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OBJECTIVES Using optical coherence tomography (OCT), we evaluated the effect of a cutting balloon (CB) compared with a conventional balloon after rotational atherectomy (RA) and before stenting in severely calcified coronary lesions. BACKGROUND A CB is designed to create discrete incisions to facilitate fracture of severely calcified plaque. METHODS OCT was performed preintervention (if possible), post-RA, and poststent implantation. RA modification of calcium was defined as a polished, concave, round-shaped surface. Calcium fracture was defined as a break in the calcium plate. The effects of calcium modification and stent expansion between CB (n = 18) versus conventional balloon (n = 23) following RA were compared. RESULTS Median patient age was 72 years with 24% on hemodialysis. The amount of calcium and the length of RA modification were comparable between the CB and conventional balloon groups. Final poststent OCT showed that the number and thickness of calcium fracture were greater after CB versus conventional balloon, resulting better stent expansion (78.9% [IQR: 72.4-88.1] vs. 66.7% [IQR: 55.0-76.7], p

There are a few studies about the clinical impacts of plasma B-type natriuretic peptide (BNP) at discharge with the occurrence of worsening renal function (WRF) on mortality in patients with heart failure (HF). We divided total 301 patients with acute decompensated HF into four groups by the median value (278.7 pg/mL) of BNP level at discharge and by the occurrence of WRF. WRF developed in 100 patients (33.2%). Cardiovascular mortality was significantly different between the four groups (P = 0.0002). Patients with WRF and elevated BNP had a higher cardiovascular mortality than patients without WRF and elevated BNP in Cox proportional hazard models (hazard ratio [HR], 10.48; 95% confident interval [95% CI], 1.27–225.53; P = 0.03). Patients with either WRF or elevated BNP did not have an increased risk of cardiovascular mortality compared to patients without WRF and elevated BNP. Regarding HF readmission and cardiovascular mortality, patients with WRF and elevated BNP had the highest risk (HR, 5.17; 95% CI, 2.07–14.30, P = 0.0003) and patients with either WRF or elevated BNP had a higher risk than patients without WRF and elevated BNP. The occurrence of WRF combined with elevated BNP at discharge was associated with increased 1-year cardiovascular mortality and HF readmission.

Aims Our purpose was to investigate the association between the B‐type natriuretic peptide (BNP) level at discharge, the occurrence of worsening renal function (WRF), and long‐term outcomes in patients with heart failure (HF). Methods and results We enrolled hospitalized acute HF patients. We divided patients into four groups on the basis of BNP

Chronic second-generation drug-eluting stent recoil in severely calcified coronary lesions has not been studied. We aimed to evaluate chronic stent recoil by optical coherence tomography (OCT) in severely calcified lesions treated with thin strut stents after rotational atherectomy. In 28 lesions (26 patients with 23% on hemodialysis) treated with everolimus-eluting stents after rotational atherectomy, baseline and 8-month follow-up OCT were compared. Stent recoil was defined as >10% decrease in stent area from baseline to follow-up. Overall, there was no change in minimal stent area (6.0 mm2 [5.0, 8.1] to 6.0 mm2 [4.8, 8.6], p = 0.51) from baseline to follow-up, although neointimal hyperplasia measured 16.3 ± 15.8%. Thirty-six percent of lesions showed stent recoil associated with 6 non-nodular calcifications, 1 calcified nodule, and 3 stent deformations. The overall mean calcium angle with attenuation decreased (54° [29–76] to 31° [19–48], p

The relationship between epicardial adipose tissue volume (EATV) and plaque vulnerability in non-culprit coronary lesions is not clearly understood.Fifty-four consecutive patients/158 lesions with suspected coronary artery disease underwent computed tomography (CT) and 40 MHz intravascular ultrasound imaging (iMap-IVUS) in cardiac catheterization. Cross-sectional CT slices were semiautomatically traced from base to apex of the heart. Using a 3D workstation, EATV was measured as the sum of fat areas (-190 to -30 Hounsfield units [HU]). All coronary vessels were imaged using iMap-IVUS before stenting to analyze coronary plaques as fibrotic, lipidic, necrotic, or calcified tissue.Mean EATV was 73.7 ± 24.6 (range: 30.2 to 131.8) mL. Patients were divided into two groups by mean EATV (group H: n = 27, EATV ≥ 73.7 mL; group L: n = 27, EATV < 73.7 mL). Total luminal volume, total vessel volume, and total plaque volume were significantly larger in group H. Fibrotic plaque and lipidic plaque volumes were also significantly larger in group H. There was a significant negative correlation between EATV and fibrous tissue (r = -0.31, P = 0.02) and a significant positive correlation between EATV and necrotic tissue (r = 0.37, P = 0.007). EATV was related to plaque with vulnerability in the right coronary artery (RCA) (r = 0.57, P = 0.04) and the left anterior descending artery (LAD) (r = 0.53, P = 0.02). In conclusion, increased EATV was associated with the total coronary plaque burden and composition, particularly in the RCA and LAD.

This was a retrospective intravascular ultrasound (IVUS) study of mechanisms of in-stent restenosis (ISR) chronic total occlusions (CTOs). ISR CTOs were defined as TIMI (Thrombolysis In Myocardial Infarction) flow grade 0 within a stented lesion (including 5-mm margins) with estimated occlusion

AIMS Few studies have reported the impact of high-dose loop diuretics at discharge on prognosis in Japanese patients with heart failure (HF). Our purpose was to assess the relationship between the dose of loop diuretics at discharge and cardiovascular mortality in patients with HF. METHODS AND RESULTS We enrolled decompensated HF patients who were admitted to our hospital between March 2010 and March 2015, and compared HF patients who received high-dose loop diuretics at discharge (HD group) with low-dose loop diuretics at discharge (LD group) with regard to risk of cardiovascular mortality, and all-cause mortality. High-dose loop diuretic was defined as ≥40 mg/day of oral furosemide at discharge. A total of 215 patients were enrolled to the study. The median follow-up duration was 641 days. All-cause and cardiovascular mortality were significantly lower in the LD group than in the HD group (10.4% vs. 31.6%, P

Recently several studies showed that worsening renal function (WRF) during hospitalization might be a strong independent predictor of poor prognosis in decompensated heart failure (HF) patients. However, these studies had a relatively short follow-up duration and their data were limited to in-hospital outcomes. Our purpose was to assess the relationship between WRF and long-term cardiovascular mortality in HF patients.We enrolled decompensated HF patients who were admitted to our hospital between April 2010 and March 2015. WRF was defined as a relative increase in serum creatinine of at least 25% or an absolute increase in serum creatinine ≥0.3mg/dL from the baseline. We assessed the cardiovascular mortality and all-cause mortality in HF patients with WRF (WRF group) and without WRF (no WRF group).Among 301 patients enrolled, WRF developed in 118 patients (39.2%). During a median follow-up period of 537days [interquartile range, 304.3 to 1025.8days], cardiovascular mortality and all-cause mortality were significantly higher in the WRF group than in the no WRF group (23.2% vs. 6.1%, P0.001; 30.3% vs. 14.7%, P0.001, respectively). In the multivariate Cox proportional hazards model, age and serum B-type natriuretic peptide (BNP) level were associated with both cardiovascular death and all-cause death. However, WRF was not the independent predictor of cardiovascular death (P=0.19) nor all-cause death (P=0.57).WRF was associated with cardiovascular death in patients with HF. Although not an independent predictor, WRF might be one of useful markers to identify patients who should be followed carefully after discharge.

To better understand relationship between histological medial degenerative changes (MDC), pathological status [thoracic aorta aneurysm (TAA), thoracic aorta dissection (TAD), bicuspid aortic valve (BAV), and non-BAV] and aortic size at imaging.We collected 496 ascending aorta surgical specimens from patients with degenerative aortic diseases (mean age, 61 years) whose imaging data were available, including BAV in 191 (TAD 4%, TAA 96%) and with non-BAV in 305 (TAD 45%, TAA 55%). We analyzed them according to the pathology consensus statement and scored MDC [elastic fiber fragmentation and/or loss (EFFL); smooth muscle nuclei loss (SMNL); mucoid extracellular matrix accumulation (MEMA), intralamellar (I) or translamellar (T)] and measured medial wall thickness on correlation with imaging data and the status (TAA, TAD, BAV, or non-BAV). In TAA subset, EFFL, SMNL and MEMA-T scores were lower in BAV than in non-BAV. In relation to the aortic diameter, EFFL, SMNL and MEMA-T scores were more important in TAD subset than in TAA at the small aortic diameters. Independent predictors of aortic dissection included thicker medial wall (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.4 to 17.6; p 0.0001) and greater SMNL score (OR, 1.2; 95% CI, 1.1 to 1.3; p = 0.003).This large cohort study confirms that non-BAV aortas present higher MDC scores than BAV aortas. Higher MDC scores are correlated with increased aortic diameter. TAD can occur not infrequently in smaller aortas associated with high MDC scores. This suggests that risk stratification of aortic dissection based on aorta dimensions is imperfect.

Background : Not rarely aortitis is firstly identified in thoracic aorta aneurysm/dissection specimens only by histopathology in the absence of clinical evidence of systemic inflammatory disease emphasizing the importance of histology for the diagnosis of aortitis. Regardless of the improvement of the pathological assessment of aortic diseases by the recent consensus statements on surgical pathology of the aorta, histology can be confusing since medial degenerative changes (MDC) can be prominent in a background where inflammation is sometimes limited. This raises the question of the role of aging or other degenerative process versus the role of inflammation in the damage to aorta wall. Patients and Methods : In this study, besides inflammation, we evaluated aorta samples from aortitis cases focusing on the histological scoring of MDC. In this retrospective single center study we retrieved 719 cases of ascending aorta aneurysms or dissections operated on from January 2010 until June 2018. MDC (elastic fiber fragmentation and/or loss, smooth muscle nuclei loss, mucoid extracellular matrix accumulation intralemellar or translamellar) were estimated using a scoring system derived from that of the consensus statement. Non-infectious aortitis group versus age-matched non-inflammatory degenerative aortic disease group were compared. Results : Non-infectious aortitis was pathologically diagnosed in 62 patients (8.6%). Among the 62 non-infectious aortitis patients, 47 patients (75.8%) had aortitis identified pathologically prior to the clinical diagnosis. Higher MDC scores were observed at all aortic sizes in aortitis group versus non-aortitis group, especially for elastic fiber damage and smooth muscle cell loss. Conclusions : Aortitis is remarkably associated with severe damage to the aorta wall resulting in advanced MDC scores. Inflammatory process is responsible for higher MDC in the aorta wall than aging or other degenerative process.

Rotational atherectomy (RA) and orbital atherectomy (OA) are designed to ablate calcified plaque, but differences in their mechanisms of action in vivo are not well described [(1,2)][1], despite the importance of atherectomy in treating complex coronary artery disease. This was a retrospective

We report here a case of capillary vascular malformation developed in a bicuspid aortic valve incidentally detected during valve replacement in a 67-year-old male patient. The International Society for the Study of Vascular Anomalies (ISSVA) classification was used to classify this vascular lesion instead of using the term hemangioma. The differential diagnosis and the literature are reviewed.

Background: Tolvaptan is a promising drug for the prevention of contrast-induced acute kidney injury (CI-AKI) because it induces aquaresis without adversely affecting renal hemodynamics. CI-AKI is a major cause of acute renal failure associated with increased morbidity and mortality. Objective: To investigate the effectiveness of different doses of tolvaptan for the prevention of CI-AKI. Method: Ninety-one consecutive patients with congestive heart failure (CHF) and chronic kidney disease (CKD) were prospectively enrolled as the tolvaptan group in this study (T-group; 7.5-mg: n = 42, 15-mg: n = 49). In addition, 91 consecutive patients with CHF and CKD were collected retrospectively as a control group (C-group, n = 91). All patients received continuous intravenous infusion of isotonic saline, and tolvaptan was administered to the T-group. Results: One patient developed CI-AKI in the T-group versus 3 in the C-group (1.1 vs. 3.3%, p = 0.61). On the other hand, the change of serum creatinine in the T-group was lower than that in the C-group. Additionally, in the 7.5-mg group, serum creatinine was unchanged up to 72 h after contrast administration, showing a significant difference from the 15-mg group (–0.00 ± 0.09 vs. 0.05 ± 0.12 mg/dL, p = 0.009). Similarly, the change of eGFR was significantly smaller in the 7.5-mg group than that in the 15-mg group (0.7 ± 5.4 vs. –2.8 ± 5.1 mL/min/1.73 m2, p = 0.002). No patient required hemodialysis and there was no prolongation of hospitalization due to exacerbation of heart failure. Conclusions: Compared to hydration alone, tolvaptan combined with hydration could be a safer method for preventing CI-AKI while avoiding exacerbation of heart failure, and a dosage of 7.5-mg might be safer than 15-mg.

Introduction There were few studies that investigated the association between serum zinc concentration and acute myocardial infarction (AMI) in percutaneous coronary intervention era. Objective We assessed the relationships between serum zinc concentration, complications, and prognosis in AMI patients after primary percutaneous coronary intervention. Methods We conducted a single-center, prospective, observational study including 50 patients with AMI. We divided patients into two groups (High-zinc group and Low-zinc group) by median serum zinc concentration and compared two groups about clinical outcomes up to 1 year follow up. Results The mean age of patients was 66.2 ± 11.8 years old. Patients in the Low-zinc group had ST-segment elevation more frequently than those in the High-zinc group (96.0% vs. 72.0%, P = 0.02). All-cause mortality at 1 year was similar in both groups (P (log-rank) = 0.33). However, the lengths of hospital stay and in coronary care unit were longer in patients in the Low-zinc group than in those in the High-zinc group (15.6 ± 9.2 days vs. 11.9 ± 2.9 days, P = 0.06; 3.9 ± 2.8 days vs. 2.3 ± 0.8 days, P = 0.01). Multivariate regression analysis showed that low serum zinc concentration was associated with the use of cardiac or respiratory assist devices (adjusted odds ratio, 17.79; 95% CI 1.123 to 1216.5; P = 0.04). Conclusions Although there was no significance difference in mortality in Low-zinc and High-zinc groups, low serum zinc concentration was associated with longer stay in the coronary care unit, and was one of the independent predictors for the use of cardiac or respiratory assist devices.

Summary Background Heart failure (HF) with hypoalbuminemia is associated with poor response to conventional therapy. We investigated whether tolvaptan, a potent aquaretic agent, might be of benefit in HF patients with hypoalbuminemia. Methods We prospectively enrolled 40 patients hospitalized for HF. Patients received conventional therapy including loop diuretics. We subsequently added tolvaptan in the range of 3.75–15 mg daily and it was discontinued after improvement of HF symptoms. We compared clinical and laboratory data in HF patients with and without hypoalbuminemia (defined as serum albumin

Background— Optical coherence tomographic (OCT) morphologies associated with lesion progression are not well studied. The aim of this study was to determine the morphological change for untreated lesion progression using both OCT and intravascular ultrasound (IVUS). Methods and Results— We used baseline and 8-month follow-up 3-vessel OCT and IVUS to assess 127 nonculprit lesions (IVUS plaque burden ≥40%) in 45 patients with stable angina after target lesion treatment. Lesion progression was defined as an IVUS lumen area decrease >0.5 mm 2 . A layered pattern was identified as a superficial layer that had a different optical intensity and a clear demarcation from underlying plaque. Lesion progression was observed in 19% (24/127) lesions, and its pattern was characterized into 3 types: type I, new superficial layered pattern at follow-up that was not present at baseline (n=9); type II, a layered pattern at baseline whose layer thickness increased at follow-up (n=7); or type III, no layered pattern at baseline or follow-up (n=8). The increase of IVUS plaque+media area was largest in type I and least in type III (1.9 mm 2 [1.6–2.1], 1.1 mm 2 [0.9–1.4], and 0.3 mm 2 [−0.2 to 0.8], respectively; P =0.002). Type III, but not types I or II, showed negative remodeling during follow-up (IVUS vessel area; from 14.3 mm 2 [11.4–17.2] to 13.5 mm 2 [10.4–16.7]; P =0.02). OCT lipidic plaque was associated with lesion progression (odds ratio, 13.6; 95% confidence interval, 3.7–50.6; P Conclusions— Lesion progression was categorized to distinct OCT morphologies that were related to changes in plaque mass or vessel remodeling.

PURPOSE The aim of this study was to derive optimal coronary angiography (CAG) angle for the form information on the left main trunk (LMT) by use of multi detector computed tomography (MDCT). METHODS To verify the accuracy of angle measurement with MDCT, the angle of phantom with known angle was compared with MDCT (CT method) and angiography (AG method). The take-off angle of LMT was derived using CT method from 200 cases who underwent cardiac CT in this institution. RESULTS In the phantom, both CT and AG methods were indicated to have high accuracy and the errors were very small (0.3%, 0.3%). The take-off mean angle of LMT was 130.7±19.0 degrees in male, and 139.1±19.3 degrees in female. The optimal CAG angle was indicated at left anterior oblique (LAO) 41 degrees (male) and LAO 49 degrees (female). CONCLUSION The optimal CAG angle of LMT was derived from the CT method.

Background: Exercise training (ET) after coronary stenting is considered to have a risk of stent thrombosis (ST). The present study investigated whether ET increases the incidence of ST in patients undergoing coronary stenting. Methods and Results: The current study was a prospective observational study. We enrolled 3,672 patients who underwent successful coronary stenting. Patients decided whether to participate in exercise and were divided into an ET group (n=1,592) and a control group (n=2,080). The primary endpoint was the incidence of ST. Secondary endpoints were major adverse cardiovascular events (MACE: death, myocardial infarction, and stroke) and unscheduled hospital visits for angina. The incidence of ST and MACE were similar in both groups (1.8% vs. 2.0%, P=0.73, 14.9% vs. 15.0%, P=0.97, respectively). Unscheduled hospital visits were significantly lower in the ET group (20.2% vs. 27.2%, P

EAT shares a common embryological origin with intra-abdominal visceral fat depots and obtains its vascular supply from the coronary arteries. EAT volume was larger in the presence of obstructive CAD and non-calcified plaques. A high EAT volume was associated with the presence of vulnerable plaque

AIM We used quantitative coronary angiography (QCA) to investigate whether coronary plaque progression can be inhibited by controlling lipids with rosuvastatin at Japanese standard doses following elective percutaneous coronary intervention (PCI). METHODS A total of 143 patients who underwent elective PCI were randomized to either the rosuvastatin (5 or 2.5mg/day) or non-statin group. Changes from baseline in the minimal lumen diameter (MLD) and average lumen diameter (ALD) measured using QCA were analyzed in both target and non-target lesions. RESULTS The changes in MLD and ALD from baseline to 24 months in the non-target lesions were significantly smaller in the rosuvastatin group than in the non-statin group (-0.079 ± 0.014 mm vs.-0.135 ± 0.019 mm, p=0.022; -0.062 ± 0.012 mmvs. -0.109 ± 0.016mm, p=0.025). The changes in MLD from six to 24 months in the target lesions were significantly lower in the rosuvastatin group than in the non-statin group among the patients treated with drug-eluting stents (-0.046 ± 0.108 mm vs. -0.133 ± 0.108 mm, p=0.009) versus those treated with bare-metal stents (-0.011 ± 0.094 mm vs. -0.015 ± 0.040 mm, p=0.255). CONCLUSIONS The present study demonstrated that the administration of a standard dose of rosuvastatin slows coronary plaque progression and may prevent the late catch-up phenomenon associated with drug-eluting stents in patients who undergo elective PCI.

Cutting balloon (CB) after rotational atherectomy (RA) for severely calcified coronary lesions has not been reported. Optical Frequency Domain Imaging (OFDI) was performed post-RA, post-CB or conventional balloon, and post-stent in 41 lesions. Calcium (Ca) volume index was mean Ca angle × Ca

Objective: To evaluate how post stent dilatation with large balloons has impact on stent elongation. Methods: Four kind of stents (Fig1-b) were deployed into a silicon tube model; 10mm of one side of the stent was attached to the model wall and 10mm on the opposite side of the stent was free from the vessel wall (Fig1-a). Then, in each model, post stent dilatation (PD) (Fig1-b) was performed with four different kind of 3.5mm balloons at nominal (NP) and rated balloon pressure (RP). A total of 16 stents were tested, and difference of degree of stent elongation in the stent portion which was free from the wall (delta stent length) was measured and compared among different kind of stents and different kind of balloons. Furthermore, four kind of deployed stents were also dilated three times at RP to evaluate the impact of repeated dilataton on stent elongation. Result: Stent elongation was observed in all models. Delta stent length before and after PD at NP and RP were 0.41±0.15mm and 1.15±0.37mm, respectively. Compared with different four kind of stents, there was no significant difference in delta stent length before and after PD at both NP and RP (p=0.58, 0.96, respectively), however compared with different four kind of post dilatation balloons, significant difference in delta stent length before and after PD was observed at both NP and RP (p=0.016

Purpose: Several studies had revealed that three dimensional (3D) quantitative coronary angiography (QCA) overcomes the shortcoming of 2-dimensional QCA regarding bifurcation angle analysis. The impact of bifurcation angle (BA) in left main (LM) on clinical outcomes after single stenting treated with drug-eluting stent (DES) have never been documented. The Aim of this study was to investigate the impact of unprotected LM bifurcation angle on clinical outcomes after cross over single stent strategy using DES with 3D QCA. Methods: A total of 152 patients who underwent PCI in unprotected LM bifurcation with successful single cross over DES stenting from the LM into the left anterior descending artery (LAD) were enrolled. The distal BA (between LAD and left circumflex [LCX]: shown in Fig) were computed in end-diastole before PCI with 3D QCA software. The patients were diveded into two groups with median value of the distal BA (high-angle group; BA≥86.04°, low-angle group; BA

Treating left main (LM) bifurcation with stents is complex as LM trunks have larger vessel references than others. Kissing balloon technique (KBT) and/or post stent dilatation to LM trunks are needed in order to obtain adequate stent apposition in LM trunks. The objective of this study was to