Atsunori Okamura's research while affiliated with Sakurabashi Watanabe Hospital and other places
Objectives: This study sought to compare the procedural outcomes of percutaneous coronary intervention for chronic total occlusion between the periods before and after introduction of 3-dimensional (3D) wiring. Background: Previously, we reported a 3D wiring method by which the operator can construct real-time mental 3D images from 2 perpendicular angles of X-ray system monitor during percutaneous coronary intervention for chronic total occlusion. Methods: A total of 137 chronic total occlusion lesions that could not be passed by tapered soft wires in our hospital between 2012 and 2017 were retrospectively enrolled in the study. Results: Overall success rate was significantly higher in the 3D wiring group (n = 69) than the non-3D wiring group (n = 68) (98% vs. 90%, respectively; p = 0.027). In the primary antegrade cases, the first antegrade approach time was significantly shorter in the 3D wiring group than the non-3D wiring group (42 ± 29 vs. 30 ± 16 min, respectively; p = 0.01). In cases where the antegrade approach was continued throughout the procedure, the success rate was significantly higher in the 3D wiring group than the non-3D wiring group (100% vs. 89.2%, respectively; p = 0.033). Vessel perforation by the antegrade wire tended to be lower in the 3D wiring group than the non-3D wiring group (1% vs. 11%, respectively; p = 0.055). Conclusions: 3D wiring enables accurate guidewire control, which improves the success rate of antegrade wiring and reduces the antegrade procedure time, resulting in improvement of the overall success rate.
Background: Automated ablation lesion annotation with optimal settings for parameters including contact force (CF) and catheter stability may be effective for achieving durable pulmonary vein isolation. Methods and Results: We retrospectively examined 131 consecutive patients who underwent initial catheter ablation (CA) for paroxysmal atrial fibrillation (PAF) by automatic annotation system (VISITAG module)-guided radiofrequency CA (RFCA) (n=61) and 2nd-generation cryoballoon ablation (CBA) (n=70) in terms of safety and long-term efficacy. The automatic annotation criteria for the RFCA group were as follows: catheter stability range of motion ≤1.5 mm, duration ≥5 s, and CF ≥5 g. We ablated for >20 s with a force-time integral >150 gs at each site, before moving to the next site. Each interlesion distance was <6 mm. Procedural complications were more frequent in the CBA group (1.6% vs. 10.0%, P=0.034). Across a median follow-up of 2.98 years, 88.5% and 70.0% of patients in the RFCA and CBA groups, respectively, were free from recurrence (log-rank test, P=0.0039). There was also a significant difference in favor of RFCA with respect to repeat ablations (3.3% vs. 24.3%, log-rank test, P=0.0003). Conclusions: RF ablation guided by an automated algorithm that includes CF and catheter stability parameters showed better long-term outcomes than CBA in the treatment of patients with PAF without increasing complications.
Early recurrence of atrial arrhythmia (ERAA) during a blanking period after catheter ablation (CA) for atrial fibrillation (AF) does not always result in subsequent AF recurrence. We investigated whether failed electrical cardioversion (ECV) during the blanking period was associated with recurrence. A total of 1,240 consecutive patients who underwent first-time CA for AF at our institution between March 2012 and March 2016 were investigated. Among the 517 patients (42%) who experienced ERAA, 262 underwent ECV. Failure or success of ECV was defined according to the current expert consensus statement. Failed ECV was defined as failure to terminate AF and/or relapse into AF within 30 seconds after transient sinus rhythm conversion by ECV with a shock energy of 270 J in this study. Of the patients, 254 (97%) with restored sinus rhythm were included, and 8 who experienced sustained AF afterward and discontinued the rhythm-control strategy were excluded. We divided the 254 patients into the following 2 groups on the basis of failed or successful ECV: failed-ECV (n = 105; at least 1 failed ECV but experienced successful ECV at a later date nevertheless) and successful-ECV (n = 149, no failed ECV) groups. At the median follow-up period of 610 days after CA, the recurrence rate was higher in the failed-ECV group than in the successful-ECV group (76.2% vs 45.6%, log-rank p < 0.001). After adjustment for baseline differences, failed ECV was found to be a significant predictor of recurrence in the multivariate model (p < 0.001). In conclusion, failed ECV for ERAA was an independent predictor of future recurrence.
The efficacy of catheter ablation (CA) of nonparoxysmal atrial fibrillation (PAF) in patients with left ventricular systolic dysfunction is controversial. We investigated the outcomes of CA for non-PAF in patients with reduced left ventricular ejection fraction (LVEF) and the impact of early left atrial (LA) reverse remodeling on these outcomes. A total of 251 consecutive patients who underwent CA for non-PAF were divided into 2 groups (reduced: preoperative LVEF ≤55%, LVEF: 46.5 ± 8.7%, n = 63; normal: >55%, 65.8 ± 5.8%, n = 188). We analyzed the 4-year atrial fibrillation- or atrial tachycardia (AT)-free survival rate and assessed changes in LVEF, hemodynamics, and LA reverse remodeling at the end of a 90-day blanking period. We also evaluated LA reverse remodeling in patients with and without recurrence. The atrial fibrillation- or AT-free survival rates were similar (reduced vs normal 48% vs 42%, p = 0.32). The reduced group exhibited significant LVEF improvement (before vs after, 46.5 ± 8.7% vs 58.4 ± 11.5%, p<0.001), reduced mitral regurgitation, and spectral tissue Doppler-derived index, and had greater percent maximum left atrial volume reduction (reduced vs normal 25.3 ± 18.2% vs 19.3 ± 16.2%, p = 0.014). Percent maximum left atrial volume reduction was greater in patients without recurrence (with recurrence vs without recurrence 17.3 ± 16.7% vs 25.4 ± 16.1%, p<0.001). In conclusion, the efficacy of non-PAF CA in patients with reduced LVEF was comparable with that in patients with normal LVEF. Greater LA reverse remodeling in these patients suggests an association with a reduced recurrence rate.
Background: This study evaluated the safety and efficacy of venous figure-of-eight (FoE) suture to achieve femoral venous hemostasis after radiofrequency (RF) catheter ablation (CA) for atrial fibrillation (AF).Methods and Results:We retrospectively examined 517 consecutive patients undergoing RFCA for AF. The control group (n=247) underwent manual compression for femoral venous hemostasis after sheath removal with 6 h of bed rest. The FoE group (n=270) underwent FoE suture technique with 4 h of bed rest. All patients achieved successful hemostasis within 24 h after CA. Although the incidence of hematoma was similar between the groups, the incidence of rebleeding was lower in the FoE group than in the control group (FoE vs. control, 3.7% vs. 18.6%, P<0.001). The post-procedural use of analgesic and/or anti-emetic agents was less frequent in the FoE group (19.3% vs. 32.0%, P<0.001). On multiple logistic regression analysis after adjustment for age and sex, the use of a vitamin K antagonist (OR, 2.42; 95% CI: 1.18-4.99, P=0.02) and the FoE suture technique (OR, 0.17; 95% CI: 0.08-0.35, P<0.001) were independent predictors of rebleeding after CA. Conclusions: FoE suture technique effectively achieved femoral venous hemostasis after RFCA for AF. It reduced the risk of rebleeding, shortened bed rest duration, and relieved patient discomfort.
Background Among patients treated with percutaneous coronary intervention for chronic total occlusion (CTO‐PCI), patients on long‐term hemodialysis are at significantly high risk for cardiovascular mortality and morbidity. However, clinical or angiographic predictors that might aid in better patient selection remain unclear. We aimed to assess the acute impact of hemodialysis in patients who underwent CTO‐PCI. Methods and Results The Retrograde Summit registry is a multicenter, prospective registry of patients undergoing CTO‐PCI at 65 Japanese centers. Patient characteristics and procedural outcomes of 4749 patients were analyzed, according to the presence (n=313) or absence (n=4436) of baseline hemodialysis. A prediction model for technical failure among hemodialysis patients was also developed. The technical success rate of CTO‐PCI was significantly lower in hemodialysis than in nonhemodialysis patients (78.0% versus 89.1%, P<0.001). The rates of in‐hospital major adverse cardiac and cerebrovascular events were similar between the 2 groups (1.6% versus 0.9%, P=0.24). Irrespective of clinical/angiographic characteristics or previously developed scoring systems, hemodialysis independently predicted technical failure for CTO‐PCI. Among hemodialysis patients, predictors of technical failure were blunt stump (odds ratio 2.45, 95% confidence interval, 1.15–5.21, P=0.021), severe lesion calcification (odds ratio 2.50, 95% confidence interval, 1.19–5.24, P=0.015), and absence of diabetes mellitus (odds ratio 3.15, 95% confidence interval, 1.49–6.64, P=0.003). In hemodialysis patients without these predictors, the technical success rate was 96.2%. Conclusions Hemodialysis is significantly associated with technical failure. Contemporary CTO‐PCI seems feasible and safe in selected hemodialysis patients.
Objectives: This report describes the registry and presents an initial analysis of outcomes for the different PCI approaches taken by the specialists. Background: Strategies for percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) are complex. The Japanese Board of CTO Interventional Specialists has developed a prospective, nonrandomized registry of patients undergoing CTO-PCIs performed by 41 highly experienced Japanese specialists. Methods: Over the study period of January 2014 to December 2015, the registry included 2,846 consecutive CTO-PCI cases undertaken in Japan. The authors compared clinical outcomes between the different PCI approaches, following the intention-to-treat principle. Results: The overall technical success rate of the procedures was 89.9%. The specialists frequently chose a retrograde approach as the primary CTO-PCI strategy (in 27.8% of cases). The technical success rate of the primary antegrade approach was significantly better than that of the primary retrograde approach (91.0% vs. 87.3%; p < 0.0001). The technical success rate decreased to 78.0% with the rescue retrograde approach. Parallel guidewire crossing and intravascular ultrasound-guided wire crossing were performed after guidewire escalation during antegrade CTO-PCI with a high technical success rate (75.0% to 88.9%). Severe lesion calcification was a strong predictor of failed CTO-PCI. Conclusions: CTO-PCI performed by highly experienced specialists achieved a high technical success rate.
Background:Durable pulmonary vein isolation (PVI) is critical in reducing recurrence after radiofrequency catheter ablation for atrial fibrillation (AF). The VISITAG Module, an automatic annotation system that takes account of catheter stability and contact force (CF), might be useful in accomplishing this. Methods and Results:In 49 patients undergoing VISITAG-guided AF ablation (group A), we set the following automatic annotation criteria: catheter stability range of motion ≤1.5 mm, duration ≥5 s, CF ≥5 g, time ≥25% and tag diameter at 6 mm. We used ablation >20 s and force-time integral >150 gs at each site, then moved to the next site where a new tag appeared that overlapped with the former tag. Results and outcome were retrospectively compared for 42 consecutive patients undergoing CF-guided AF ablation without this algorithm (group B). Successful PVI at completion of the initial anatomical line was more frequent in group A than B (66.3% vs. 36.9%, P=0.0006) while spontaneous PV reconnection was less frequent (14.2% vs. 30.9%, P=0.0014) and procedure time was shorter (138±35 min vs. 180±44 min, P<0.001). One-year success rate off anti-arrhythmic drugs was higher in group A (91.8% vs. 69.1%, log rank P=0.0058). Conclusions:An automated annotation algorithm with an optimal setting reduced acute resumption of left atrium-PV conduction, shortened procedure time, and improved AF ablation outcome.
The present study aimed to assess the mechanisms of effects of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) from two different aspects: left ventricular (LV) systolic function assessed by two-dimensional speckle tracking echocardiography (2D-STE) and electrical stability evaluated by late potential on signal-averaged electrocardiogram (SAECG). We conducted a prospective observational study with consecutive CTO-PCI patients. 2D-STE and SAECG were performed before PCI, and after 1-day and 3-months of procedure. 2D-STE computed global longitudinal strain (GLS) and regional longitudinal strain (RLS) in CTO area, collateral blood-supplying donor artery area, and non-CTO/non-donor area. A total of 37 patients (66 ± 11 years, 78% male) were analyzed. RLS in CTO and donor areas and GLS were significantly improved 1-day after the procedure, but these improvements diminished during 3 months. The improvement of RLS in donor area remained significant after 3-months the index procedure (pre-PCI −13.4 ± 4.8% vs. post-3M −15.1 ± 4.5%, P = 0.034). RLS in non-CTO/non-donor area and LV ejection fraction were not influenced. Mitral annulus velocity was improved at 3-month follow-up (5.0 ± 1.4 vs. 5.6 ± 1.7 cm/s, P = 0.049). Before the procedure, 12 patients (35%) had a late potential. All components of the late potential (filtered QRS duration, root-mean-square voltage in the terminal 40 ms, and duration of the low amplitude signal <40 μV) were not improved. CTO-PCI improved RLS in the donor area at 3-month follow-up without changes of LV ejection fraction. Although higher prevalence of late potential in the current population compared to healthy population was observed, late potential as a surrogate of arrhythmogenic substrate was not influenced by CTO-PCI.
Aims: To assess the incidence and impact on the midterm outcomes of intimal versus subintimal tracking with both antegrade and retrograde approaches in patients undergoing successful percutaneous coronary intervention for chronic total occlusion (CTO). Methods and results: In 2012, a total of 1573 CTO cases from 30 hospitals were enrolled in the Japanese CTO registry. Successful guidewire crossing was performed in 1411 cases (89.7%). Among them, the guidewire penetration position was clearly identified using intravascular ultrasound (IVUS) imaging in 352 cases, and clinical follow-up at 12 months was performed in 323 cases. These 323 cases were enrolled in this retrospective study and included 242 cases treated with the antegrade approach (antegrade group) and 81 cases were treated with the retrograde approach (retrograde group). The endpoint of this study was target vessel revascularization (TVR) and major adverse cardiac events (MACE) at 12 months follow-up. Subintimal tracking occurred more frequently in the retrograde group (11.6% vs. 30.9%, P<0.01). TVR was more frequent in the subintimal tracking group in the retrograde group (7.1% vs. 16.0%, P=0.03) but not in the antegrade group (2.8% vs. 3.6%, P=0.99). Although the occlusion length was similar, the subintimal tracking group required a longer stent length compared to the intimal tracking group in the retrograde approach (59.7±24.4 mm vs. 74.0±24.4 mm, P<0.01). Conclusions: Subintimal tracking was more frequent in the retrograde approach. Intimal tracking should be recommended in the retrograde approach to reduce stent length and to improve follow-up outcomes.
Objectives: To evaluate factors for predicting retrograde CTO-PCI failure after successful collateral channel crossing. Background: Successful guidewire/catheter collateral channel crossing is important for the retrograde approach in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Methods: A total of 5984 CTO-PCI procedures performed in 45 centers in Japan from 2009 to 2012 were studied. The retrograde approach was used in 1656 CTO-PCIs (27.7%). We investigated these retrograde procedures to evaluate factors for predicting retrograde CTO-PCI failure even after successful collateral channel crossing. Results: Successful guidewire/catheter collateral crossing was achieved in 77.1% (n = 1,276) of 1656 retrograde CTO-PCI procedures. Retrograde procedural success after successful collateral crossing was achieved in 89.4% (n = 1,141). Univariate analysis showed that the predictors for retrograde CTO-PCI failure were in-stent occlusion (OR = 1.9829, 95%CI = 1.1783 - 3.3370 P = 0.0088), calcified lesions (OR = 1.9233, 95%CI = 1.2463 - 2.9679, P = 0.0027), and lesion tortuosity (OR = 1.5244, 95%CI = 1.0618 - 2.1883, P = 0.0216). On multivariate analysis, lesion calcification was an independent predictor of retrograde CTO-PCI failure after successful collateral channel crossing (OR = 1.3472, 95%CI = 1.0614 - 1.7169, P = 0.0141). Conclusions: The success rate of retrograde CTO-PCI following successful guidewire/catheter collateral channel crossing was high in this registry. Lesion calcification was an independent predictor of retrograde CTO-PCI failure after successful collateral channel crossing. Devices and techniques to overcome complex CTO lesion morphology, such as lesion calcification, are required to further improve the retrograde CTO-PCI success rate. © 2016 Wiley Periodicals, Inc.
Objectives: This study was performed to evaluate the acute outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) based on operator experience. Background: Despite developments in both technology and techniques, PCI procedures for CTO's remain challenging. Methods: A total of 3,229 eligible subjects who underwent CTO-PCI were enrolled from 56 centers by a retrograde summit using a web registry system. To compare the acute outcomes of the CTO data, 18 centers were classified as higher volume centers (HC) and 38 centers as lower volume centers (LC) depending on the CTO-PCI experience of the operator. Results: The mean procedural success rate of all centers was 88.4%. The overall procedural success rate was significantly higher in HC than LC (90.6% vs. 85.6%, respectively; P < 0.0001). In addition, overall antegrade success rate was also higher in HC than LC (91.0% vs. 83.9%, respectively; P < 0.0001). Although the overall retrograde approach success rate was significantly higher in HC than LC (85.0% vs. 77.6%, respectively; P < 0.0001), there was no significant difference in that of the retrograde alone (89.0% vs. 93.7%, respectively; P = 0.051). Major in-hospital adverse events were observed in 0.53% of cases, and the rates were similar between the two groups (0.45% vs. 0.62%, respectively; P = 0.25). Conclusions: Although CTO-PCI was safe in both groups, the procedural success rate was significantly higher in HC than LC, even in this new era of CTO-PCI. This difference was attributed to the difference in the antegrade procedural success rate. © 2015 Wiley Periodicals, Inc.
Objectives: This study was performed to determine the complications occurring during retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) based on analysis of the multicenter, prospective, nonrandomized Retrograde Summit registry. Background: Retrograde PCI for CTO has improved treatment success rates, but several complications related to the retrograde approach have been reported, including collateral channel injury and donor artery injury due to their use as retrograde roots. Methods: This registry included data from 1,166 patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2011. Results: Overall procedure success and retrograde procedure success were achieved in 985 (84.5%) and 838 (71.9%) of the 1,166 patients, respectively. In-hospital major adverse cardiac and cerebrovascular events (MACCE) occurred in 18 (1.5%) of the 1,166 patients. With regard to complications related to the retrograde approach, channel injury occurred in 111 (9.5%) of the 1,166 patients, but treatment was required in only 24 (2.1%) patients and subsequent cardiac tamponade occurred in only 4 (0.3%) patients. Donor artery problems occurred in only 10 (0.9%) of the 1,166 patients. In sub-analysis regarding the types of collateral channels, the septal channel was significantly safer than epicardial channel because of the lower frequency of non-Q-wave myocardial infarction (non-QMI) and channel injury requiring treatment. Conclusions: The MACCE rate during retrograde PCI for CTO determined from the Retrograde Summit registry was low and the frequency of complications related to the retrograde approach was acceptable. © 2015 Wiley Periodicals, Inc.
Background: Percutaneous coronary interventions involving small coronary vessels represent a true challenge because of the increased risk of restenosis and adverse outcomes. We evaluated the 2-year clinical outcomes between single everolimus-eluting stents (EES) and paclitaxel-eluting stents (PES) in small coronary artery disease. Methods: From the data of SACRA (SmAll CoronaRy Artery treated by TAXUS Liberté) and PLUM (PROMUS/Xience V Everolimus-ELUting Coronary Stent for sMall coronary artery disease) registries, 245 patients with 258 lesions and 264 patients with 279 lesions, respectively, were enrolled in this study. Results: The 2-year clinical driven target lesion revascularization (4.5% vs. 10.6%, p=0.01) and target vessel revascularization (8.0% vs. 13.9%, p=0.03) rates were significantly lower in the EES group compared with the PES group. Major adverse cardiac events in the EES group tended to be lower than those in the PES group (8.7% vs. 14.3%, p=0.05). On the other hand, all new lesions for remote target vessel revascularization were observed at the proximal site of target lesions in both groups and those rates were not different between the two groups (3.4% vs. 3.3%, p>0.99). Conclusion: EES showed better clinical results at 2-year follow-up compared with PES in small coronary artery diseases, however, new lesions at the proximal remote site of the target lesion remain problematic.
Three-dimensional (3D) wiring is one method for accurate guidewire control in chronic total occlusion (CTO) lesions during manipulation of CTO-specific stiff guidewires. However, the construction of a mental 3D image is difficult. We propose the idea of image patterns to allow immediate construction of 3D images from the two perpendicular angles of the X-ray system detector and report a case of CTO treated with 3D wiring.
Objectives This registry evaluated the current trends and outcomes associated with retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Background Since its introduction, several techniques and technologies have been introduced for retrograde PCI for CTO. Methods Eight hundred and one patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2010 were enrolled in this registry. ResultsOverall procedural and clinical success rates were 84.8 and 83.8%, respectively, of which, retrograde procedures accounted for 71.2 and 70.3%, respectively. The use of channel dilators increased in 2010 compared to that in 2009 (36 vs. 95.3%, P<0.0001), attributed improving collateral channel crossing using a wire and catheter (70.6% vs. 81.1%, P=0.0005) and increased availability of epicardial channels (27.6% vs. 36.9%). The use of the reverse controlled antegrade and retrograde tracking technique also increased (41.9 vs. 66.5%). Although these changes decreased procedure time (203.3 min vs. 187.9 min, P=0.024), they did not significantly improve overall procedural success rate (84.1% vs. 85.3%, P=0.63). Multivariate analysis identified age 65 years or more and lesion calcification as unfavorable factors and the use of a channel dilator as a favorable factor for retrograde procedural success. Conclusions Increased availability of channel dilators has altered strategies for retrograde PCI for CTO. However, retrograde PCI for CTO could be improved by overcoming its main obstacle of severe calcification. (c) 2013 Wiley Periodicals, Inc.
We describe an initial clinical chronic total occlusion (CTO) case in which CTO-specific intravascular ultrasound (IVUS): Navifocus WR was useful for navigating the second guidewire into the true lumen under the IVUS observation from the subintimal space.
Purpose: In the era of drug-eluting stents, multiple overlapping stents was performed for more than 10% of patients with diffuse coronary artery diseases. However, there are limited clinical follow-up data of multiple overlapping everolimus-eluting stents (EES). Methods: XILLION (XIence/promus for Long coronary LesION) registry is a prospective, multi-center registry to assess the efficacy of multiple overlapping everolimus-eluting stents in patients with diffuse long coronary artery disease. Inclusion criteria were 1) Non occluded lesions with >75% diameter stenosis in vessels >2.5mm in diameter, 2) lesion length >30mm required at least two EESs. The primary endpoint is major adverse cardiac events (MACE) at one year. Results: A total of 245 patients with 259 lesions were enrolled. Seventy percent of patients had multi-vessel diseases. Averaged length of stents was 49.5±12.4 mm (2 stents: 90%, 3 stents: 7%, 4 stents: 3%). MACE rate was 7.7% (target lesion revascularization: 3.8%, target vessel revascularization: 6.1%, myocardial infarction: 1.2%, cardiac death: 0.4%). However, the rate of any revascularization for the new lesions in non target vessels was 15.5%. Conclusion: EES may provide a good long-term clinical outcome after the treatment of the target long coronary artery diseases. However, the incidence of new coronary artery disease during one year follow-up period in non-target vessels was still high.
Background: The Japanese Retrograde Summit was established to analyze the latest results of retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Total 1,166 of retrograde procedure data have been collected between 2009 and 2011. Retrograde procedure success rate has not been dramatically improved throughout these 3 years. Methods: For the purpose of investigating the reason of procedural failure, we analyzed total 328 cases which failed retrograde procedure based on procedural characteristics, and also analyzed the lesion and collateral channel characteristics of our registry failure cases in 2011. Results: Among 328 failed retrograde, the most common failure mode was due to failed collateral channel crossing by guidewire or catheter (72.6%), followed by CTO crossing (22.3%). For deeper analysis of retrograde failure cases, we tried to investigate angiograms of retrograde failure cases and collected 91 of 97 cases (93.8%) from the latest 2011 registry data. Among 91 cases, the reasons of retrograde failure were unsuccessful crossing of collateral channel (57) or CTO (28) and discontinuation due to complication (5). The table describes the features of collateral channel and CTO site of failure cases and occurrence of guidewire perforation for each. View this table:Enlarge table
We describe one case of septal and two cases of epicardial collateral channel perforation during percutaneous coronary intervention by the retrograde approach for chronic total occlusion. After coil embolization of the channel perforation area, additional treatments were required in all three cases to stop bleeding. All three cases required injection of autologous clots, with one case also requiring subsequent injection of fibrin glue. © 2013 Japanese Association of Cardiovascular Intervention and Therapeutics.
We performed microscopic examination of the debris collected by a distal protection device and investigated the usefulness of grayscale and integrated backscatter intravascular ultrasound (IB-IVUS) for the prediction of distal embolization during percutaneous coronary intervention (PCI) in cases of unstable angina. The prediction of distal embolization during PCI has not been studied in depth because assessment of distal embolization is difficult. We prospectively studied 39 consecutive patients with unstable angina who underwent PCI with a filter distal protection device. The preprocedural plaque volume at target lesions was measured with grayscale IVUS and plaque characteristics were assessed with IB-IVUS. We performed microscopic examination of the particles collected by the distal protection device. There was a significant correlation between the plaque volume and the number of the collected particles >100 μm in diameter (r = 0.48, P = 0.0034). Filter no-reflow (FNR) phenomenon was found in nine patients. The plaque volume was significantly greater (355 ± 133 mm3 vs. 199 ± 90 mm3, P = 0.0004), and the lipid ratio was significantly higher (29.3 ± 4.3% vs. 26.1 ± 4.3 P = 0.045) in the FNR group compared with the non-FNR group. Multivariate logistic regression analysis showed that the plaque volume was an independent predictor of FNR phenomenon. Although tissue characterization of IB-IVUS may provide additional information for distal embolization, plaque volume is the only significant predictor of distal embolization during PCI.
The major mechanism underlying the early recurrence of atrial fibrillation (AF) after ablation is mainly reconnection of the isolated pulmonary vein (PV); however, the mechanism responsible for very late recurrence (VLR) has not been fully elucidated. The purpose of the present study was to investigate the mechanism underlying VLR. The study population included 150 consecutive patients with AF who underwent a second session of catheter ablation because of recurrence. We divided them into 2 groups according to the point of initial AF recurrence: the late recurrence group (LR group, initial recurrence 3 to 12 months after ablation, n = 124) and the VLR group (initial recurrence >12 months after ablation, n = 26). We identified PVs with ectopic foci (trigger PVs) in the first procedure and checked their electrical reconnection in the second procedure. The prevalence of PV reconnection and trigger PV reconnection were significantly lower in the VLR group than in LR group (LR vs VLR, 90% vs 69% and 48% vs 27%, p = 0.007 and p = 0.045, respectively). In the VLR group, left ventricular systolic and diastolic function were significantly worse than in the LR group, and more patients in the VLR group required non-PV trigger ablation in the second session than did those in the LR group (30% vs 54%, p = 0.034). In conclusion, electrical PV reconnection contributed less to VLR than to LR. Progression of the AF substrate might be an important mechanism responsible for VLR.
Aims: Diastolic late mitral annular velocity (a') measured by transthoracic echocardiography (TTE) is reported to represent left atrial (LA) pump function and the severity of LA remodelling. The purpose of this study is to investigate the association between a' and LA blood stasis in patients with non-valvular paroxysmal atrial fibrillation. Methods and results: We enrolled 138 consecutive patients with non-valvular paroxysmal atrial fibrillation who had spontaneous sinus rhythm at the time of echocardiography. Using TTE, a' was determined as an average of tissue Doppler velocities measured at septal and lateral mitral annuli. Transoesophageal echocardiography was also performed on the same day as TTE, and spontaneous echo contrast (SEC) and LA appendage flow velocity were examined. Spontaneous echo contrast was observed in 21 (15%) patients. Patients in the lowest quartile of a' (≤6.4 cm/s) demonstrated SEC more frequently (44 vs. 6%, P < 0.0001) and had lower LA appendage flow velocity (39 ± 13 vs. 53 ± 16 cm/s, P < 0.0001) than those in the other quartiles. Receiver-operating characteristic curve analysis showed that the best cut-off value of a' was 7.0 cm/s for the prediction of SEC with a sensitivity of 80%, specificity of 81%, and predictive accuracy of 80%. Multivariate analysis revealed that decreased a' (OR = 0.61, P = 0.0026) was independently associated with SEC. Conclusion: Decreased a' may be a useful parameter for the estimation of LA blood stasis in patients with paroxysmal atrial fibrillation.
AimsIn patients with paroxysmal atrial fibrillation (AF), the P-wave signal-averaged electrocardiogram often demonstrates a low-amplitude potential at the terminal part of filtered P-wave (atrial late potential: ALP), which would originate from delayed pulmonary vein (PV) potentials. The aim of this study was to investigate the impact of PV isolation on P-wave morphology, and explore the association between ALP and AF recurrence after ablation.Methods and resultsWe enrolled 88 consecutive paroxysmal AF patients scheduled for ablation. The signal-averaged electrocardiogram was obtained at baseline and 1 day after ablation. An ALP was defined as a P-wave duration of ≥130 ms and a root-mean-squared voltage of the terminal 20 ms of ≤2.0 μV. A pre-procedural ALP was found in 37 (42%) patients and a post-procedural ALP was found in 26 (30%) patients. We completed PV isolation in all patients and followed them for 16 ± 4 months. The AF recurrence rate was 30% (26 patients) and was similar between patients with and without pre-procedural ALP (27 vs. 31%, respectively, P = 0.66); however, AF recurrence was significantly higher in patients with than without post-procedural ALP (54 vs. 19%, respectively, P = 0.001). In multivariate logistic regression analysis, post-procedural ALP was independently associated with AF recurrence (odds ratio = 4.22, 95% confidence interval = 1.52 - 11.7).Conclusion Pulmonary vein isolation can modify ALP in a substantial number of patients with paroxysmal AF. Post-procedural ALP is associated with increased risk of future AF recurrence.
Background: Concealed sick sinus syndrome may become manifest after restoration of sinus rhythm by ablation in patients with long-standing persistent atrial fibrillation (AF). The purpose of this study was to investigate the association between the preprocedural ventricular rate during AF and sinus node function in patients with long-standing persistent AF. Methods: Consecutive patients (n = 102) who underwent ablation for long-standing persistent AF were enrolled. We measured the ventricular rate during AF before ablation in the absence of antiarrhythmic drugs. Sinus node function was assessed by electrophysiological study and serial Holter recordings after ablation. Results: Patients in the lowest quartile of ventricular rate during AF had longer corrected sinus node recovery time (1.06 ± 1.39 seconds) than those in the other quartiles (0.54 ± 0.31 seconds; P = 0.006) and lower mean heart rate on 24-hour Holter recording 3 months after ablation (68 ± 9 beats/min vs 75 ± 10 beats/min, P = 0.01). During a mean follow-up of 23 ± 10 months, sick sinus syndrome necessitating permanent pacemaker implantation developed in five (5%) patients, and multivariate analysis revealed that a low ventricular rate during AF rate was an independent risk factor for sick sinus syndrome (odds ratio = 0.90 for a 1 beat/min increase in AF rate, P = 0.04). Conclusions: A low preprocedural ventricular rate during AF indicates the existence of sinus node dysfunction after restoration of sinus rhythm by ablation in patients with long-standing persistent AF.
Background and purpose: Percutaneous cardiopulmonary support (PCPS) is useful in the rescue of patients who have experienced severe cardiogenic shock. We investigated the predictive factors of survival among patients with cardiogenic shock requiring PCPS. Methods and subjects: We enrolled 29 patients (21 men and 8 women, 73 ± 10 years old) with circulatory collapse complicating acute myocardial infarction (AMI) requiring PCPS. Fifteen patients could be weaned from PCPS and survived for more than 1 month (group A), while the other 14 patients could not (group B). We investigated the initial PCPS settings, and performed the appropriate laboratory tests. Hemodynamic data and arterial base excess (BE) values were recorded throughout the PCPS treatment. Results: There was no difference in the laboratory test results or the left ventricular ejection fraction between the groups at the start of PCPS. PCPS flow (l/min) was significantly lower in group A than in group B at the 24th hour of PCPS (2.26 ± 0.36 and 2.54 ± 0.41, respectively). There were no differences in blood pressure between the groups. During the 24-h period prior to the end of PCPS, BE remained almost normal in group A. In group B, BE decreased continuously throughout the same period. BE values were significantly lower compared to those obtained in group A 12h prior to the end of PCPS. Conclusions: A reduction in PCPS flow without hemodynamic collapse may allow for successful weaning from PCPS. BE may be a potent factor in determining when to terminate PCPS.
Background: Atrial ibrillation (AF) has been reported to cause left atrial dilatation with dilatation of mitral annulus (MA) which is associated with functional mitral regurgitation (MR). The impact of catheter ablation (CA) for AF on MR remains unknown.
Estimation of left atrial (LA) pump function is important for the management of cardiac patients. The purpose of this study is to elucidate the role of mitral annular late diastolic velocity (A') determined by transthoracic echocardiography as a parameter to predict LA pump function. One hundred and four consecutive patients that were scheduled for paroxysmal atrial fibrillation (AF) ablation, in whom both multi-detector computed tomography (MDCT) and echocardiography during sinus rhythm prior to ablation were performed, were enrolled in this study. To determine the echocardiographic parameters that most accurately represent LA pump function, the relationship between LA emptying fraction (LAEF) obtained by MDCT and echocardiographic parameters including A' were examined. A' was the only echocardiographic parameter that was significantly correlated with LAEF (r=0.59, P<0.0001). Receiver-operating characteristic curve analysis showed that when impaired LA booster pump performance was defined as an LAEF <30%, an A' cutoff value of 7.4 cm/s had a sensitivity of 93%, specificity of 81%, predictive accuracy of 83%, positive predictive value of 43% and a negative predictive value of 99%. A' is a simple, non-invasive and reliable method to estimate LA pump function in patients with paroxysmal AF.
Background: In recent years, we attained higher procedural success in percutaneous coronary interventions (PCI) for chronic total occlusions (CTO) due to development of devices and techniques. Therefore we have established Retrograde Summit to investigate the current status in Japan and promote the improvement of initial success in CTO-PCI. We retrospectively collected retrograde procedural data of CTO-PCI performed in 2010 and compared it with that of in 2009 to see the change of procedural trend and clinical results.
Microembolization during percutaneous coronary intervention (PCI) causes minor myocardial injury, and a Doppler guidewire can detect embolic particles as high-intensity transient signals (HITS). The present study investigated the effect of microembolization during PCI on regional wall motion using a Doppler guidewire and myocardial strain analysis. We performed PCI to the left anterior descending coronary artery in 25 patients (18 men and 7 women, 68 ± 8 years old) with stable angina pectoris. Coronary flow spectrums were obtained with a Doppler guidewire to count the total number of HITS throughout the PCI procedures. On the days before and after PCI, we recorded echocardiography and measured the longitudinal peak systolic strain, peak strain rate, and early diastolic strain rate in the left anterior descending territory using a 2-dimensional speckle tracking method. PCI was successfully performed, and 10 ± 6 HITS (range 0 to 22, median 9) were recognized during PCI. The echocardiographic study showed no visible wall motion abnormalities in the left anterior descending territory either after or before PCI. In cases in which the total number of HITS was ≥10, the peak systolic strain, peak strain rate, and early diastolic strain rate worsened on the day after PCI compared with those on the day before PCI (p <0.01). The rates of change in peak systolic strain and early diastolic strain rate, defined as the ratios of those parameters after PCI to those before PCI, had modest to strong inverse correlations with the total number of HITS (R(2) = 0.35 and R(2) = 0.46, respectively). In conclusion, periprocedural microembolization during PCI reduces subclinical cardiac function in patients with stable angina pectoris.
The effect of atrial fibrillation (AF) ablation on left atrial (LA) function has not been sufficiently determined. We enrolled 115 consecutive patients with paroxysmal or persistent AF that underwent AF ablation. Multidetector computed tomography was performed in sinus rhythm before and 3 months after ablation to evaluate LA volume (LAV) and function. Estimates of maximum and minimum LAV were used to calculate LA emptying fraction (LAEF) ([maximum-minimum LAV]/maximum LAV × 100). AF ablation significantly decreased maximum LAV (59.0 ± 20.4 to 53.3 ± 16.7 cm(3) , P = 0.001), and maintained LAEF (44.5 ± 13.1% to 43.7 ± 10.9%, P = 0.49). The larger the baseline maximum LAV, the greater the decrease in LAV after ablation, and a smaller baseline LAEF was associated with a larger recovery of LAEF after ablation (regression coefficient =-0.45 and -0.56, respectively, P < 0.0001). Multivariable analyses revealed that an impaired baseline LAEF was an independent predictor of an improvement in LA function (an increase in LAEF of >10%; odds ratio [OR] = 0.88, P < 0.0001), while an older age and preserved baseline LAEF were independently associated with a deterioration of LA function (a decrease in LAEF of >10%; OR = 1.06, P = 0.03; and OR = 1.10, P = 0.0001). AF ablation appears to have a beneficial effect on LA function in patients with impaired LA function at baseline. However, it may reduce LA function in patients with an older age and preserved baseline LAEF.
Background: In the treatment of bifurcation lesions, routine stenting of both branches has thus far failed to demonstrate a clear clinical advantage over a provisional one-stent strategy. On the other hand, large scale data evaluating different stent types for clinical outcomes after one-stent treatment with final kissing inflation (FKI) of bifurcation lesions is also limited. This prospective study evaluated the clinical and angiographic outcomes of paclitaxel-eluting stents (PES) vs. sirolimus-eluting stents (SES) in single crossover main branch stenting followed by FKI in patients with bifurcation lesions. Methods: We randomized 800 patients with single bifurcation lesions to PES (n=400) and SES (n=400) groups. Results: Crossover rates to the two-stent strategy were low in both groups (PES 1.5%, SES 2.8%; p=0.23). At 1 year, there was no significant difference in the primary endpoint of this study, target lesion revascularization rate (PES 3.8%, SES 3.2%, hazard ratio 0.83; 95% confidence interval 0.39 to 1.76; p=0.62). Stent thrombosis occurred in only 1 case in the SES group after 282 days. At 9 months, a total of 593 patients underwent quantitative coronary measurement. The main branch restenosis rate in the PES group was significantly higher than that of the SES group (PES 12.2%, SES 5.5%; p=0.004), however both groups exhibited similar high side branch restenosis rates (PES 17.2%, SES 19.3%; p=0.6). Conclusions: In patients with bifurcation lesions, a single stent strategy using PES and SES with FKI indicated similar 1 year clinical outcomes and safety profiles.
We investigated the possibility that a frequent trigger action might play a role in the development of persistent atrial fibrillation (PeAF) and the presence of a substrate. In 263 consecutive patients who underwent catheter ablation (CA) for PeAF, electric cardioversion was performed at the beginning of the procedure to determine the presence or absence of an immediate recurrence of AF (IRAF). We defined an IRAF as a reproducible AF recurrence within 90 s after restoration of sinus rhythm by electric cardioversion. We performed a mean±SD of 1.3±0.5 sessions of CA, including pulmonary vein isolation and ablation of the premature atrial contractions that triggered the IRAF (IRAF triggers), and observed the patients for 17 (10-27) months. An IRAF was observed in 70 patients (27%), but we could not ablate the IRAF triggers in 16 (23%) of these IRAF patients. The recurrence rate of PeAF was higher in patients with an unsuccessful IRAF trigger ablation than in those with successful IRAF trigger ablation (63% versus 11%; P<0.001). A multivariable analysis also revealed that an unsuccessful IRAF trigger ablation was 1 of the independent predictors of recurrent PeAF (odds ratio, 10.9; 95% CI, 3.4-36.7). In the PeAF patients with an IRAF, successful elimination of the IRAF triggers, in addition to pulmonary vein isolation, resulted in a successful CA. These results imply that such triggers play a major role in the AF persistence in these PeAF patients.
We evaluated the predictive factors for recurrent restenosis lesions treated on two previous occasions with sirolimus-eluting stents (SES). Angiography data related to recurrent SES restenosis have not been reported. Binary restenosis was observed in 66 patients with 78 lesions from a total of 1,393 patients with 1,965 lesions who received follow-up angiography after SES implantation. We enrolled 55 patients with 67 lesions who underwent revascularization using another SES with a second follow-up coronary angiography. These restenotic lesions were divided into two groups based on the presence or absence of recurrent restenosis: no recurrent restenosis group (n = 56) and recurrent restenosis group (n = 11). The coronary angiography data during first and second SES implantation were compared between the groups. Minimal lumen diameter (MLD) was smaller before first and second percutaneous coronary interventions (PCI) with SES implantation in the recurrent restenotic group compared with no recurrent restenosis group (first PCI, 0.28 ± 0.19 mm vs. 0.54 ± 0.42 mm, P = 0.040; second PCI, 0.44 ± 0.36 mm vs. 0.69 ± 0.39 mm, P = 0.036, respectively). Acute stent recoil after second SES implantation was significantly greater in the recurrent restenosis group compared with no recurrent restenosis group (0.08 ± 0.17 mm vs. 0.20 ± 0.22 mm, P = 0.049, respectively). Multivariate analysis showed preprocedural MLD at first PCI and acute stent recoil at second PCI as independent predictors of recurrent restenosis. Preprocedural smaller MLD at first PCI and acute stent recoil at second PCI are predictors of recurrent restenosis treated on two previous occasions with SES.
It has been reported that an inflammatory process is involved in the development of atrial fibrillation (AF). In this study, we examined the hypothesis that a pre-existent inflammatory response may enhance the recurrence of AF after catheter ablation (CA). A total of 257 consecutive AF patients undergoing CA were enrolled in this study. The C-reactive protein was assessed by a high-sensitive radio-immunoassay 1 day before the procedure. Of the clinical characteristics, an advanced age, structural heart disease, and the left atrial (LA) diameter were significantly increased when the C-reactive protein level was elevated. Atrial fibrillation occurrences were significantly increased when the C-reactive protein level was elevated. A multivariate analysis demonstrated that an elevated C-reactive protein level [hazard ratio (95% CI); 2.23 (1.04-4.35)], the LA diameter [1.26 (1.10-1.66)], and persistent AF duration [2.13 (1.13-3.79)] were independent factors related to the recurrence of AF after CA. In the procedural findings, burst-inducible AF after pulmonary vein (PV) isolation was significantly increased, and the incidence of AF from the PVs was significantly lower when the C-reactive protein level was elevated. An elevated C-reactive protein level was associated with atrial structural and electrical remodelling maintaining AF, and the increased re-entrant atrial substrate might increase the recurrence of AF after the CA procedure.
Terumo intravascular ultrasound (IVUS) ViewIT facilitates IVUS-guided wiring in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) due to its low profile and surface coating. In PCI for CTO, the first guidewire is sometimes inserted into the subintimal space, and observation by IVUS through the first guidewire in the subintima can allow the second guidewire to be led visually into the true lumen. We describe a case of CTO in which ViewIT was inserted into the subintimal space of the CTO lesion and scanning from the coronary ostium to the CTO subintimal space allowed the second guidewire to be led into the true lumen.
The presence of multiple arrhythmogenic sources may be associated with the perpetuation of atrial fibrillation (AF). In this study, we investigated the hypothesis that multiple foci might be involved in the development of AF persistency. Two hundred fourteen consecutive patients with AF undergoing catheter ablation were enrolled in this study. The location of the arrhythmogenic foci was determined using simultaneous recordings from multipolar catheters before and after pulmonary vein isolation during an isoproterenol administration. We detected 500 arrhythmogenic foci (263 foci as AF initiators, and 237 foci as non-AF initiators). High-dose isoproterenol infusions (ranging from 2 to 20 microg/min) revealed potential arrhythmogenic foci, especially non-pulmonary vein foci (55%). Persistent AF was more highly associated with an incidence of multiple (>2) foci than paroxysmal AF (88% versus 65%, P=0.002), and a multivariate analysis demonstrated that multiple foci (>2) were an independent contributing factor for persistent AF (odds ratio; 95% confidence interval, 4.69; 1.82 to 12.09, P<0.001). In paroxysmal AF, the number of foci was higher in patients with long-term AF (>24 hours) than in those with short-lasting AF (2.64+/-0.14 versus 1.77+/-0.16, P=0.001). In the persistent AF group, the patients with short-lasting AF (<12 months) had a greater number of foci than did those with long-term AF (>12 months) (3.62+/-0.15 versus 1.92+/-0.16, P=0.04). Multiple foci were likely to be involved in the development of persistent AF. However, if AF persisted for >12 months, they may not have had a significant effect on the AF perpetuation.
We have occasionally encountered restenosis due to the crushing of drug-eluting stents (DES) implanted in severely calcified lesions. We aimed to establish the role of rotational atherectomy (RA) in its treatment. At first, we conducted an experimental study and found that the size of the metallic particles generated during RA of stent struts was 5.6 +/- 3.6 mum. We performed RA on the restenosis of the sirolimus-eluting stents implanted in the severely calcified lesions of a 66-year-old male who had received hemodialysis for 13 years. He had restenosis in the proximal and mid-segments of the right coronary artery, and intravascular ultrasound images documented that these stents were crushed by calcified plaque behind them. RA ablated both crushed stent struts and the calcified lesions behind them, and there was no hemodynamic derangement during the procedure. Maximum dilatation of the lesions was achieved with balloon angioplasty, followed by stent implantation. RA is an effective strategy to treat restenotic lesions resulting from the crushing of DES in severely calcified lesions.
This study sought to investigate the timing and amount of embolic particles generation during the percutaneous coronary intervention (PCI) procedure and studied the relationship between embolic burden and coronary blood flow and myocardial damage. Distal embolization is a major complication of PCI. The Doppler guidewire (DGW) can detect the embolic particles as high-intensity transient signals (HITS) during the PCI procedure. We prospectively studied 37 patients with acute myocardial infarction (MI). Under monitoring with the DGW, we performed first and second balloon angioplasty, followed by stenting and post-high-pressure dilatation. Left ventricular ejection fraction (LVEF) (%) and regional wall motion (RWM) (standard deviation/chord) were measured on days 1 and 22. The HITS were detected in 35 of 37 patients. The number of HITS was the greatest after stenting (16 +/- 18) followed by first balloon inflation (5 +/- 4). There was a significant correlation between the total number of HITS and the corrected Thrombolysis In Myocardial Infarction frame count (r = 0.52, p = 0.003) and a significant weak inverse correlation between the total number of HITS and changes in LVEF and RWM (r = 0.37, p = 0.03 and r = 0.35, p = 0.04, respectively). Distal embolization is common during PCI in patients with acute MI, and the majority of HITS were observed after stenting. An increase in the total number of HITS is associated with reduced coronary blood flow, and is weakly associated with poor recovery of left ventricular function.
Aims: We have sometimes encountered difficulty in stent positioning, and managed to achieve optimal positioning of the stent by luck when there was extensive movement of the stent delivery system in association with the cardiac cycle. We assessed the safety and efficacy of rapid ventricular pacing in order to achieve precise positioning of the stent in this percutaneous coronary intervention (PCI) situation.Methods and results: Among 363 patients who underwent PCI, difficulty in positioning of the stent was encountered in 7 consecutive patients due to extensive movement of the stent delivery system. We applied rapid ventricular pacing in these 7 patients. We measured the length of motion of the stent delivery system relative to the coronary artery and systolic blood pressure before and under rapid ventricular pacing at a rate of 160 min-1. The extent of motion was markedly reduced by rapid ventricular pacing (7.3+/-2.6 mm to 1.7+/-0.6 mm; p<0.001). Systolic blood pressure was decreased slightly by rapid ventricular pacing (116+/-15 mmHg to 90+/-7 mmHg; p=0.002), but there were no cases of haemodynamic degeneration or ventricular arrhythmia. Conclusions: Rapid ventricular pacing is a safe and promising option for precise stent positioning, when movement of the stent delivery system prevents precise deployment.
Angiographic no-reflow occurs occasionally during percutaneous coronary intervention in patients with acute myocardial infarction. Recently, we reported that coronary embolic particles can be detected as high-intensity transient signals with the Doppler guidewire. In the present study, the Doppler guidewire revealed that embolization of a cluster of embolic particles liberated by balloon inflation was responsible for angiographic no-reflow.
We detected embolic particles liberated from plaque during percutaneous coronary intervention (PCI) as high-intensity transient signals (HITS) with a Doppler guidewire and studied their impact on coronary flow dynamics and the myocardium in patients with stable angina pectoris. These embolic particles during PCI may cause myocardial injury. However, this was difficult to confirm because it was impossible to detect embolic particles. We performed balloon angioplasty followed by stenting in 31 patients while monitoring coronary flow velocity. After PCI, we measured average peak velocity at baseline and after infusion of adenosine 5'-triphosphate to calculate coronary flow velocity reserve (CFVR) and coronary resistance index (CRI). In patients with PCI to the left coronary artery (n = 21), we calculated relative CFVR as the ratio of CFVR in the target vessel to that in the reference vessel. We measured cardiac troponin T (cTnT) the day after PCI. HITS were detected in 27 (87%) of 31 patients and the majority were observed after stenting. The total number of HITS was correlated with CRI (r = 0.36, P = 0.049) or relative CFVR (r = 0.65, P = 0.0036) but not with CFVR (r = 0.048, P = 0.82). Thirteen patients showed elevated cTnT (range, 0.05-0.31 ng/ml) and the total number of HITS was greater in those with elevated cTnT than in those without elevated cTnT (24 +/- 9 vs. 10 +/- 7, P = 0.0007). Embolic particles are frequently observed during PCI to stable plaque and the majority are liberated after stenting. There appears to be a quantitative relationship between amounts of HITS and coronary microvessel dysfunction and minor myocardial injury.
Atrial fibrillation (AF) may originate from catecholamine-sensitive vein of Marshall (VOM) or its ligament in addition to pulmonary veins (PVs). The anatomy of VOM and its relation to arrhythmogenic foci in the left atrium are unknown. We studied the anatomy of VOM and its relation to foci in patients with AF. The study population consisted of 100 patients with AF (mean age, 62 years; chronic AF, n = 15). AF sources were determined at baseline and after isoproterenol administration without sedation. VOM was identified by balloon-occluded coronary sinus (CS) angiography. We determined its anatomy in relation to left PVs. VOM was visualized in 73 patients (73%). Ninety-seven patients had 269 arrhythmogenic foci (PV, n = 77; non-PV, n = 48). Non-PV foci included left atrial posterior wall (24, 9%), left lateral area (12, 4.5%), roof (6, 2.2%), superior vena cava (28, 10.4%), crista terminalis (8, 3.0%), CS (10, 3.7%), and others (10, 3.7%). The incidence of PV foci in the left superior PV (LSPV) was significantly higher in patients with well-developed VOM than in those without (66% vs 42%, P < 0.05). Twenty-eight patients had 30 non-PV foci around the LSPV ostium. We successfully ablated the non-PV foci at the distal end of VOM in 11 patients. The ends of the VOM branches were good markers to search for non-PV foci. Seven of 11 (64%) patients with successful ablation of non-PV foci were free from arrhythmia, whereas only 6 of 17 (35%) were free from arrhythmia in those with residual non-PV foci. To determine VOM anatomy is important to identify non-PV foci around the ends of VOM.
The no reflow phenomenon and left ventricular (LV) diastolic dysfunction are surrogate markers of poor outcomes in patients with myocardial infarction (MI). We studied the relationship between contrast perfusion defects and restrictive filling patterns for predicting prognosis after MI. Mitral inflow velocity and myocardial contrast perfusion were studied 2 weeks after reperfusion in 226 consecutive patients with acute MI. The cohort was divided into two groups according to the number of perfusion defect segments (PD); large-PD and small-PD. Mitral inflow was classified into two categories according to deceleration time; non-restrictive and restrictive. The patients were divided into 4 groups (small-PD/non-restrictive, n = 124; small-PD/restrictive, n = 29; large-PD/non-restrictive, n = 50; large-PD/restrictive, n = 23). LV end-diastolic volume index was the greatest and cardiac event rate was the highest in large-PD/restrictive, followed by large- PD/non-restrictive, small-PD/restrictive, and by small- PD/non-restrictive (81 +/- 19 vs. 74 +/- 17 vs. 66 +/- 19 vs. 59 +/- 15 ml/m2, events: 61 % vs. 16% vs. 14% vs. 8 %). Multivariate analysis revealed the large-PD is the most powerful predictive factor related to cardiac events (odds ratio = 5.5, P = 0.004) followed by the restrictive filing pattern (4.3, P = 0.005). Co-existence of large-PD and restrictive filling is a strong predictor of adverse outcomes in the patients with MI.
The relation between changes in blood pressure and changes in autonomic activity over a very short period of time has not been reported thus far. To examine this relation, we here introduced a new method of power spectrum analysis with wavelet transformation, which has very fine time resolution and is able to assess changes in autonomic activity quantitatively even during movement. Our subjects were 15 hypertensive and 17 normotensive subjects. A head-up tilt test was performed in all subjects, and during the test, electrocardiogram and blood pressure were recorded continuously. The power spectrums for both parameters were calculated simultaneously every 5 s using wavelet transformation. The high frequency of the RR interval of the electrocardiogram (RR-HF) and low frequency of systolic blood pressure (SBP-LF) were defined and calculated as markers of parasympathetic and alpha-1 receptor blocker, bunazosin-sensitive sympathetic activity, respectively. Focusing on the changes for 2 min immediately after head-up tilting, it was found that the changes in SBP-LF and RR-HF were significantly delayed, by at least 40 s, in hypertensives compared with normotensives and also in elderly compared with non-elderly subjects. Multiple regression analysis demonstrated that the instantaneous change in RR-HF was the most important confounding factor for a fall in blood pressure immediately after head-up tilting. In conclusion, real-time changes in autonomic activity calculated by wavelet transformation may provide sensitive and useful information about acute changes in cardiovascular regulation, such as delayed reaction of the autonomic regulation after head-up tilting, that may be major causes of the blood pressure fall in hypertensive and elderly subjects.
High-resolution real-time 3-dimensional echocardiography (RT3DE) allows observation of the left ventricular endocardial surface in vivo. This study was performed to characterize the endocardial surface structure and its contractile function in the myocardial infarction (MI) zone in relation to the healing stage. RT3DE was performed in 90 subjects: 10 normal subjects, 50 patients with Q-wave MI 2 weeks after onset (acute MI), and 30 patients >2 months after onset (healed MI). Recordings of the left ventricular endocardial surface allowed observation of the endocardial structure in 76 patients (84%) from the apical window. The endocardial surface of normal myocardium has rough muscle folds that shrink during systole, implying endocardial contraction. In acute MI, the endocardial surface had lost systolic contraction, but appeared as normal surface structure and showed normal acoustic intensity. The endocardial surface of healed MI showed loss of systolic contraction, disappearance of folds (smooth surface), and high acoustic intensity. The frequencies of smooth surface and highest acoustic intensity were significantly higher in healed MI than acute MI (72% vs 32%, 68% vs 37%, p <0.05, respectively). Loss of systolic endocardial contraction was a common finding of Q-wave MI irrespective of the healing stage, and we could roughly estimate the size of the MI from the spatial extent of the noncontractile zone with reasonable reproducibility (r = 0.90, p <0.001). In conclusion, RT3DE is a new modality that allows observation of the structure and contraction of the endocardial surface of the left ventricular wall. We can make rough estimation of the size of the MI and its healing stage from endocardial observation with RT3DE.
... Grade 2 refers to opacification of the entire artery distal to the obstruction point, however the flow is slower than normal, and grade 3 refers to normal coronary flow. 13 The CHA2DS2-VASc score was the sum of 1 point each for the presence of congestive heart failure, hypertension, diabetes mellitus, age of 65 to 74 years, female sex, and vascular diseases (history of MI, peripheral arterial disease, or complex aortic plaques) and 2 points for age ≥ 75 years and a history of stroke or transient ischemic attack (TIA). 14 Congestive heart failure, hypertension, diabetes mellitus and hyperlipidemia was diagnosed based on patient's past medical history. ...
... AngII formation was shown to be higher in human atheroscle- rotic and aneurysmal lesions, compared to normal aortas [27,28] (Fig. 2). ACE is thought to be the major AngII-generating enzyme in the intima of both normal and atherosclerotic human vessels . In healthy carotid human arteries, ACE protein was found to be restricted to both luminal and vasa vasorum ECs  (Fig. 2). ...
... To further improve the overall procedural success rate, it is important to achieve success with an antegrade approach in cases where a retrograde approach is difficult. For CTO treatment, it is necessary for the operator to learn advanced techniques , such as IVUS-guided wiring . Use of a BridgePoint device is necessary, although it was approved in Japan for this study period. ...
... To overcome this deficit, in the present study we have used a different method of time– frequency domain analysis. The discrete wavelet transform has been shown by us (Postolache et al. 2003Postolache et al. , 2004 SilvaCarvalho et al. 2006; Ducla-Soares et al. 2006) and others (Mallat, 1998; Wiklund et al. 2002; Mainardi et al. 2002; van den Berg et al. 2005, Urbancic-Rovan et al. 2006 Moriguchi et al. 2006) to be applicable to cardiovascular signals. Wavelets are oscillating mathematical functions of short duration that separate a signal into its different component frequencies and then analyse each frequency with a resolution matched to its scale. ...
... However, there remains an apparent paucity of data concerning outcomes subsequent to R-ISR for DES. Thus we find R-ISR a clinical enigma and a challenge for the interventional cardiology field [15,16], and sought to elucidate its' clinical presentation, angio- graphic morphology, and outcomes. ...
... Akin to combining radionuclide imaging with computed tomography, many institutions are installing combined X-ray angiographic and MR imaging suites (Fig. 6). The advantages of each imaging technology for imaging the heart—the high temporal resolution of X-ray fluoroscopy and the high anatomical and functional detail of MRI—can be exploited [1,29,30]. Since the images from both modalities are intrinsically registered, the fusion of the two imaging modalities is simplified and can be more rapidly updated. X-ray fusion with MRI in such a suite has recently been used to use X-ray fluoros-copy to target transmyocardial iron-oxide labeled mesenchymal stem cells in infarcted swine to avoid thinned or non-viable myocardium . ...
Reference: Imaging of stem cells using MRI
...  Metal particles produced by the stent ablation maybe not able to potentiate the microvascular embolization, because the metal particle was smaller than the diameter of an erythrocyte.  In our case, the glycoprotein IIb/IIIa inhibitors were used following the recommendation and slow-flow did not arise. Despite more than 10 cases of stent ablation was reported, few of them proved that the metallic component of the stent was removed by ablation of RA. ...
... Lo mismo podría decirse del abordaje retró grado, que en nuestra serie resulta predictor de complicaciones y es otro de los factores modificables para aumentar la tasa de e ´ xito. No resulta predictor independiente de e ´ xito el uso de 2 caté teres (uno para inyecció n contralateral), lo que podría indicar que tan solo se emplea esta estrategia en los casos má s complejos y no en todos en los que puede resultar beneficiosa 20,21 ; esta misma explicació n puede darse al hecho de que la tasa de recanalizació n exitosa sea mayor en caso de la ICP sobre la arteria circunfleja, cuando en series previas ha resultado siempre menor  . De hecho, menos del 15% de los intentos se realizaron sobre dicha arteria, lo que señ ala que para un porcentaje no despreciable de pacientes que podrían beneficiarse de recanalizació n percutá nea mediante té cnicas específicas se estaría tomando el tratamiento mé dico como primera y u ´ nica opció n. ...
... Therefore, we could not conclude the benefit of PCPS over medical therapy or other mechanical assist devices. As a randomized trial of strategy would be quite difficult to perform and the sample size of our study was larger than that of previous studies,13,14,15 our data could provide more assistive information about clinical outcomes of AMI shock treatment. ...
... However, there are some situations in which it is difficult to advance the guide wire and microcatheter into the CTO lesion, even though the guide wire and microcatheter can pass through the collateral channel retrogradely . Although intravascular ultrasound (IVUS)-guided guidewire manipulation is often useful to cross the lesion  and solve retrograde CTO-PCI failure cases, this technique is usually complex because we need many devices and it requires many steps. ...