坂倉 建一

INTRODUCTION: In-stent calcification is recognized as a significant contributor to unfavorable clinical outcomes. Understanding the various types and underlying mechanisms of in-stent calcification can help interventional operators to make decisions. AREAS COVERED: This review will describe the distinct types of in-stent calcification, which are categorized into in-stent smooth calcification and in-stent calcified nodule. The mechanisms and characteristics of in-stent smooth calcification and calcified nodule will be summarized. Given the differences between these two types, treatment approaches will be discussed. This review will focus on histopathology and intracoronary imaging. For the purpose of this review, evidence was gathered from electronic literature searches via PubMed, with a particular focus on primary evidence published in the last 5 years. EXPERT OPINION: Several treatment devices are available such as conventional balloon, modified balloon, atherectomy device and intravascular lithotripsy, etc. In-stent smooth calcification and calcified nodule might result in different clinical courses after repeated target lesion revascularization. Understanding the mechanisms with the various types of in-stent calcification may assist operators in selecting appropriate treatment strategies.

The impact of mid-range (mr) ejection fraction (EF) on long-term clinical outcomes has been reported in patients with heart failure but remains unclear in patients with ST-segment elevation myocardial infarction (STEMI). The purpose of this study was to compare the long-term clinical outcomes among STEMI patients with preserved EF (pEF), mrEF, and reduced EF (rEF), and to evaluate the significance of mrEF as a prognostic factor for patients with STEMI. We included 705 patients with STEMI and divided them into rEF group (n = 155), mrEF group (n = 155), and pEF group (n = 395) according to the pre-discharge EF. The primary endpoint was the major adverse cardiovascular events (MACE), which were defined as the composite of all-cause death, re-admission for heart failure, and non-fatal myocardial infarction (MI). The median follow-up duration was 906 days (Q1:349.5-Q3:1479). The Kaplan-Meier curves showed that MACE and re-admission for heart failure were more frequently observed in the rEF group, followed by the mrEF group, and least in the pEF group (p < 0.001). The multivariate Cox hazard analysis revealed that mrEF as well as rEF were significantly associated with MACE after controlling for confounding factors [rEF: hazard ratio (HR) 2.333, 95% confidence interval (CI) 1.350-4.034, p = 0.002, mrEF:HR1.852, 95%CI 1.139-3.010, p = 0.013]. Mid-range EF as well as rEF was significantly associated with MACE and re-admission for heart failure in patients with STEMI. Our results suggest that mrEF is an important prognostic factor in patients with STEMI.

Background: Peripheral arterial disease (PAD) is associated with cardiovascular events in patients with acute myocardial infarction (AMI). However, there are limited reports regarding the association between PAD and bleeding events. In this study, we aimed to evaluate whether PAD is independently associated with an increased risk of major bleeding events, in addition to major adverse cardiovascular events (MACEs), in patients with AMI undergoing percutaneous coronary intervention (PCI). Methods: We included 1391 patients with AMI who underwent PCI and divided them into the PAD group (n = 210) and the non-PAD group (n = 1181). The primary endpoint was total bleeding events, defined as Bleeding Academic Research Consortium type 3/5. The secondary endpoint was MACE, defined as the composite of all-cause death, non-fatal myocardial infarction, and hospitalization for heart failure. Results: The median follow-up duration was 653 days. Total bleeding events were more frequently observed in the PAD group than in the non-PAD group (24.8% vs. 11.3%, p < 0.001). The multivariate Cox hazard analysis confirmed that PAD was significantly associated with total bleeding events (HR 1.509; 95% CI 1.056-2.156, p = 0.024) as well as MACEs (HR 2.152; 95% CI 1.510-3.066, p < 0.001) after controlling for confounding factors. Conclusions: PAD was independently associated with a higher risk of major bleeding and cardiovascular events in patients with AMI undergoing PCI. These findings suggest that PAD should be recognized as a critical factor in risk stratification for AMI and may affect individualized bleeding risk management strategies in patients with AMI.

BACKGROUND: In pulmonary vein isolation (PVI) for atrial fibrillation (AF), intraoperative defibrillation is often required. Intracardiac defibrillation catheters (ICDCs) are most effective when positioned to enclose the heart between the coronary sinus (CS) and right atrium (RA) (CS/RA configuration). However, achieving this positioning via the inferior vena cava (IVC) can be challenging, and alternative configurations remain underexplored. METHODS: This study included patients with paroxysmal or persistent AF who underwent cryoballoon ablation followed by intracardiac cardioversion using an ICDC via the IVC. The catheter was initially positioned with distal electrodes in the CS and proximal electrodes in the IVC (CS-only configuration). If cardioversion failed, the catheter was repositioned to place distal electrodes in the superior vena cava (SVC configuration). A maximum of 30 J of energy was used for all cardioversion attempts. RESULTS: A total of 81 patients were included. Cardioversion in the CS-only configuration restored sinus rhythm in 11% (9/81) of patients. Repositioning to the SVC configuration achieved successful cardioversion in 93.1% (67/72) of the remaining cases without complications. Patients requiring the SVC configuration had a significantly higher prevalence of persistent AF (33.3% vs. 80.6%; p = 0.045). No adverse events were observed following cardioversion in the SVC configuration. CONCLUSIONS: While the CS-only configuration offers ease of placement, its efficacy is limited. Repositioning to the SVC configuration significantly enhances cardioversion success and represents a safer, more effective alternative for ICDC use during AF ablation.