non-TP group (n = 186). Factors associated with TP were retrospectively investigated using multivariate logistic regression model. RESULTS: The incidence of right ventricular (RV) infarction was significantly higher in the TP group (19.6%) than in the non-TP group (7.5%) (p = 0.024), but the incidence of in-hospital death was similar between the 2 groups (4.3% vs. 4.8%, p = 1.000). Long-term major adverse cardiovascular events (MACE), which were defined as a composite of all-cause death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and readmission for heart failure, were not different between the 2 groups (p = 0.100). In the multivariate logistic regression analysis, statin at admission [odds ratio (OR) 0.230, 95% confidence interval (CI) 0.062-0.860, p = 0.029], HAVB at admission (OR 9.950, 95% CI 4.099-24.152, p<0.001), and TIMI-thrombus grade ≥3 (OR 10.762, 95% CI 1.385-83.635, p = 0.023) were significantly associated with TP. CONCLUSION: Statin at admission, HAVB at admission, and TIMI-thrombus grade ≥3 were associated with TP in patients with inferior STEMI. Although the patients with TP had the higher incidence of RV infarction, the incidence of in-hospital death and long-term MACE was not different between patients with TP and those without.

Careful auscultation is the first step to diagnose aortic stenosis (AS). The aim of this study was to compare clinical outcomes following transcatheter aortic valve implantation (TAVI) between the patients primarily diagnosed by heart murmur and those diagnosed by other reasons. We retrospectively included 258 patients who underwent TAVI in our medical center, and divided those into the murmur group (n = 81) and the other-reason group (n = 177) according to the primary reason for AS diagnosis. The primary endpoint was the major adverse cardiovascular and cerebrovascular events (MACCE), which was defined as the composite of cardiovascular death, hospitalization due to acute decompensated heart failure, and disabling stroke. The murmur group included younger patients than the other-reason group (82.8 year-old vs. 84.0 year-old, P = 0.02). History of AF was more frequently observed in the other-reason group than in the murmur group (21.5% vs. 7.4%, P <0.01). STS score and logistic EuroSCORE were lower in the murmur group than in the other-reason group (STS: 4.7% vs. 7.2%, P <0.01, logistic EuroSCORE: 8.3% vs. 11.2%, P <0.01). The median follow-up period was 562 days. MACCE was more frequently observed in the other-reason group than in the murmur group (27.7% vs. 9.9%, Log Rank P <0.01). The multivariate COX hazard analysis revealed that the AS patients primarily diagnosed by heart murmur was inversely associated with MACCE (HR 0.38, 95%CI 0.17-0.86, P = 0.020). Among AS patients who underwent TAVI, the patients primarily diagnosed by heart murmur were significantly associated with favorable long-term clinical outcomes.

Although the incidence of acute myocardial infarction (AMI) has been decreasing in the elderly, it has been increasing in the young, especially in Japan. A social impact of AMI would be greater in the young, because loss of the young directly influences social activities such as business, child-raising, and tax payment. The aim of this study was to identify the specific characteristics of young AMI patients. We retrospectively included 408 consecutive AMI patients < 70 years of age, divided into a young group (< 55 years: n = 136) and an older group (55 to < 70 years: n = 272). The prevalence of overweight was greater in the young group (58.5%) than in the older group (40.7%) (P = 0.001). The frequency of current smokers was higher in the young group (67.6%) than in the older group (44.9%) (P < 0.001). Although the prevalence of hypertension was lower in the young group (66.7%) than in the older group (77.2%) (P = 0.017), that of untreated hypertension was greater in the young group (40.4%) than in the older group (27.2%) (P = 0.007). Furthermore, the prevalence of untreated dyslipidemia was greater in the young group (45.0%) than in the older group (26.6%) (P < 0.001). In conclusion, the young AMI patients had more modifiable risk factors such as obesity, smoking, untreated hypertension, and untreated dyslipidemia than the older patients. There is an unmet medical need for the prevention of AMI in the young generation.

Periprocedural myocardial infarction (PMI) is closely associated with long-term cardiovascular events. The factors associated with PMI are not fully understood. The purpose of this study was to investigate the determinants of PMI in contemporary elective percutaneous coronary intervention (PCI). Overall, 731 elective PCI was divided into the PMI (n = 27) and non-PMI (n = 704) groups. Univariate and multivariate logistic regression analysis was used to find factors associated with PMI. In the univariate analysis, PMI was associated with complex lesion characteristics, such as the lesion length, lesion angle, calcification, and Medina classification. In the multivariate logistic regression analysis, the lesion length (per 10-mm increase: odds ratio (OR), 1.477; 95% confidence interval (CI), 1.161‒1.879; P = 0.002), lesion angle ≥ 45° (versus lesion angle < 45°: OR, 4.244; 95% CI, 1.187‒15.171; P = 0.026), and Medina classification (0,1,1) / (1,1,1) (versus other lesions: OR, 14.843; 95% CI, 6.235‒35.334; P < 0.001) were significantly associated with PMI. Of the 24 lesions with lesion angle ≥ 45° in the PMI group, 14 had final TIMI flow grade ≤ 2 in side branches and 9 had transient slow flow in main branches/transient ST elevation during PCI. Of the 87 lesions with Medina classification (1,1,1) / (0,1,1), 19 had final TIMI grade ≤ 2 in side branches. In conclusion, the lesion length, lesion angle ≥ 45°, and Medina classification (0,1,1) / (1,1,1) were significantly associated with PMI in contemporary elective PCI. Preventing flow limitation in both side branches and main vessels in elective PCI for the diffuse long, angulated, or true bifurcation lesions is important.

Acute myocardial infarction (AMI) would sometimes raise severe in-hospital complications such as cardiopulmonary arrest, shock, stroke, atrioventricular block, and respiratory failure. The purpose of this retrospective study was to compare the clinical outcomes of AMI patients who recovered from severe in-hospital complications with those who did not have in-hospital complications. We included 494 AMI patients, and divided those into the in-hospital complications group (n = 166) and noncomplications group (n = 328). The primary end point was the major adverse cardiovascular events (MACE) defined as the composite of all cause death, nonfatal myocardial infarction (MI), and readmission for heart failure within 1 year after the hospital discharge. A total of 50 postdischarge MACE were observed during the study period. MACE was more frequently observed in the in-hospital complications group (14.5%) than in the noncomplications group (7.9%) (p = 0.023). The presence of in-hospital complications was significantly associated with the MACE (Odds Ratio 1.889, 95% Confidence Interval 1.077 to 3.313, p = 0.026) after controlling age, gender, ST-elevation MI, and culprit of AMI. In conclusion, the MACE was significantly frequent in AMI patients who recovered from severe in-hospital complications and discharged to home, as compared with those who did not have in-hospital complications. AMI patients who recovered from complications could be recognized as a high risk group, and should be carefully managed after discharge to prevent cardiovascular events.

Rotational atherectomy (RA) has been widely used for percutaneous coronary intervention (PCI) to severely calcified lesions. As compared to other countries, RA in Japan has uniquely developed with the aid of greater usage of intravascular imaging devices such as intravascular ultrasound (IVUS) or optical coherence tomography (OCT). IVUS has been used to understand the guidewire bias and to decide appropriate burr sizes during RA, whereas OCT can also provide the thickness of calcification. Owing to such abundant experiences, Japanese RA operators modified RA techniques and reported unique evidences regarding RA. The Task Force on Rotational Atherectomy of the J apanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document to summarize the contemporary techniques and evidences regarding RA.

Since slow flow can be a fatal complication in left main coronary artery (LMCA)-acute coronary syndrome (ACS) patients, it should be important to anticipate and prepare slow flow during primary PCI for LMCA-ACS. We hypothesized that intravascular ultrasound (IVUS) findings would be useful to predict slow flow for LMCA-ACS patients without cardiogenic shock (CS). The purpose of this study was to investigate clinical factors associated with slow flow in LMCA-ACS patients without CS. We included 60 LMCA-ACS patients without CS, and divided into the slow flow group (n = 18) and the non-slow flow group (n = 42). Slow flow was defined as either transient or persistent TIMI flow grade ≤ 2. The prevalence of ST-segment elevation myocardial infarction (STEMI) was significantly higher in the slow flow group (55.6%) than in the non-slow flow group (11.9%) (p = 0.002). In the IVUS analysis, remodeling index was significantly greater in the slow flow group (1.15 ± 0.17) than in the non-slow flow group (0.99 ± 0.11) (p = 0.001). The multivariate logistic regression analyses in the IVUS factors revealed that remodeling index was significantly associated with slow flow (0.1 increase: OR 2.238, 95% CI 1.144-4.379, p = 0.019). In conclusion, remodeling index was significantly associated with slow flow. Our results suggest that the remodeling index determined by IVUS would be useful to find high-risk features of slow flow in LMCA-ACS patients without CS.

Bleeding complication has been considered as a serious problem in current percutaneous coronary interventions (PCI). Fortunately, several groups have already reported the effectiveness of protamine use just after PCI to immediately remove any arterial sheath. However, there is a concern that protamine reversal may increase non-occlusive thrombus and, in turn, lead to mid-term cardiovascular events such as target vessel revascularization (TVR) or stent thrombosis. Thus, the purpose of this study was to evaluate whether protamine use following elective PCI was associated with mid-term clinical outcomes. In total, 472 patients were included in this study; subsequently, they were divided into protamine group (n = 142) and non-protamine group (n = 330). The primary endpoint was the composite of ischemia-driven TVR and stent thrombosis. The median follow-up period was determined to be at 562 days. In total, 32 primary endpoints were observed during the study period, and the incidence of primary endpoints tended to be greater in the protamine group than in the non-protamine group (P = 0.056). However, the lesion length, the degree of calcification, and the prevalence of hemodialysis were significantly determined greater in the protamine group than in the non-protamine group. In the multivariate Cox proportional hazards model, the use of protamine (versus non-protamine: hazard ratio 0.542 and 95% confidence interval 0.217-1.355, P = 0.191) was deemed not to be associated with the primary endpoint after controlling legion length, calcification, and hemodialysis. In conclusion, immediate protamine use following elective PCI did not increase mid-term ischemia-driven TVR or stent thrombosis. However, immediate protamine use after PCI should be discussed further for the safety of the patient.

Since the number of elderly patients suffering from acute myocardial infarction (AMI) has been increasing in developed countries, primary percutaneous coronary intervention (PCI) for the very elderly aged ≥80 years old is already common. The study aimed to examine the determinants of in-hospital death among the very elderly with AMI in current PCI era. We included 412 consecutive AMI patients aged ≥ 80 years old who received PCI to the culprit lesion; however, 42 patients (10.2%) died during the index hospitalization. Thus, univariate and multivariate logistic regression analyses were performed to identify the determinants of in-hospital death. Of note, the modified KATZ index, which is a seven-point scale ranging from 0 to 6 (0 point indicating no dependence and six points indicating full dependence), was calculated to evaluate pre-admission activity of daily living (ADL). In multivariate analysis, cardiac arrest (OR 4.642, 95% CI 1.177-18.305, P = 0.028), Killip class IV (versus Killip class I: OR 5.732, 95% CI 1.076-16.630, P = 0.001), modified KATZ index (OR 1.212, 95% CI 1.001-1.469, P = 0.049), hemoglobin levels (OR 0.803, 95% CI 0.656-0.983, P = 0.033), use of temporary pacemaker (OR 2.603, 95% CI 1.010-6.709, P = 0.048), final Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 (versus TIMI ≤ 2: OR 0.240, 95% CI 0.093-0.618, P = 0.003), and mechanical circulatory support (OR 4.264, 95% CI 1.818-10.005, P = 0.001) were found to be significantly associated with in-hospital death. In conclusion, in-hospital outcomes of the very elderly with AMI were still poor in the current PCI era. Poor pre-admission ADL as well as cardiogenic shock and anemia were determined to be strongly associated with in-hospital death.

In most areas in Japan, patients with ST-elevation myocardial infarction (STEMI) would be transferred to the secondary hospitals or tertiary hospitals according to the judgement of emergency medical service (EMS) staff members. We hypothesized that in-hospital outcomes would be worse in STEMI patients judged as tertiary emergency than in those judged as secondary emergency, which may support the judgement of the current EMS systems. The purpose of this study was to compare in-hospital outcomes of STEMI between patients judged as secondary emergency and those judged as tertiary emergency. We included 238 STEMI patients who were transferred to our institution using EMS hotline, and divided those into the secondary emergency group (n = 106) and the tertiary emergency group (n = 132). The primary endpoint was in-hospital death. The prevalence of shock was significantly higher in the tertiary emergency group than in the secondary emergency group (32.6% vs. 10.4%, p < 0.001). The GRACE score was significantly higher in the tertiary emergency group than the secondary emergency group [146 (118-188) vs. 134 (101-155), p < 0.001]. The incidence of in-hospital death was significantly higher in the tertiary emergency group than in the secondary emergency group (8.0% vs. 2.1%, p = 0.014). The multivariate logistic regression analysis revealed that the tertiary emergency was significantly associated with in-hospital death (OR 3.52, 95% CI 1.24-10.02, p = 0.018) after controlling age and gender. In conclusion, the tertiary emergency was significantly associated with in-hospital death. Our results might validate the judgement of levels of emergency by local EMS staff members.

BACKGROUND: Peak skin dose (PSD) is closely associated with skin radiation injuries such as skin ulcers in percutaneous coronary intervention (PCI). Although PSD is greater in PCI for chronic total occlusion (CTO) lesions as compared with non-CTO lesions, the determinants of PSD in CTO-PCI are not fully understood. The purpose of this study was to investigate the clinical factors associated with excess PSD in PCI for CTO. METHODS: The study population included a total of 220 CTO-PCI cases that were divided into a standard PSD group (<2 Gy, n = 187) and an excess PSD group (≥2 Gy, n = 33). Clinical, lesion, and procedural characters were compared between the 2 groups. Multivariate logistic regression was performed to investigate the clinical factors associated with excess PSD. RESULTS: Body surface area (BSA) was significantly higher in the excess PSD group (1.85 ± 0.24 m2) than the standard PSD group (1.71 ± 0.18 m2) (p = 0.001). The J-CTO score was significantly higher in the excess PSD group (2.51 ± 1.28) than the standard PSD group (1.60 ± 1.13) (p < 0.001). Multivariate logistic regression analysis revealed that BSA (0.1 mm increase: OR 1.663, 95% CI 1.300-2.128, p < 0.001) and J-CTO score (1-point increase: OR 2.015, 95% CI 1.322-3.071, p = 0.001) were significantly associated with excess PSD. CONCLUSIONS: A large BSA and high J-CTO score were significantly associated with excess PSD. It is important to pay special attention to CTO patients who have a large BSA and/or high J-CTO score to reduce patient's PSD.

The current Japanese guideline for ST-segment elevation myocardial infarction (STEMI) recommends 500-m walk electrocardiogram (ECG) test for patients with STEMI during hospitalization. However, little is known regarding the association between acute phase 500-m walk ECG test and clinical outcomes. The purpose of this study was to investigate the association between 500-m walk ECG test and mid-term clinical outcomes in patients with STEMI. A total of 313 STEMI patients who underwent primary percutaneous coronary interventions were included, and were divided into the successful 500-m group (n = 263) and the unsuccessful 500-m group (n = 50). The primary endpoint was the major adverse cardiovascular events (MACE), which were defined as the composite of all cause death, acute myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization (TVR). During the follow-up period (median 223 days), a total of 55 MACE were observed. The log-rank test revealed that MACE, all cause death, readmission for heart failure, and ischemia-driven TVR were more frequently observed in the unsuccessful 500-m group than the successful 500-m group. In the multivariate Cox proportional hazard model, the unsuccessful 500-m walk ECG test was significantly associated with MACE (OR 5.62, 95% CI 3.08-10.08, P < 0.01) after controlling confounding factors such as age, and serum creatinine levels. In conclusion, the unsuccessful 500-m walk ECG test was significantly associated with poor mid-term outcomes in patients with STEMI. Our results suggest the usefulness of 500-m walk ECG test to stratify the high-risk group from patients with STEMI.

Although the usefulness of intravascular ultrasound (IVUS) in rotational atherectomy (RA) has been widely recognized, an IVUS catheter may not cross the target lesion because of severe calcification. The aim of this study was to compare the incidence of slow flow following RA between IVUS-crossable versus IVUS-uncrossable calcified lesions. We included 284 RA lesions, and divided into an IVUS-crossable group (n = 150) and an IVUS-uncrossable group (n = 134). The primary endpoint was slow flow just after RA. The incidence of slow flow (TIMI flow grade ≤ 2) was significantly greater in the IVUS-uncrossable group than in the IVUS-crossable group (26.1% vs. 10.7%, p = 0.001). The incidence of severe slow flow (TIMI grade ≤ 1) was also greater in the IVUS-uncrossable group than in the IVUS-crossable group (9.7% vs. 2.7%, p = 0.022). The multivariate logistic regression model showed a significant association between slow flow and pre-IVUS uncrossed lesions (vs. crossed lesions: odds ratio 2.103, 95% confidence interval 1.047-4.225, p = 0.037). In conclusion, the incidence of slow flow/severe slow flow just after RA was significantly greater in the IVUS-uncrossable lesions than in the IVUS-crossable lesions. Our study suggests the possibility that the IVUS-crossability can be used as a risk stratification of severe calcified lesions.

Since intravascular imaging such as intravascular ultrasound (IVUS) can provide useful information for rotational atherectomy (RA), intravascular imaging should be attempted before RA. However, some calcified lesions do not allow imaging catheters to cross before RA. Although small burrs (1.25 mm or 1.5 mm) should be selected for such tight lesions, it is unknown whether a 1.25-mm burr or 1.5-mm burr is safer as the initial burr. The aim of this study was to compare the incidence of complications with a 1.25-mm versus a 1.5-mm burr as the initial burr for IVUS-uncrossable lesions. This was a retrospective, single-center study. A total of 109 IVUS-uncrossable lesions were included, and were divided into a 1.25-mm group (n =52) and a 1.5-mm group (n =57). The incidence of slow flow just after RA was not different between the 2 groups (1.25-mm group: 25%, 1.5-mm group: 31.6%, P =0.45). The incidence of peri-procedural MI with slow flow was not different and equally low in the 2 groups (1.25-mm group: 1.9%, 1.5-mm group: 3.5%, P =0.61). The use of the 1.5-mm burr as the initial burr was not significantly associated with slow flow after controlling for chronic renal failure on hemodialysis and reference diameter (vs. 1.25-mm: OR 2.34, 95% CI 0.89-6.19, P =0.09). In conclusion, the incidence of complications following RA was comparable between the 1.25-mm and the 1.5-mm burrs as the initial burr for IVUS-uncrossable lesions. The present study provides insights into the selection of an appropriate burr for IVUS-uncrossable lesions.

Objective Although the importance of evidence-based optimal medical therapy (OMT) after acute myocardial infarction (AMI) has been recognized, the prescription rate of OMT is not sufficiently high in real-word clinical settings. The purpose of this study was to identify the clinical characteristics of AMI patients who did not receive OMT. Methods The present study was a retrospective study. OMT was defined as the combination of antiplatelet therapy, angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, and statins at the time of hospital discharge. Non-OMT was defined as the lack of either antiplatelet therapy, ACE inhibitors/ARBs, beta-blockers, or statins. Results A total of 457 AMI patients were included as the final study population, and 98 patients (22.4%) lacked at least 1 OMT medication. The prescription rates of antiplatelet therapy, ACE inhibitors/ARBs, beta-blockers, and statins were 98.7%, 87.5%, 90.4%, and 96.7%, respectively. In the multivariate logistic regression analysis, age [per 1-year increase: odds ratio (OR) 1.033, 95% confidence interval (CI) 1.007-1.059, p=0.014], hemodialysis (vs. no hemodialysis: OR 2.707, 95% CI 1.082-6.774, p=0.033), estimated glomerular filtration rate <30 mL/min/1.73 m2 without hemodialysis (OR 4.585, 95% CI 1.975-10.644, p<0.001), AMI caused by vasospastic angina (VSA) (vs. no VSA: OR 13.198, 95% CI 1.809-96.260, p=0.011), and asthma (vs. no asthma: OR 7.241, 95% CI 1.716-30.559, p=0.007) were significantly associated with non-OMT, whereas heart rate on admission (per 1-bpm increase: 0.987, 95% CI 0.975-0.999, p=0.033), any PCI (vs. no PCI: OR 0.156, 95% CI 0.066-0.373, p<0.001), and ST-elevation myocardial infarction (STEMI) (vs. NSTEMI: OR 0.384, 95% CI 0.218-0.675, p=0.001) were inversely associated with non-OMT. Conclusion An advanced age, VSA, bradycardia, asthma, impaired renal function, non-PCI revascularization, and non-ST-elevation myocardial infarction were significantly associated with non-OMT.

Fractional flow reserve (FFR) has become an increasingly important index for decision making concerning coronary revascularization. It is commonly accepted that significant improvement in FFR following percutaneous coronary intervention (PCI) is associated with better symptomatic relief and a lower event rate. However, in lesions with insufficient FFR improvement, PCI may not improve prognosis. Leading to the observation that the clinical and angiographic characteristics associated with insufficient FFR improvement have not been fully explored. The purpose of this study was to investigate the factors associated with insufficient improvement in FFR. Using our own PCI database, established between January 2014 and December 2018, we identified 220 stable coronary artery lesions, which had been evaluated for both pre- and post-PCI FFR values. All 220 of these lesions were included in this study. The improvement in FFR (ΔFFR) was calculated in each lesion with the lowest quartile of ΔFFR being defined as the lowest ΔFFR group, and the other quartiles being defined as the intermediate-high ΔFFR group. The mean ΔFFR in the lowest and intermediate-high ΔFFR groups was 0.07 ± 0.02 and 0.21 ± 0.11, respectively. In multivariate logistic regression analysis, a short total stent length (10 mm increase: OR 0.67, 95% CI 0.47-0.96, P = 0.030), higher pre-PCI FFR (0.1 increase: OR 4.07, 95% CI 1.83-9.06, P = 0.001), in-stent restenosis (ISR) (OR 8.02, 95% CI 1.26-51.09, P = 0.028), myocardial infarction (MI) in the target vessel (OR 6.87, 95% CI 1.19-39.69, P = 0.031) and non-use of intravascular imaging (OR 0.35, 95% CI 0.12-0.99, P = 0.048) were significantly associated with the lowest ΔFFR group. The use of short stents, higher pre-PCI FFR values, ISR, MI in the target vessel, and non-use of intravascular imaging were significantly associated with insufficient FFR improvement. It was conversely suggested that full coverage and adequate dilatation of the lesions under an intravascular imaging guidance might contribute to an improvement in FFR.

Recently, we developed a novel acute myocardial infarction (AMI) risk stratification system (nARS), which stratifies AMI patients into low- (L), intermediate- (I), and high- (H) risk groups. We have shown that the nARS shortened the length of intensive care unit (ICU) stay as well as that of hospitalization. However, the incidence of AMI-related adverse outcomes has not been fully investigated. The purpose of this study was to investigate the incidence of severe complications requiring ICU care among the 3 risk groups stratified by nARS. We retrospectively reviewed AMI patients between October 2016 and December 2018. A total of 592 patients were divided into the L- (n = 285), I- (n = 124), and H- (n = 183) risk groups. The primary endpoint was in-hospital complications requiring ICU care defined as death/cardiopulmonary arrest, shock, stroke, atrioventricular block, and respiratory failure. Among 592 patients, 239 (40.4%) developed at least 1 complication requiring ICU care, but only 28 (11.7%) developed complications in general wards. Complications requiring ICU care were most frequently observed in the H-risk group (68.9%), followed by the I-risk group (50.8%), and least in the L-risk group (17.5%) (P < 0.001). Complications requiring ICU care that occurred in the general wards were more frequently observed in the H-risk group (8.7%) compared to the I-risk (3.2%) and L-risk (2.8%) groups (P = 0.009). In conclusion, complications requiring ICU care rarely happened in the general wards, and were less in the I- and L-risk groups than in the H-risk group. These results validated the nARS, and might support the widespread use of nARS.

Recent guidelines do not recommend the routine use of intra-aortic balloon pumping (IABP) for patients with cardiogenic shock. However, IABP support is still selected for acute myocardial infarction (AMI) in clinical practice because an Impella device did not show superiority over IABP and the mortality of AMI with cardiogenic shock is still high. This study aimed to find factors associated with in-hospital mortality in patients with AMI who required IABP support. Overall, 104 patients with AMI who required IABP support were included as the study population. Of 104 patients, in-hospital death was observed in 19 (18.3%). Multivariate stepwise logistic regression analysis was performed to investigate the determinants of in-hospital death. Shock, resuscitation, estimated glomerular filtration rate (eGFR), pre-systolic blood pressure of IABP insertion, multi-vessel disease, fluoroscopy time, initial lactic acid dehydrogenase levels, and timing of IABP support were included as independent variables. Shock (OR 25.27, 95% CI 3.26-196.11, P = 0.002) was significantly associated with in-hospital death after controlling other covariates, whereas eGFR (every 10 mL/minute/1.73 m2 increase: OR 0.65, 95% CI 0.51-0.82, P < 0.001) and pre-percutaneous coronary intervention (pre-PCI) insertion of IABP (versus on-PCI insertion of IABP: OR 0.06, 95% CI 0.008-0.485, P = 0.008) were inversely associated with in-hospital death. In conclusion, shock was significantly associated with in-hospital death, whereas eGFR and pre-PCI insertion of IABP were inversely associated with in-hospital death in patients with AMI who received IABP support. Pre-PCI insertion of an IABP catheter might be associated with better survival in AMI patients who potentially require IABP support.

Since the amount of contrast media during percutaneous coronary intervention (PCI) is closely related to the exacerbation of renal function, it should be important to reduce the dose of contrast media during PCI. The purpose of this retrospective study was to evaluate the association of less-contrast media with clinical factors in elective PCI. A total of 709 patients were divided into the less-contrast media group (n = 142) and the conventional-contrast media group (n = 567) according to the quintile of total contrast volume. Univariate and multivariate logistic regression analyses were performed to find associations between the clinical variables and the less-contrast media group. The intravascular ultrasound (IVUS) use rate in the study population was considerably high (94.9%). In multivariable logistic regression analysis, an eGFR < 30 mL/min/1.73 m2 without hemodialysis was significantly associated with the less-contrast media group [odds ratio (OR) 43.73, 95% confidence interval (CI) 14.05-136.09, P < 0.001]. Left main-left anterior descending artery lesion (OR 0.28, 95% CI 0.17-0.48, P < 0.001), bifurcation lesion (OR 0.39, 95% CI 0.16-0.92, P = 0.03), chronic total occlusion (OR 0.22, 95% CI 0.06-0.90, P = 0.03) were inversely associated with the less-contrast media group. In conclusion, complex lesion characteristics were inversely associated with the less-contrast media in elective PCI. Since operators could access patients' renal function before elective procedure, an eGFR < 30 mL/min/1.73 m2 was most significantly associated with the less-contrast media. Our results suggest the possibility that the amount of contrast media is controllable in current PCI under IVUS-guidance.

Acute myocardial infarction (AMI) in the very elderly is associated with high morbidity and mortality. Although there are earlier studies regarding AMI in octogenarians, clinical evidences of AMI in nonagenarians are sparse. The aim of the present study was to compare in-hospital outcomes of AMI between octogenarians and nonagenarians. We included consecutive 415 very elderly (≥ 80 years) with AMI and divided them into the nonagenarian group (n = 38) and the octogenarian group (n = 377). Clinical characteristics and in-hospital outcomes were compared between the two groups. Furthermore, we used propensity score matching to find the matched octogenarian group (n = 38). Percutaneous coronary interventions (PCI) to the culprit of AMI were similarly performed between the nonagenarian (86.8%) and octogenarian (87.0%) groups. The incidence of in-hospital death in the nonagenarian group (10.5%) was similar to that in the octogenarian group (12.5%) (P = 0.487). After using the propensity score matching, the incidence of in-hospital death was less in the nonagenarian group (10.5%) than in the matched octogenarian group (18.4%) without reaching statistical significance (P = 0.328). The length of hospitalization was significantly shorter in the nonagenarian group [7.0 (4.0-9.0)] than in the matched octogenarian group [10.0 (6.5-15.0)] (P = 0.01). In conclusion, the in-hospital mortality of nonagenarians with AMI was comparable to that of octogenarians with AMI. In-hospital outcomes in nonagenarians with AMI may be acceptable as long as acute medical management including PCI to the culprit of AMI is performed.

BACKGROUND: Stent thrombosis (ST) remains a severe complication following stent implantation. We previously reported the risk factors for ST after 2nd-generation drug-eluting stent (DES) in the REAL-ST (Retrospective Multicenter Registry of ST After First- and Second-Generation DES Implantation) registry.Methods and Results:In this subanalysis, we aimed to reveal the difference in ST between right coronary (RCA) and left (LCA) coronary arteries. A total of 307 patients with ST were divided into the RCA-ST group (n=93) and the LCA-ST group (n=214). Multivariate analysis revealed younger age (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99, P=0.01), ostial lesion at the time of index percutaneous coronary intervention (OR 4.37, 95% CI 1.43-13.33, P=0.01), bifurcation lesion at the time of index PCI (OR 0.05, 95% CI 0.02-0.12, P<0.01), chronic total occlusion (CTO) lesion at the time of index PCI indication (OR 4.19, 95% CI 1.05-16.71, P=0.04), and use of prasugrel at the time of ST (OR 7.30, 95% CI 1.44-36.97, P=0.02) were significantly associated with RCA-ST. CONCLUSIONS: Younger age, ostial or CTO lesion, and use of prasugrel at the time of ST were prominent factors in RCA-ST, whereas bifurcation lesion was associated with LCA-ST. We should pay attention to the differences between RCA-ST and LCA-ST to prevent ST.

BACKGROUND: Recent guidelines for ST-elevation myocardial infarction (STEMI) recommended the door-to-balloon time (DTBT) <90 minutes. However, some patients could have poor clinical outcomes in spite of DTBT <90 minutes, which suggest the importance of therapeutic targets except DTBT. The purpose of this study was to find factors associated with poor clinical outcomes in STEMI patients with DTBT <90 minutes. METHODS: This retrospective study included 383 STEMI patients with DTBT <90 minutes. The primary endpoint was the major adverse cardiac events (MACE) defined as the composite of all-cause death, acute myocardial infarction, and acute heart failure requiring hospitalization. RESULT: The median follow-up duration was 281 days, and the cumulative incidence of MACE was 16.2%. In the multivariate Cox hazard model, low body mass index (< 20 kg/m2) (vs. >20 kg/m2: HR 2.80, 95% CI 1.39-5.64, p = 0.004), history of previous myocardial infarction (HR 2.39, 95% CI 1.06-5.37, p = 0.04), and Killip class 3 or 4 (vs. Killip class 1 or 2: HR 2.39, 95% CI 1.30-4.40, p = 0.005) were significantly associated with MACE. In another multivariate Cox hazard model, flow worsening during percutaneous coronary intervention (PCI) (HR 3.24, 95% CI 1.79-5.86, p<0.001) and use of mechanical support (HR 3.15, 95% CI 1.71-5.79, p<0.001) were significantly associated with MACE, whereas radial approach (HR 0.54, 95% CI 0.32-0.92, p = 0.02) was inversely associated with MACE. CONCLUSION: Low body mass index, Killip class 3/4, history of previous myocardial infarction, use of mechanical support, and flow worsening were significantly associated with MACE, whereas radial-access was inversely associated with MACE. It is important to avoid flow worsening during primary PCI even when appropriate DTBT was achieved.

OBJECTIVES: This study aimed to compare the mid-term clinical outcomes of intravascular ultrasound (IVUS)-calcified nodules between percutaneous coronary intervention (PCI) with and without rotational atherectomy (RA). BACKGROUND: There has been a debate whether to use RA for the revascularization of calcified nodule. Although RA can ablate the calcified structure within calcified nodule and may facilitate adequate stent expansion, RA may provoke severe coronary perforation, because calcified nodule typically shows eccentric calcification. METHODS: We included 204 lesions with IVUS-calcified nodule, and divided into 73 lesions treated with RA (RA group) and 131 lesions without RA (non-RA group). After propensity-score matching, 42 lesions with RA (matched RA group) and 42 lesions without RA (matched non-RA group) were selected. We compared the clinical characteristics and outcomes between the 2 groups before and after propensity-score matching. The primary endpoint was ischemia-driven target vessel revascularization (TVR) within 1 year. RESULTS: Acute lumen area gain on IVUS was comparable between the matched RA group and matched non-RA group (3.9 ± 2.1 mm2 vs. 3.4 ± 1.6 mm2, p = 0.18). The stent malapposition at calcified nodules was frequently observed in both groups. The ischemia-driven TVR was not different between the 2 groups before (p = 0.82) and after propensity score-matching (p = 0.87). CONCLUSIONS: The use of RA could not reduce the incidence of ischemia-driven TVR in lesions with IVUS-calcified nodule. Our results do not support the routine use of RA for lesions with IVUS-calcified nodule.