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Background: Very few data have been reported for ST-segment elevation myocardial infarction (STEMI) caused by unprotected left main coronary artery (ULMCA) occlusion, and very little is known about the results of this subgroup of patients who underwent primary percutaneous coronary intervention (PCI). The aim of this study was to determine the clinical features and outcomes of patients with STEMI who underwent primary PCI for acute ULMCA occlusion., Methods: From January 2000 to February 2014, 372 patients with STEMI caused by ULMCA acute occlusion (ULMCA-STEMI) who underwent primary PCI at one of two centers were enrolled. The 230 patients with non-ST-segment elevation MI (NSTEMI) caused by ULMCA lesion (ULMCA-NSTEMI) who underwent emergency PCI were designated the control group. The main indexes were the major adverse cardiac events (MACEs) in-hospital, at 1 month, and at 1 year., Results: Compared to the NSTEMI patients, the patients with STEMI had significantly higher rates of Killip class≥III (21.2% vs. 3.5%, χ 2 = 36.253, P < 0.001) and cardiac arrest (8.3% vs. 3.5%, χ 2 = 5.529, P = 0.019). For both groups, the proportions of one-year cardiac death in the patients with a post-procedure thrombolysis in myocardial infarction (TIMI) flow grade<3 were significantly higher than those in the patients with a TIMI flow grade of 3 (STEMI group: 51.7% [15/29] vs. 4.1% [14/343], P < 0.001; NSTEMI group: 33.3% [3/9] vs. 13.6% [3/221], P = 0.001; respectively]. Landmark analysis showed that the patients in STEMI group were associated with higher risks of MACE (16.7% vs. 9.1%, P = 0.009) and cardiac death (5.4% vs. 1.3%, P = 0.011) compared with NSTEMI patients at 1 month. Meanwhile, in patients with ULMCA, the landmark analysis for incidences of MACE and cardiac death was similar between the STEMI and NSTEMI (all P = 0.72) in the intervals of 1-12 months. However, patients who were diagnosed with STEMI or NSTEMI had no significant difference in reinfarction (all P > 0.05) and TVR (all P > 0.05) in the intervals of 0-1 month as well as 1 month to 1 year. The results of Cox regression analysis showed that the differences in the independent predictors for MACE included the variables of Killip class ≥ III and intra-aortic balloon pump support for the STEMI patients and the variables of previous MI, ULMCA distal bifurcation, and 2-stent for distal ULMCA lesions for the NSTEMI patients., Conclusions: Compared to the NSTEMI patients, the patients with STEMI and ULMCA lesions still remain at a much higher risk for adverse events at 1 year, especially on 1 month. If a successful PCI procedure is performed, the 1-year outcomes in those patients might improve., Competing Interests: There are no conflicts of interest

Objective: The objective was to delineate the current knowledge of fractional flow reserve (FFR) in terms of definition, features, clinical applications, and pitfalls of measurement of FFR., Data Sources: We searched database for primary studies published in English. The database of National Library of Medicine (NLM), MEDLINE, and PubMed up to July 2014 was used to conduct a search using the keyword term "FFR"., Study Selection: The articles about the definition, features, clinical application, and pitfalls of measurement of FFR were identified, retrieved, and reviewed., Results: Coronary pressure-derived FFR rapidly assesses the hemodynamic significance of individual coronary artery lesions and can readily be performed in the catheterization laboratory. The use of FFR has been shown to effectively guide coronary revascularization procedures leading to improved patient outcomes., Conclusions: FFR is a valuable tool to determine the functional significance of coronary stenosis. It combines physiological and anatomical information, and can be followed immediately by percutaneous coronary intervention (PCI) if necessary. The technique of FFR measurement can be performed easily, rapidly, and safely in the catheterization laboratory. By systematic use of FFR in dubious stenosis and multi-vessel disease, PCI can be made an even more effective and better treatment than it is currently. The current clinical evidence for FFR should encourage cardiologists to use this tool in the catheterization laboratory.

Background: Recent studies reported that percutaneous coronary intervention with stent implantation was safe and feasible for the treatment of left main coronary artery (LMCA) disease in select patients. However, it is unclear whether drug-eluting stents (DESs) have better outcomes in patients with LMCA disease compared with bare-metal stent (BMS) during long-term follow-up in Chinese populations., Methods: From a perspective multicenter registry, 1136 consecutive patients, who underwent BMS or DES implantation for unprotected LMCA stenosis, were divided into two groups: 1007 underwent DES implantation, and 129 underwent BMS implantation. The primary outcome was the rate of major adverse cardiac events (MACEs), including cardiovascular (CV) death, myocardial infarction (MI), and target lesion revascularization (TLR) at 5 years postimplantation., Results: Patients in the DES group were older and more likely to have hyperlipidemia and bifurcation lesions. They had smaller vessels and longer lesions than patients in the BMS group. In the adjusted cohort of patients, the DES group had significantly lower 5 years rates of MACE (19.4% vs. 31.8%, P = 0.022), CV death (7.0% vs. 14.7%, P = 0.045), and MI (5.4% vs. 12.4%, P = 0.049) than the BMS group. There were no significant differences in the rate of TLR (10.9% vs. 17.8%, P = 0.110) and stent thrombosis (4.7% vs. 3.9%, P = 0.758). The rates of MACE (80.6% vs. 68.2%, P = 0.023), CV death (93.0% vs. 85.3%, P = 0.045), TLR (84.5% vs. 72.1%, P = 0.014), and MI (89.9% vs. 80.6%, P = 0.029) free survival were significantly higher in the DES group than in the BMS group. When the propensity score was included as a covariate in the Cox model, the adjusted hazard ratios for the risk of CV death and MI were 0.41 (95% confidence interval [CI]: 0.21-0.63, P = 0.029) and 0.29 (95% CI: 0.08-0.92, P = 0.037), respectively., Conclusions: DES implantation was associated with more favorable clinical outcomes than BMS implantation for the treatment of LMCA disease even though there was no significant difference in the rate of TLR between the two groups.

Background: The double kissing (DK) crush technique is a modified version of the crush technique. It is specifically designed to increase the success rate of the final kissing balloon post-dilatation, but its efficacy and safety remain unclear., Methods: Data were obtained from the DKCRUSH-I trial, a prospective, randomized, multi-center study to evaluate safety and efficacy. Post-procedural and eight-month follow-up intravascular ultrasound (IVUS) analysis was available in 61 cases. Volumetric analysis using Simpson's method within the Taxus stent, and cross-sectional analysis at the five sites of the main vessel (MV) and three sites of the side branch (SB) were performed. Impact of the bifurcation angle on stent expansion at the carina was also evaluated., Results: Stent expansion in the SB ostium was significantly less in the classical crush group ((53.81 ± 13.51)%) than in the DK crush group ((72.27 ± 11.46)%) (P = 0.04). For the MV, the incidence of incomplete crush was 41.9% in the DK group and 70.0% in the classical group (P = 0.03). The percentage of neointimal area at the ostium had a tendency to be smaller in the DK group compared with the classical group ((16.4 ± 19.2)% vs. (22.8 ± 27.1)%, P = 0.06). The optimal threshold of post-procedural minimum stent area (MSA) to predict follow-up minimum lumen area (MLA) < 4.0 mm(2) at the SB ostium was 4.55 mm(2), yielding an area under the curve of 0.80 (95% confidence interval: 0.61 to 0.92)., Conclusion: Our data suggest that the DK crush technique is associated with improved quality of the final kissing balloon inflation (FKBI) and had smaller optimal cutoff value of post-procedural MSA at the SB ostium.

Background: Sirolimus-eluting stents (SES) are reported to be associated with reduced late lumen loss (LLL), resulting in less frequent restenosis when compared to bare-metal stent. The current study aimed to assess the difference in LLL between SES with biodegradable and with permanent polymer., Methods: From March 2010 to June 2011, 300 consecutive patients having only biodegradable polymers or permanent polymer SES for all diseased vessels were included. Serial quantitative coronary analysis was performed on both the "in-stent" and "segment" area, including the stented segment, as well as both five mm margins proximal and distal to the stent. The primary endpoint was the LLL defined as the minimal lumen diameter (MLD) post-stenting minus the MLD at nine-month after the indexed procedure., Results: LLL was comparable between the two stents. Importantly, LLL for the distal segment (median 0.05 mm, interquartile 0 to 0.09 mm) was less severe compared with in-stent (median 0.13 mm, interquartile 0.08 to 0.18 mm) and proximal segment LLL (median 0.12 mm, interquartile 0.06 to 0.14 mm, all P < 0.001). In general, the LLL was associated with the post-procedure MLD (b = 0.28, P = 0.002), hyperlipidemia (b = 0.14, P = 0.021), and calcified lesions (b = 0.58, P = 0.001). The R(2) and Radj of the multiple regression model were 0.651 and 0.625, respectively., Conclusions: SES with either biodegradable or permanent polymer had lower value of LLL. The small amount of LLL at the distal segment possibly contributed to the less distal edge stenosis.

Background: The correlation between angiographic or intravascular ultrasound (IVUS) variables and fractional flow reserve (FFR) in patients with single left anterior descending artery (LAD) lesion has not been studied. The current study aimed at determining the best cutoff value of angiographic and IVUS parameters for defining FFR < 0.80 in patients with LAD lesion., Methods: Quantitative coronary analysis, IVUS and FFR measurements were undergone in 169 patients with single LAD lesion. The best angiographic and IVUS cutoff value and their predictive value for FFR < 0.80 were compared using area under the receiver-operator characteristic curve (AUC) in overall patients or in subgroups stratified by lesion sites., Results: FFR < 0.80 was found in 99 lesions (58.6%). Minimal lumen area (MLA), and plaque burden (PB) were two predictors of FFR < 0.80. Lesion length had less value in predicting FFR < 0.80. The cutoff value of PB and MLA for FFR < 0.80 was 75.4% and 3.03 mm(2). MLA and PB had similar high diagnostic value for proximal (cutoff value 3.04 mm(2) and 76.5%) and distal LAD lesion (2.82 mm(2) and 80.6%). Combination of MLA (2.82 mm(2)) and PB (80.6%) had increased diagnostic value for distal LAD lesion., Conclusions: MLA and plaque burden had equivalent diagnostic value for FFR < 0.80 when lesion localized in LAD. The predictive value of combination of MLA and plaque burden for distal LAD lesion was strengthened.

Background: The difference in clinical outcome between paclitaxal-eluting stents (PES) and sirolimus-eluting stents with bio-degradable polymer (SES-BDP) for bifurcation lesions remains unclear. The present study aimed to investigate the one-year clinical outcome after DK crush stenting using PES (Taxus(TM)) vs. SES-BDP (Excel(TM)) from our database., Methods: A total of 275 patients (90 from the DKCRUSH-I and 185 from the DKCRUSH-II study) were studied. The primary endpoint was the occurrence of major adverse cardiac events (MACE) at 12 months; including cardiac death, myocardial infarction (MI), or target vessel revascularization (TVR). The rate of binary restenosis and stent thrombosis served as secondary endpoints., Results: At follow-up, minimal luminal diameter (MLD) in the Taxus group was (2.11 ± 0.66) mm, with resultant increased target lesion revascularization (TLR) 12.2% and TVR 14.4%, significantly different from the Excel group; (2.47 ± 0.56) mm, P < 0.001, 3.2%, P = 0.006, 4.9%, P = 0.019, respectively. As a result there was a significant difference in MACE between the Taxus (20.0%) and Excel (10.3%, P = 0.038) groups. Overall stent thrombosis was monitored in 11 patients (4.0%), with five in the Excel group (2.7%) and six in the Taxus group (6.7%). All stent thrombosis in the Excel group was classified as early, and all were defined as late in the Taxus group., Conclusion: The Excel stent had lower rate of stent thrombosis, TLR, TVR, and composite MACE at 12-month after an indexed stenting procedure, compared to the Taxus stent.

Background: Coronary endothelial shear stress (ESS) triggered the development of atherosclerosis. However, the effect of calcium channel antagonist on the distribution of ESS remained unclear., Methods: Twenty consecutive patients with acute coronary syndrome (ACS) 48 hours after maximal medication with single left anterior descending artery stenosis < 50% were studied. Nicardipine was intravenously injected at 1 µg/kg after a bolus of 10 mg in order to achieve mean blood pressure (MBP) reduced by 10% or more, or the heart rate increased by 10 - 15 beats/min. Hemodynamic variables and angiogram at baseline and during injection of nicardipine were recorded, respectively. Coronary artery 3-D reconstruction was used for the analysis of ESS., Results: Distal reference-vessel-diameter and minimal lumen diameter decreased significantly from (2.42 ± 0.41) mm and (1.47 ± 0.49) mm at baseline to (2.22 ± 0.35) mm and (1.35 ± 0.49) mm at maximal drug-dosage (P = 0.018 and 0.020, respectively). Nicardipine did not change blood velocity. Lowest mean shear stress at segments 2-mm distal to plaque increased significantly from (0.034 ± 0.519) Pa at baseline to (0.603 ± 0.728) Pa (P = 0.013) at peak effect of drug., Conclusions: Nicardipine was associated with the constriction of diseased vessel segment that adapted to the reduction of blood pressure, without dynamic change of blood velocity at each stage of whole cardiac cycle. Increased ESS value at segments distal to plaque reflected the cardioprotection by nicardipine (ChiCTR-TRC-10000964).

Background: Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) is associated with fewer unfavorable events. However, the hemodynamic change in FFR after different stenting approaches for bifurcation lesions is still not fully studied. The aim of this study was to analyze the hemodynamic changes in FFR after double kissing (DK) crush and provisional side branch (SB) stenting (PS) for true coronary bifurcation lesions., Methods: Seventy-five patients with true bifurcated lesions were randomly divided into DK (n = 38) and PS (n = 37) groups. Additional SB stenting in the PS group was required if there was any pinched SB ostium > 70% stenosis, or ≥ type B dissection, or TIMI flow < grade 3. FFR at hyperemia in the main vessel (MV) and SB was measured prior- and post-stenting, and at 8 months follow-up., Results: Baseline clinical, angiographic and lesion characteristics were matched well between the two groups, with the exception of the final kissing balloon inflation (FKBI, 100.0% in the DK vs. 83.8% in the PS group, P < 0.001). Baseline FFR was comparable between the DK and the PS groups, however, the acute gain and late loss of SB FFR at 8-month follow-up in the DK group were 0.18 ± 0.15 and -0.06 ± 0.11, compared to 0.12 ± 0.18 (P = 0.044) and -0.002 ± 0.07 (P = 0.037) in the PS group, respectively. MV FFR post-stenting > 0.94 was seen in about 40% of patients. There was no significant difference in the clinical events at 1-year follow-up between the two groups., Conclusions: DK crush was associated with improved acute gain and late loss of SB FFR. The lower rate of FFR > 0.94 after stenting underscored the further improvement of stenting quality.

Background: The predictive value of bifurcation angle (BA) for worse events after stenting bifurcation lesions remains to be unknown. The present study was to investigate the dynamic change of BA and clinical relevance for patients with coronary bifurcation lesions treated by drug-eluting stent (DES)., Methods: BA was calculated by 3-D quantitative coronary analysis from 347 patients in DKCRUSH-II study. Primary endpoint was the occurrence of composite major adverse cardiac events (MACE) at 12-month, including cardiac death, myocardial infarction (MI) and target vessel revascularization (TVR). Secondary end points were the rate of binary restenosis and stent thrombosis at 12-month., Results: Stenting was associated with the reduction of distal BA. The cut-off value of distal BA for predicting MACE was 60°. Distal BA in < 60° group had less reduction after stenting ((-1.96 ± 13.58)° vs. (-12.12 ± 23.58)°, P < 0.001); two-stent technique was associated with significant reduction of distal BA (Δ(-4.05 ± 14.20)°), compared to single stent group (Δ + 1.55 ± 11.73, P = 0.003); the target lesion revascularization (TLR), TVR and MACE rate was higher in one-stent group (16.5%, 19.0% and 21.5%), compared to two-stent group (3.8%, P = 0.002; 7.5%, P = 0.016; and 9.8%, P = 0.024), respectively. Among patients in ≥ 60° group, there were no significant differences in distal BA, stent thrombosis (ST), MI, MACE, death, TLR, TVR between one- and two-stent groups; after stenting procedure, there was only slight change of distal BA in left anterior descending (LAD)-left circumflex (LCX) subgroup (from (88.54 ± 21.33)° at baseline to (82.44 ± 31.72)° post-stenting), compared to either LAD-diagonal branch (Di), or LCX-obtuse marginal branch (OM), or RCA distal (RCAd) (all P < 0.001)., Conclusion: Two-stent technique was associated with significant reduction of distal BA. DK crush stenting had reduced rate of MACE in patients in < 60° group, compared to one-stent technique.

Background: The definitive treatment for myocardial ischemia is reperfusion. However, reperfusion injury has the potential to cause additional reversible and irreversible damage to the myocardium. One likely candidate for a cardioprotection is adenosine. The present study aimed at investigating the effect of intravenous adenosine on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI)., Methods: Patients with STEMI within 12 hours from the onset of symptoms were randomized by 1:1:1 ratio to receive either adenosine 50 µg×kg(-1)×min(-1) (low-dose group, n = 31), or 70 µg×kg(-1)×min(-1) (high-dose group, n = 32), or saline 1 ml/min (control group, n = 27) for three hours. Drugs were given to the patients immediately after the guide wire crossed the culprit lesion. Recurrence of no-reflow, TIMI flow grade (TFG) and TIMI myocardial perfusion grade (TMPG), and collateral circulation were recorded. The postoperative and preoperative ST segment elevation sum of 18-lead electrocardiogram (ECG) and their ratio (STsum-post/STsum-pre) were recorded, as well as the peak time and peak value of CK-MB enzyme. Serial cardiac echo and myocardial perfusion imaging were performed at 24 hours and 6 months post-stenting. The primary endpoint was left ventricular function, and infarct size. The secondary end-point was the occurrence of cardiac and non-cardiac death, non-fatal myocardial infarction, and heart failure., Results: A total of 90 STEMI patients were studied. No-reflow immediately after stent procedure was seen in 11 (35.5%) patients in the control group, significantly different from 6.3% in the low-dose group or 3.7% in the high-dose group (both P = 0.001). STsum-post/STsum-pre in the low-dose and high-dose groups was significantly different from the control group (low-dose group vs. control group, P = 0.003 and high-dose group vs. control group, P = 0.001), without a dose-dependent pattern (P = 0.238). The peak value of CK-MB enzyme was significantly reduced in the high-dose group compared to the control group (P = 0.024). Compared to the left ventricular ejection fraction (LVEF) in control group, LVEF in the low-dose group increased by 5.8% at 24 hours (P = 0.012) and by 10.9% at 6 months (P = 0.007), LVEF in the high-dose group increased by 9.5% at 24 hours (P = 0.001) and by 10.0% at 6 months (P = 0.001), respectively. Significant reduction of infarct size by 24.2% was detected in the high-dose group vs. low-dose or control groups (P = 0.008). There was no significant difference regarding secondary endpoints at 6 months among the treated groups. Cardiac function by NYHA classification in both the low-dose and the high-dose groups was improved significantly (P = 0.013, P = 0.016)., Conclusion: Intravenous adenosine administration might significantly reduce the recurrence of no-reflow, with resultant improved left ventricular systolic function. High-dose adenosine was further associated with significant reduction of infarct size.

Background: Fluid dynamic mechanisms attributed to coronary bifurcation lesions remain a subject of study. The present study aimed at investigating the hemodynamic change of wall shear stress (WSS) in patients with coronary bifurcation lesions treated by double kissing (DK) crush or one-stent with final kissing balloon inflation (FKBI)., Methods: Eighty-one patients with bifurcation lesions treated by stenting who had 3-D model reconstruction were studied. The bifurcation vessels were divided into main vessel (MV), main branch (MB), side branch (SB), and polygon of confluence (POC). MB and SB were classified by internal- and lateral-subsegments, respectively., Results: The baseline magnitude of WSS in proximal MV, POC-MV, POC-MB, POC-SB and MB-internal segments increased significantly, compared to MB-lateral, SB-internal and SB-lateral. DK crush had the potential of uniformly reducing WSS, turbulent index and the WSS gradient. The WSS value at the POC-SB and SB in the one-stent group remained higher. The turbulent index and WSS gradient between the POC-SB minus the SB-lateral had equal predictive values for in-stent restenosis (ISR)., Conclusion: Fluid dynamic results favor the use of DK crush over the one-stent technique.

Background: Stenting strategies and clinical outcomes of bifurcation lesions in a chronic total occlusion (CTO) vessel after successful recanalization remain to be unknown., Methods: Between January 2001 and December 2009, 195 (41.1%) patients with 254 (47.0%) bifurcation lesions in CTO vessels from a pool of 564 patients with 659 CTO lesions were included and divided into proximal (n = 134) and distal (n = 120) groups, according to the location of the bifurcation lesions. The primary endpoint was the occurrence of major adverse cardiac events (MACE) at the end of clinical follow-up, including cardiac death, myocardial infarction, or target vessel revascularization (TVR)., Results: Collaterals with Rentrop class 3 were seen more in distal group (100% and 68.3%), compared to proximal group (76.9% and 45.6%). Two-stent technique for proximal bifurcation lesions was used in 24.6%, significantly different from the distal group (6.7%, P < 0.001), without significant difference in composite MACE between proximal and distal groups, or between one- and two-stent subgroups in proximal group. The composite MACE after 1-year in complete revascularization subgroup was 17.9% relative to 29.6% in the incomplete revascularization group (P = 0.044). Stents in long false lumen in main vessel were mainly attributive to decreased TIMI grade flow, with resultant increased in-stent restenosis, total occlusion, TVR and coronary aneurysms. Imcomplete revasculzarization (HR 2.028, P = 0.049, 95%CI 1.002 - 4.105) and post-stenting TIMI flow (HR 6.122, P = 0.020, 95%CI 1.334 - 28.092) were two independent predictors of composite MACE at the 1-year follow-up., Conclusions: Two-stent was more used for proximal bifurcation lesions. No significant difference was observed in MACE between proximal and distal, or between one- and two-stent subgroups in the proximal group. Placement of a safety wire was critical for proximal bifurcation lesions. Complete revascularization was mandatory to improve clinical outcomes.

Background: The gender-based differences in adverse events after drug-eluting stent (DES) implantation between Chinese women and men have not been fully studied. The present study aimed to compare the 5-year clinical outcome after DES implantation in Chinese women and men., Methods: Chinese women (n = 298) and men (n = 698) with newly diagnosed de novo coronary lesions were studied after DES implantation. The primary endpoint was the occurrence of major adverse cardiac events (MACEs) over a 5-year follow-up, including myocardial infarction (MI), cardiac death, and target vessel revascularization (TVR). Propensity score matching (PSM) was used to compare the adjusted MACE rates between sexes., Results: Women differed in body habitus and had increased fasting cholesterol. Fewer women presented with MI, and they had better cardiac function with less complex disease. The unadjusted rate of MI at 3 years (2.1%) and 5 years (5.0%) and MACE (25.2%) at 5 years in men was significantly higher than that of women (0.3%, 1.0% and 17.8%, P = 0.050, P = 0.032, and P = 0.011, respectively). After PSM, the adjusted adverse events between sexes were similar. The stent thrombosis rate rapidly increased after 2 years in men., Conclusions: There were significant gender-based differences in baseline characteristics. Chinese men had equivalent outcomes to women after DES after adjustment by PSM. The increased rate of MI in men was attributed to an increased unadjusted rate of MACE.

Background: Frequent premature ventricular complexes from the right ventricular outflow tract (RVOT-PVCs) are associated with left ventricular dysfunction. This study adopted two-dimensional speckle tracking imaging to evaluate global and regional left ventricular myocardial function in patients with frequent RVOT-PVCs., Methods: This study included 30 patients with frequent RVOT-PVCs and 30 healthy subjects. Aortic systolic velocity-time integral (AoVTI) and myocardium strain in circumferential (CS), radial (RS) and longitudinal (LS) directions were evaluated by conventional echocardiography and speckle tracking imaging. All values of patients with RVOT-PVCs were recorded during sinus (PVC-S) and PVC beats (PVC-V)., Results: Significant differences were demonstrated in global CS, RS and LS between the control subjects and the PVC-V (CS: (17.46 ± 2.48)% vs. (11.52 ± 3.28)%, RS: (48.26 ± 10.20)% vs. (20.92 ± 9.78)%, LS: (19.89 ± 2.62)% vs. (11.79 ± 3.66)%, P < 0.01), and in segmental RS and LS of nearly all the left ventricular segments. Statistical differences in segmental CS between the PVC-V and the control subjects were only observed in anterior, anteroseptal and septal segments (only seen in anteroseptal and septal segments at apex). Furthermore, V/S AoVTI (AoVTI during the PVC beat divided by AoVTI during the sinus beat, then multiplied by 100%) correlated with coupling interval (r = 0.67, P < 0.001) and global strain (CS: r = 0.48, P = 0.007; RS: r = 0.65, P < 0.001; LS: r = 0.65, P < 0.001)., Conclusions: Frequent RVOT-PVCs can induce global and regional left ventricular systolic dysfunction. The reduction of hemodynamic parameters relates to the coupling interval and the global systolic function.

Background: Implantation of either bare metal stent (BMS) or drug-eluting stent (DES) has been used in every day practice for patients with unprotected left main stenosis (UPLMS). There are still a lack of data regarding the subsequent results of UPLMS in-stent restenosis (ISR). The present study aimed at determining the clinical outcome of UPLMS ISR patients after implantation of either BMS or DES., Methods: Patients with UPLMS ISR after stenting were included. The primary endpoint was the cumulative major adverse cardiac events (MACE), including cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR)., Results: UPLMS ISR rate was 14.8% (n = 73, 15.7% after BMS, 14.5% for DES) after average of (3.89 +/- 2.01) years (range from 1 to 10.5 years) follow-up. Angiographic follow-up between 6 - 8 months was available in 85.3%. Of these, repeat percutaneous coronary intervention (PCI) was used in 62 (84.9%) patients, with medicine only in 9 (12.4%) and coronary artery bypass graft (CABG) in 2 (2.7%). Most repeat PCI patients were with unstable angina (87.0%), and had decreased left ventricular ejection fraction ((42.58 +/- 5.12)%), fewer focal/ostial left circumflex branch (LCX) lesions, in relative to medicine only group. After (31.9 +/- 23.3) months, the MACE, MI, TVR and cardiac death were 31.5%, 1.4%, 24.1% and 8.2%, respectively. Definite and possible stent thrombosis occurred in 1 (1.4%) patient., Conclusions: Medical therapy for asymptomatic isolated ostial LCX was safe. Repeat PCI for UPLMS ISR was associated with acceptable early and short-term clinical outcome. Further study was needed to elucidate the role of CABG in treating UPLMS ISR.

Background: The safety of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions in remote hospitals without surgical facilities remains unknown. This study aimed to evaluate three-year outcomes after CTO for PCI in ten centers around China where no on-site coronary artery bypass grafting (CABG) support was available., Methods: A total of 152 patients from 10 Chinese hospitals without on-site surgical facilities were prospectively studied. Intra-procedural and in-hospital events were assessed. Angiographic follow-up was indexed eight months after the initial procedure. Clinical follow-up was extended to three years. The primary outcome was the rate of major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction and target-vessel revascularization (TVR)., Results: The incidence of CTO was 7.9% in patients who underwent PCI. Successful recanalization was achieved in 132 patients (86.8%). Compared with patients in the PCI success group, patients with PCI procedural failure had longer lesion lengths ((42.32 +/- 22.08) mm vs (27.61 +/- 22.85) mm, P = 0.023), a higher rate of perforation (25.0% vs 0, P = 0.014), and a greater need for pericardial puncture. There were significant differences in MACE in-hospital and at one year and three years between the failure (10.0%, 30.0% and 35.0%) and the success (3.0%, 12.1% and 14.4%) groups (P = 0.037, 0.034 and 0.040, respectively). These led to a significant decrease in the MACE-free survival rate at one and three years in the failure group, compared with the success group (P = 0.031 and 0.023, respectively). Stump was the only predictor of recanalization success (HR 0.158, 95% CI 0.041-0.612, P = 0.008), whereas procedural failure (OR 13.023, 95% CI 6.67-13.69, P = 0.002), incomplete revascularization (OR 9.71, 95% CI 2.93-5.59, P = 0.005), and total stent length (OR 6.02, 95% CI 1.55-11.93, P = 0.027) were three independent predictors of MACE., Conclusions: PCI for CTO was unsafe in remote hospitals without CABG facilities. Paying attention to coronary perforation is important for successful procedures.

Background: Stenting a bifurcation lesion is technically challenging. No study has reported the clinical outcome of a dedicated bifurcation stent in China. We aimed to analyze the safety and clinical outcome of a novel side branch ostial stent (BIGUARD) stent in treating coronary bifurcation lesions., Methods: Forty-seven patients were enrolled in this first-in-man study, with 61.7% true bifurcation lesions (0,1,1 and 1,1,1) and 26.7% diabetes. A two-stent technique was used in 27.6% of the patients, and 64.7% of patients crossed from the one-stent technique to the two-stent arm. Clinical and angiographic follow-up data at 12 months were available in all the 47 patients and in 43 patients (91.9%), respectively. The study endpoint was the occurrence of major adverse cardiac events (MACE) at 12 months., Results: Only one patient had a non-ST segment elevation myocardial infarction, which led to 2% of the in-hospital composite MACE. Notably, the target lesion revascularization at 12 months was 8.6%, with a 10.6% composite MACE at 12 months. Neither cardiac death nor stent thrombosis was seen during the follow-up. By quantitative coronary analysis, the restenosis rate at the main vessel and ostium of the side branch was 9.4% and 2.1%, respectively. Four of 12 patients (33.3%) treated with one-stent and kissing balloon inflation had restenosis in the main vessel., Conclusion: BIGUARD stent was safe and feasible in treatment of bifurcation lesions.

Background: The mechanisms responsible for the occurrence of a kissing unsatisfied (KUS) result after classical crush stenting remain unclear. The present study aimed at analyzing the mechanisms and clinical significance of KUS., Methods: Two hundred and thirteen patients with true bifurcation lesions treated with classical crush stenting and final kissing balloon inflation (FKBI) were assigned to upper, middle, and lower groups according to the position of the side branch re-wiring assessed by visual estimation, quantitative coronary analysis (QCA) and intravascular ultrasound (IVUS). Angiographic follow-up was indexed at 12 months., Results: The upper group was characterized by a larger bifurcation angle of 55.53 degrees +/- 25.25 degrees (P = 0.030) and a longer procedural time (42.43 +/- 23.92) minutes (P = 0.015). The overall rate of KUS by visual estimation was 10.48%, with 5.4% in the upper group, 3.9% in middle group, and 36.1% in lower group (P < 0.001). For the diagnosis of KUS, visual inspection demonstrated a good correlation with both QCA and IVUS. Smaller stent diameter was the main reason for KUS in the upper group, while extra-stent side wire location, or re-wire in a low position was the main mechanism attributed to KUS in the lower group. The Lower group had more restenosis, with most restenotic lesions at a lower position of the side branch ostium. KUS (HR 1.652, 95% CI 1.332 - 2.088, P < 0.001) and re-wiring position (HR 2.341, 95% CI 1.780 - 4.329, P < 0.001) were two independent predictors of side branch restenosis. Re-wiring position (OR 0.458, 95%CI 0.336 - 0.874, P = 0.001) and side stent expansion (OR 3.122, 95%CI 2.883 - 5.061, P = 0.014) were factors predicting the findings of KUS., Conclusions: Side wire outside side stents resulted in more KUS and restenosis. Different restenotic lesion types reflected individual mechanisms contributing to the development of plaque proliferation.

Background: It is unclear whether edge segments have different responses to paclitaxel eluting stent (PES) and sirolimus eluting stent (SES) implantation in patients with unstable angina. This study aimed to compare the different vascular edge responses in patients with unstable angina and single de novo coronary lesion treated with SES and PES., Methods: Two hundred and fifty-five patients with unstable angina and single de novo lesion were randomly assigned to PES and SES groups. Serial volumetric intravascular ultrasound (IVUS) images were taken immediately after stenting and at an eight-month follow-up. Five-mm edge segments proximal and distal to the stents were analyzed., Results: Baseline characteristics were comparable between the two groups. At proximal-edge segment, the vessel area decreased and the plaque area increased significantly in the PES group as compared with the SES group. A significant net loss of lumen area was found in the PES group (from (11.10 +/- 3.12) mm(2) at baseline to (9.92 +/- 3.59) mm(2) at the follow-up, P < 0.001). At the distal-edge segment, the net loss of lumen area in the PES group (from (7.71 +/- 2.81) mm(2) at baseline to (6.66 +/- 2.29) mm(2) at the follow-up, P < 0.001) was attributed to a significant increase of plaque area. Proximal-edge stenosis was commonly seen in the PES group (20.0%) as compared with the SES group (5.0%, P = 0.001). This correlated with the higher incidence of target lesion revascularization in the PES group (P = 0.03). Subsegmentally, the smallest Delta lumen area was located at 2 mm proximally in both groups, at 0 mm distally in the PES group, and at 1 mm distally in the SES group., Conclusions: The two groups demonstrated negative remodeling of edge segments. PES was less effective than SES in inhibiting the growth of plaque within the first 1-mm length proximal to the stent.

Background: Bifurcation angles may have an impact on the clinical outcomes of crush stenting. We sought to compare high (> or = 60 degrees ) with low (< 60 degrees ) bifurcation angle in patients who underwent either classical or double kissing (DK) crush stenting for bifurcation lesions from the DKCRUSH-1 data base., Methods: There were 212 patients with 220 lesions, some with low-angle (n = 138) and some with high-angle (n = 74). Angiography was indexed at 8-month after procedure. Primary endpoint was the occurrence of major adverse cardiac events (MACEs), defined as cardiac death, myocardial infarction and target lesion revascularization (TLR). Secondary endpoint included late lumen loss, the rate of restenosis, and final kissing balloon inflation (FKBI)., Results: At 8 months, clinical follow-up was 100%; angiographic follow-up was 75% in the low-angle group and 83.3% in the high-angle group. There were no significant differences in the FKBI between the high-angle group (91.43%) and the low-angle group (82.39%). In the high angle group, there was a significant difference in contrast volume used (P = 0.005) but no significant difference in acute gain, minimum lumen diameter (MLD), late loss and diameter stenosis in the pre-bifurcation segment, post-bifurcation segment or side branch. When lesions were assigned into with-(n = 133) and without-FKBI (n = 42), significant side-branch late loss was seen in the group without-FKBI ((0.65 +/- 0.49) mm vs (0.47 +/- 0.62) mm, P = 0.02), with a resultant greater restenosis rate (37.68% vs 18.32%, P = 0.001). No difference was detected in the MACE free survival rate between the high and low angle groups (82.39% vs 82.36%, P = 0.84). The rate of stent thrombosis tended to be higher in the lower-angle group although there was no significant difference (P = 0.38). The TLR free survival rate was 87.2% in the with-FKBI group vs 73.5% in the without-FKBI group (P = 0.001). Cox regression analysis showed that the independent predictors for target vessel revascularization were the side branch stent MLD post stenting (hazard ratios (HR) 1.028, 95% CI 2.357 - 16.233, P = 0.002), lack of FKBI (HR 4.910, 95% CI 4.706 - 8.459, P = 0.001) and unsatisfactory kissing (HR 3.120, 95% CI 2.975 - 5.431, P = 0.001)., Conclusions: Bifurcation angles do not influence the clinical outcome of crush stenting. Successful final kissing balloon inflation, regardless of bifurcation angles, can predict TLR.

Background: Because no data regarding the comparison of crush stenting with paclitaxel (PES) or sirolimus eluting stents (SES) for coronary bifurcate lesions have been reported, we compared the clinical outcomes of these two types of stents., Methods: Two hundred and thirty patients with 242 bifurcate lesions were enrolled in a prospective, nonrandomized trial. Primary endpoints included myocardial infarction, cardiac death and target vessel revascularization at 8 months., Results: All patients were followed up clinically and 82% angiographically at 8 months. Final kissing balloon inflation was performed in 72% in the PES and 75% in the SES groups (P>0.05). Compared to the SES group, PES group had a higher late loss and incidence of restenosis (P=0.04) in the prebifurcation vessel segment. The postbifurcation vessel segment in the PES group had a greater late loss ((0.7+/-0.6) mm vs (0.3+/-0.4) mm, P<0.001) and higher restenosis in the side branch (25.5% vs 15.6%, P=0.04) when compared to the SES group. There was significant difference of insegment restenosis in the entire main vessel between PES and SES groups (P=0.004). Target lesion revascularization was more frequently seen in the PES group as compared to the SES group (P=0.01). There was significant difference in the accumulative MACE between these two groups (P=0.01). The survival rate free from target lesion revascularization was significantly higher in the SES group when compared to the PES group (P<0.001)., Conclusion: SES is superior to PES in reducing restenosis and target lesion revascularization by 8-month follow-up after crush stenting for bifurcate lesions.

Background: Hypertrophic obstructive cardiomyopathy (HOCM) carries an increased risk for sudden cardiac death. No data regarding the percutaneous transseptal myocardial ablation (PTSMA) and epicardial left ventricular pacing (LVP) were reported., Methods: Seven patients with recurrent symptoms and increased resting left ventricular outflow tract pressure gradient (LVOTG) after PTSMA and another 14 patients with HOCM without history of PTSMA were studied. Both resting and dobutamine stress echocardiography, PTSMA and LVP were routinely performed., Results: In patients without previous PTSMA procedure, mild reduction of resting LVOTG was detected at 5 minutes after left ventricular pacing, and this reduction became significant at 10 minutes. All patients were divided into successful and unsuccessful groups according to their response to LVP. In contrary to patients in unsuccessful group, resting and R-S2 stimuli-induced LVOTG during PTSMA procedure were decreased dramatically ((9 +/- 5) mmHg vs (58 +/- 12) mmHg, (12 +/- 2) mmHg vs (113 +/- 27) mmHg, P < 0.001). Analysis of Logistic regression demonstrated that only LVOTG level during left ventricular pacing was an independent factor predicting the reduction of LVOTG immediately after PTSMA (odds ratio (OR), 0.59; 95% CI 2.67 to 5.82; P = 0.0002)., Conclusion: Left ventricular endocardial temporary pacing plays a critical role in predicting acute effect on the reduction of LVOTG immediately after PTSMA procedure.

Background: Effect of percutaneous transluminal septal ablation (PTSA) with ethanol injection on electromechanical remodeling of left ventricule still remains unknown. This study was conducted to assess the potential significance of cardiac electromechanical mapping (CEMM) in analyzing the left ventricular remodeling before and immediately after percutaneous transseptal myocardial ablation (PTSMA) in patients with hypertrophic obstructive cardiomyopathy (HOCM)., Methods: Eight patients with drug-refractory HOCM and 6 patients with hypertrophic cardiopathy (HM) without increased left ventricular outtract gradien (LVOTG) were enrolled into the present study. CEMM was undergone in patients with HOCM before and immediately after PTSA procedure, and in patients with HM., Results: PTSA was successful in all patients with HOCM, LVOTG significantly decreased from (62.87 +/- 21.16) mmHg to (12.73 +/- 3.05) mmHg immediately after ablation procedure. Value of UVP in septal-base segment in HM group was higher than that in HOCM group [(22.79 +/- 2.34) mV vs (18.54 +/- 1.76) mV]. In patients with HOCM, lateral-middle and -base segments had lowest value of UVP [(15.93 +/- 1.11) mV and (15.83 +/- 1.07) mV] before PTSA. Value of UVP at posterior-middle segment decreased from (23.58 +/- 2.21) mV pre-PTSA to (18.89 +/- 1.91) mV post-procedure, PTSA led to significant increase of UVP at lateral-middle segment. Septal region in patients with HM and septal-middle, septal-base, posterior-base segments in HOCM had lower value of local linear shortening (LLS) among all patients in both HOCM and HM groups. PTSA resulted in significant reduction of LLS in anterior region and at septal-apex segment. Anterior-base and septal-middle segments in patients with HM had lowest value of local active time (LAT), and significantly differentiated from that in patients with HOCM [(-8.57 +/- 0.68) ms vs (-18.61 +/- 1.02) ms, (-6.75 +/- 0.37)ms vs (-21.90 +/- 0.96) ms, respectively]. LAT at septal-middle and -base segments in patients with HOCM was decreased significantly [(-21.90 +/- 0.96) ms vs (-13.80 +/- 1.04) ms, P < 0.002; and (-15.20 +/- 1.06) ms vs (-6.33 +/- 0.52) ms, respectively] immediately after PTSA., Conclusions: Posterior-lateral and anterior region probably played important roles in electromechanical remodeling. Significant electromechanical remodeling disassociation (uncoupling) was detected in most left ventricular regions, which would be important in differentiating of HOCM from HM, and in predicting the prognosis in patients with HOCM after PTSA procedure.

Background: The infarct size determines the long-term prognosis of patients with acute myocardial infarction (AMI). There is a growing interest in repairing scar area by transplanting bone marrow stem cells. However, effectiveness of intracoronary injection of bone marrow mesenchymal stem cells (BMSCs) in patients with AMI still remains unclear., Methods: Sixty-nine patients with AMI after percutaneous coronary intervention (PCI) were randomly divided into intracoronary injection of BMSCs (n = 34) and saline (control group, n = 35) groups. Serial single positron emission computer tomography (SPECT), cardiac echo and cardiac electromechanical mapping were done at the designed time intervals until six months after transplantation of BMSCs or injection of saline., Results: The proportion with functional defect decreased significantly in the BMSCs patients after three months [(13 +/- 5)%] compared with that pre-transplantation [(32 +/- 11)%] and the control group [(28 +/- 10)%] at three month follow-up (P < 0.05, respectively). Wall movement velocity over the infracted region increased significantly in the BMSCs group [(4.2 +/- 2.5) cm/s vs (2.2 +/- 1.3) cm/s, P < 0.05], but not in the control group [(2.2 +/- 1.5) cm/s vs (2.7 +/- 1.7) cm/s, P > 0.05]. Left ventricular ejection fraction (LVEF) three months after transplantation in BMSCs group increased significantly compared with that pre-implantation and with that of the control group at three months post-injection [(67 +/- 11)% vs (49 +/- 9)% and (53 +/- 8)%, P < 0.05 respectively]. SPECT scan results showed that perfusion defect was improved significantly in BMSCs group at three-month follow-up compared with that in the control group [(134 +/- 66) cm(2) vs (185 +/- 87) cm(2), P < 0.01]. At the same time, left ventricular end-diastolic volume [(136 +/- 31) ml vs (162 +/- 27) ml, P < 0.05] and end-systolic volume [(63 +/- 20) ml vs (88 +/- 19) ml, P < 0.05] decreased synchronously. The ratio of end-systolic pressure to end-systolic volume [Psyst/ESV, (2.84 +/- 1.30) mmHg/ml vs (1.72 +/- 1.23) mmHg/ml, P < 0.05] increased significantly. Cardiac electromechanical mapping demonstrated significant improvement at three months after implantation of BMSCs compared with that pre-injection in both cardiac mechanical capability as left line local shorting [LLS, (11.29 +/- 1.64)% vs (7.32 +/- 1.86)%, P < 0.05] and electrical property as left ventricular endocardial unipolar voltage [UV, (10.38 +/- 1.12) mV vs (7.61 +/- 1.09) mV, P < 0.01]; perfusion defect decreased from (36.2 +/- 6.2)% to (20.3 +/- 5.31)% (P < 0.01). Twenty-four-hour electrocardiographic monitoring demonstrated no arrhythmias occurred at three-months follow-up., Conclusions: The transplantation of BMSCs might improve the cardiac function and it is safe and feasible with no deaths or malignant arrhythmias.