藤田 英雄

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.

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.

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.

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: 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.

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.

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: 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.

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.

© 2018 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd. Aims: To assess the benefits of intensive statin therapy on reducing cardiovascular (CV) events in patients with type 2 diabetes complicated with hyperlipidaemia and retinopathy in a primary prevention setting in Japan. In the intension-to-treat population, intensive therapy [targeting LDL cholesterol <1.81 mmol/L (<70 mg/dL)] was no more effective than standard therapy [LDL cholesterol ≥2.59 to <3.10 mmol/L (≥100 to <120 mg/dL)]; however, after 3 years, the intergroup difference in LDL cholesterol was only 0.72 mmol/L (27.7 mg/dL), and targeted levels were achieved in <50% of patients. We hypothesized that the intergroup difference in CV events would have been statistically significant if more patients had been successfully treated to target. Materials and Methods: This exploratory post hoc analysis focused on intergroup data from patients who achieved their target LDL cholesterol levels. The primary endpoint was the composite incidence of CV events. A Cox proportional hazards model was used to estimate hazard ratios (HRs) for incidence of the primary endpoint in patients who achieved target LDL cholesterol levels in each group. Results: Data were analysed from 1909 patients (intensive: 703; standard: 1206) who achieved target LDL cholesterol levels. LDL cholesterol at 36 months was 1.54 ± 0.30 mmol/L (59.7 ± 11.6 mg/dL) in the intensive group and 2.77 ± 0.46 mmol/L (107.1 ± 17.8 mg/dL) in the standard group (P < 0.05). After adjusting for baseline prognostic factors, the composite incidence of CV events or deaths associated with CV events was significantly lower in the intensive than the standard group (HR 0.48; 95% confidence interval 0.28-0.82; P = 0.007). Conclusions: This post hoc analysis suggests that achieving LDL cholesterol target levels <1.81 mmol/L may more effectively reduce CV events than achieving target levels ≥2.59 to <3.10 mmol/L in patients with hypercholesterolaemia and diabetic retinopathy.