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Regarding stent expansion indices, previous optical coherence tomography (OCT) studies have shown minimal stent area (MSA) to be most predictive of adverse events. We sought to evaluate the impact of various stent expansion and apposition indices by post-stent OCT on clinical outcomes and find OCT-defined optimal stent implantation criteria. A total of 1071 patients with 1123 native coronary artery lesions treated with new-generation drug-eluting stents with OCT guidance and final post-stent OCT analysis were included. Several stent expansion indices (MSA, MSA/average reference lumen area, MSA/distal reference lumen area, mean stent expansion, and stent expansion by linear model [stent volume/adaptive reference lumen volume]) were evaluated for their association with device-oriented clinical endpoints (DoCE) including cardiac death, target vessel-related myocardial infarction (MI) or stent thrombosis, and target lesion revascularization. MSA was negatively correlated with the risk of DoCE (hazard ratio [HR] 0.80 [0.68‒0.94]). However, stent expansion by linear model representing the overall volumetric stent expansion was associated with greater risk of DoCE (HR 1.02 [1.00‒1.04]). As categorical criteria, MSA < 5.0 mm2 (HR 3.90 [1.99‒7.65]), MSA/distal reference lumen area < 90% (HR 2.16 [1.12‒4.19]), and stent expansion by linear model ≥ 65.0% (HR 1.95 [1.03‒3.89]) were independently associated with DoCE. This OCT study highlights the importance of sufficient stent expansion to achieve adequate, absolute, and relative MSA criteria for improving clinical outcome. It also emphasises that overall volumetric excessive stent expansion may have detrimental effects. [ABSTRACT FROM AUTHOR]

This study sought to evaluate the impact of poststent optical coherence tomography (OCT) findings, including severe malapposition, on long-term clinical outcomes. Suboptimal OCT findings following percutaneous coronary intervention (PCI) are highly prevalent; however, their clinical implications remain controversial. Of the patients registered in the Yonsei OCT registry, a total of 1,290 patients with 1,348 lesions, who underwent OCT immediately poststenting, were consecutively enrolled for this study. All patients underwent implantation of drug-eluting stents. Poststent OCT findings were assessed to identify predictors of device-oriented clinical endpoints (DoCE), including cardiac death, target vessel-related myocardial infarction (MI) or stent thrombosis, and target lesion revascularization (TLR). Significant malapposition criteria associated with major safety events (MSE) were also investigated, such as cardiac death, target vessel-related MI, or stent thrombosis. The median follow-up period was 43.0 months (interquartile range [IQR] 21.4 to 56.0 months). The incidence rates of stent edge dissection, tissue prolapse, thrombus, and malapposition after intervention were not associated with occurrence of DoCE. However, patients with significant malapposition (total malapposition volume [TMV] ≥7.0 mm3] exhibited more frequent MSE. A smaller minimal stent area (MSA) was identified as an independent predictor for DoCE (hazard ratio [HR]: 1.20 [95% confidence interval [CI]: 1.00 to 1.43]; p = 0.045). Malapposition with TMV ≥7.0 mm3 was found to be an independent predictor of MSE (HR: 6.12 [95% CI: 1.88 to 19.95]; p = 0.003). Follow-up OCT at 3, 6, or 9 months after PCI showed that poststent TMV ≥7.0 mm3 was related to a greater occurrence of late malapposition and uncovered struts. Although most suboptimal OCT findings were not associated with clinical outcomes, a smaller MSA was associated with DoCE, driven mainly by TLR, and significant malapposition with TMV ≥7.0 mm3 was associated with more MSE after PCI. (Yonsei OCT [Optical Coherence Tomography] Registry for Evaluation of Efficacy and Safety of Coronary Stenting; Yonsei OCT registry; NCT02099162) [Display omitted] [ABSTRACT FROM AUTHOR]

Background and aims: The prognosis of stented lesions differs according to in-stent neointimal characteristics on optical coherence tomography (OCT). In particular, patients who show in-stent heterogeneous neointima are associated with a higher incidence of target lesion revascularization (TLR) compared with those who show in-stent non-heterogeneous neointima. However, the relationship between in-stent neointimal characteristics and native coronary atherosclerosis progression has not been clearly elucidated. The study aimed to investigate the relationship between in-stent neointimal characteristics and progression of native atherosclerosis. Methods: The neointimal characteristics of 377 patients with 377 drug-eluting stents (DESs) were quantitatively and qualitatively assessed using OCT. The OCT-based neointima was categorized as homogeneous (n = 207), heterogeneous (n = 93), and layered (n = 77). The relationship of non-target lesion revascularization (non-TLR) with neointimal characteristics was evaluated after OCT examination of the stents. Results: After a median follow-up duration of 40.0 months, patients with heterogeneous neointima showed significantly higher non-TLR rates than those with homogeneous neointima and tended to have higher non-TLR rates than those with layered neointima (heterogeneous vs. homogeneous:14.0% vs. 8.7%, p = 0.046; heterogeneous vs. layered neointima:14.0% vs. 7.8%, p = 0.152). Multivariate analysis showed that the independent determinants for non-TLR were heterogeneous neointima (HR: 2.237, 95% CI: 1.023–4.890, p = 0.044) and chronic kidney disease (hazard ratio [HR]: 8.730, 95% CI: 2.175–35.036, p = 0.002). Conclusions: The heterogeneous neointima in DES-treated lesions was associated with a higher incidence of non-TLR and target lesion failure. This finding suggests that the neointimal pattern may reflect the progression of the native lesion. [ABSTRACT FROM AUTHOR]

We evaluated early vascular responses after new-generation drug-eluting stent (DES) implantation. From 2 randomized trials, we identified 471 patients (138 patients with acute myocardial infarction [AMI] vs 333 patients with stable angina or unstable angina [SA/UA]) treated by DESs who underwent serial optical coherence tomography (OCT) from postprocedure to 3 months. At 3-month follow-up OCT, malapposed strut percentage was higher in AMI than in SA/UA (5.3% vs 0.7%, P <.001); it was markedly increased from postprocedure in AMI (2.0%-5.3%, P <.001), whereas it decreased in SA/UA (1.7%-0.7%, P <.001). Patients with AMI showed a higher risk of persistent (59% vs 37%; P <.001) or late-acquired malapposition (15% vs 8%; P =.04). Uncovered strut percentage at 3 months was also higher in AMI than in SA/UA (13.1% vs 6.7%, P <.001). The AMI presentation was the significant risk factor for both significant stent malapposition (SM, ≥200 μm; odds ratio [OR] = 3.45, CI = 1.85-7.14, P <.001) and uncovered stent (% uncovered struts >6.0%; OR = 2.44, CI = 1.35-4.76, P =.004), together with malapposed distance and postprocedural thrombi. Further, AMI presentation was the predictor for the occurrence of early period late-acquired and persistent malapposition. Serial OCT comparison analyses showed that patients with AMI compared with patients with SA/UA showed more delayed strut coverage, more severe degree SM or uncovered stents, and higher incidences of early period persistent or late-acquired SM. [ABSTRACT FROM AUTHOR]

Abstract Objectives This study sought to measure early strut coverage in patients receiving drug-eluting stents (DESs) and to explore the feasibility of short-term dual antiplatelet therapy (DAPT) based on the degree of early strut coverage. Background Data for early strut coverage in patients receiving new-generation DESs, and its implications for DAPT continuation were limited. Methods A randomized, multicenter trial was conducted in 894 patients treated with DESs. Patients were randomly assigned to everolimus-eluting stent (EES) (n = 444) or biolimus-eluting stent (BES) (n = 450) groups and optical coherence tomography (OCT)-guided (n = 445) or angiography-guided (n = 449) implantation groups using a 2-by-2 factorial design. Early strut coverage was measured as the percentage of uncovered struts on 3-month follow-up OCT examination. The primary outcome was the difference in early strut coverage between EES and BES groups and between OCT- and angiography-guided implantation groups. The secondary outcome was a composite of cardiac death, myocardial infarction, stent thrombosis, and major bleeding during the first 12 months post-procedure in patients receiving 3-month DAPT based on the presence of early strut coverage (≤6% uncovered) on 3-month follow-up OCT. Results Three-month follow-up OCT data were acquired for 779 patients (87.1%). The median percentage of uncovered struts at 3 months was 8.9% and 8.2% in the EES and BES groups, respectively (p = 0.69) and was lower in the OCT-guided group (7.5%) than in the angiography-guided group (9.9%; p = 0.009). Favorable early strut coverage (≤6% uncovered strut) was observed in 320 of 779 patients (41.1%). At 12 months, the composite event rarely occurred in the 3-month (0.3%) or 12-month (0.2%) DAPT groups (p = 0.80). Conclusions OCT-guided DES implantation improved early strut coverage compared with angiography-guided DES implantation, with no difference in strut coverage between EES and BES groups. Short-term DAPT may be feasible in selected patients with favorable early strut coverage (Determination of the Duration of the Dual Antiplatelet Therapy by the Degree of the Coverage of The Struts on Optical Coherence Tomography From the Randomized Comparison Between Everolimus-eluting Stents Versus Biolimus A9-eluting Stents [DETECT-OCT]; NCT01752894) Graphical abstract [ABSTRACT FROM AUTHOR]

Background The assessment of fractional flow reserve (FFR) in coronary lesions determines the strategy of percutaneous coronary intervention. However, the association between FFR and characteristics of the underlying coronary plaque has not been sufficiently investigated. Methods A total of 110 coronary lesions in 106 patients were evaluated using both FFR and optical coherence tomography (OCT). Coronary plaques were classified into fibrous, fibrocalcific, or fibroatheroma according to OCT evaluation at the site of minimal lumen area. Plaque microstructures such as cap thickness, macrophage accumulation, intimal vasculature, or cholesterol crystals were also evaluated. Results Lesions with FFR ≤ 0.8 showed a higher frequency of fibroatheroma, macrophage accumulation, and cholesterol crystals when compared to those with FFR > 0.8. The angle of lipid was wider in lesions with FFR ≤ 0.8 (145.1 ± 63.0° vs. 120.7 ± 48.9°, p = 0.047), and the longitudinal length was longer in those with FFR ≤ 0.8 (4.2 ± 2.8 mm vs. 2.5 ± 2.9 mm, p = 0.007). However, multiple linear regression analysis revealed that the morphological characteristics of plaques assessed by OCT were not independently associated with FFR. Minimal lumen area [coefficient, 0.035; 95% confidence interval (CI), 0.022–0.048; p < 0.001] and area stenosis (coefficient, −0.003; 95% CI, −0.005 to −0.001; p = 0.001) assessed by OCT significantly correlated with FFR. Conclusion The morphological characteristics of coronary plaque derived from OCT are not directly related to FFR. [ABSTRACT FROM AUTHOR]

Background Angiographic stenosis of a jailed side-branch ostium is usually observed after a single-stent crossover at coronary bifurcation lesions. However, the stenosis severity is typically overestimated due to the limited information obtained from two-dimensional morphology by angiography. We evaluated the actual stenosis of jailed side-branch ostium using three-dimensional (3D) optical coherence tomography (OCT). Methods Using 3D reconstructions of OCT data, we analyzed minimal lumen area (MLA) and eccentricity of the jailed side-branch ostium in 41 patients who were treated with single stent crossover at coronary bifurcation lesions and subsequently underwent serial OCT follow-up. Results The MLA of jailed side-branch ostium calculated from quantitative coronary angiography (QCA) assuming a circular lumen markedly decreased after stent implantation (1.73 ± 1.22 mm 2 pre-intervention to 0.84 ± 0.91 mm 2 post-intervention, p < 0.001). However, the MLA of jailed side-branch ostium measured at post-intervention by 3D-OCT (2.67 ± 1.75 mm 2 ) was significantly larger than that measured by QCA ( p < 0.001). There were no statistically significant changes in MLA of jailed side-branch ostium based on 3D-OCT measurements during the follow-up (2.35 ± 1.50 mm 2 at 3–6 months post-intervention; 2.44 ± 1.27 mm 2 at 1–2 years post-intervention, p = 0.098). The shapes of the jailed side-branch ostium were nearly elliptical (mean eccentricity index: 2.97 ± 1.27 post-intervention; 2.79 ± 1.17 at 3–6 months post-intervention; 2.59 ± 1.02 at 1–2 years post-intervention). Conclusions Compared to 3D-OCT measurements, QCA measurements overestimated the jailed side-branch ostial stenosis after single stent crossover due to eccentric morphology from orthogonal projection in coronary angiography. Significant changes in the MLA of jailed side-branch ostium by 3D-OCT were not observed during the follow-up. [ABSTRACT FROM AUTHOR]

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Objectives The aim of this study was to investigate the correlation between in-stent neointimal tissue without features of neoatherosclerosis and long-term clinical outcomes. Background Recent studies have reported differential morphological characteristics of in-stent neointimal tissue assessed by optical coherence tomography (OCT). Methods The study population consisted of 336 patients with 368 drug-eluting stent-treated lesions. Patients received a follow-up OCT examination without any intervention. OCT-based neointima was categorized as homogeneous (n = 227 lesions in 208 patients), heterogeneous (n = 79 lesions in 73 patients), or layered (n = 62 lesions in 55 patients). Major adverse cardiac events (MACE) (a composite of cardiac death, nonfatal myocardial infarction, or target lesion revascularization) were assessed according to neointimal patterns during long-term clinical follow-up after OCT examination. Results The time interval between stent implantation and OCT examination was similar among the 3 groups (p = 0.64). On multivariate logistic regression analysis, the significant determinant for the heterogeneous neointima was age (odds ratio [OR]: 1.037, 95% confidence interval [CI]: 1.007 to 1.068, p = 0.015) and an initial clinical presentation of acute coronary syndrome (OR: 1.967, 95% CI: 1.159 to 3.339, p = 0.012). The overall median follow-up duration for all patients after follow-up OCT examination was 31.0 months, and this was statistically different among the heterogeneous group (22.0 months), the homogeneous group (34.0 months), and the layered group (28.0 months, overall p = 0.002). MACE occurred more frequently in patients with heterogeneous neointima over a median 31-month follow-up period after OCT examination (13.7% vs. 2.9% in homogeneous vs. 7.3% in layered, p = 0.001). A propensity score–adjusted Cox regression analysis showed that independent risk factors for MACE were inclusion in the heterogeneous neointima (hazard ratio: 3.925, 95% CI: 1.445 to 10.662, p = 0.007) and minimal lumen cross-sectional area (hazard ratio: 0.368, 95% CI: 0.242 to 0.560, p < 0.001). Conclusions Determination of neointimal characteristics is helpful in predicting long-term clinical outcomes. Our data suggest that heterogeneous lesions are linked to poor long-term clinical prognoses. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to evaluate the relationship between post-stent strut apposition and follow-up strut coverage using contour plot optical coherence tomographic analysis. Background: Tracking the fate of interested regions of struts at different time points has not been investigated. Methods: Post-intervention and 6-month follow-up optical coherence tomographic evaluations were performed in 82 patients treated with biolimus- (n = 37) or sirolimus-eluting stents (n = 45). Post-stent apposition was classified as embedded, apposed, or malapposed. For volumetric stent evaluation, the post-intervention strut-artery distance and the neointimal thickness at follow-up were measured as a function of the circumferential arc length and longitudinal stent length. Computer-generated contour plots of the strut-artery distance and neointimal thickness were compared. Results: The percentages of embedded and malapposed struts after intervention were 1.8% (Interquartile range [IQR]: 0.6% to 6.2%) and 2.3% (IQR: 0.5% to 5.2%), respectively. The percentages of uncovered and malapposed struts at 6 months were 16.0% (IQR: 7.4% to 33.3%) and 0% (IQR: 0% to 0.7%), respectively. The percentage of uncovered struts at 6 months varied significantly with post-stent strut apposition (0% [IQR: 0% to 11.4%] in embedded, 16.3% [IQR: 8.1% to 31.3%] in apposed, and 26.8% [IQR: 0% to 56.3%] in malapposed, p < 0.001 for all pairwise comparisons). In lesions without tissue prolapse, embedded struts were all covered (100% covered struts) compared with those with tissue prolapse (76.8% covered, p < 0.001). Conclusions: The optical coherence tomography–guided optimization of stent strut apposition enhances strut coverage at follow-up. This comprehensive method for evaluating strut apposition may provide more useful information to understanding the serial changes in strut coverage. (Neointimal Coverage After Implantation of Biolimus Eluting Stent With Biodegradable Polymer: Optical Coherence Tomographic Assessment According to the Treatment of Dyslipidemia and Hypertension and the Types of Implanted Drug-Eluting Stents; NCT01502904) [Copyright &y& Elsevier]

Aims No data exist regarding the relationship between aspirin/clopidogrel resistance and intra-stent thrombi on follow-up optical coherence tomography (OCT) after drug-eluting stent (DES) implantation. The purpose of this study was to evaluate the relationship between aspirin/clopidogrel resistance and intra-stent thrombi on the follow-up OCT in DES-treated patients. Methods and results A total of 308 DES-treated patients who underwent follow-up OCT and simultaneous measurement of aspirin reaction unit (ARU) and P2Y12 reaction unit (PRU) using the VerifyNow assay system were selected for the study. Aspirin and clopidogrel resistance were defined as ARU ≥550 and PRU ≥275, respectively. Intra-stent thrombi were detected in 29 patients (9.4%). The mean time interval from DES implantation to OCT was 195 ± 133 days (202.9 ± 103.0 days for patients with intra-stent thrombi vs. 194.7 ± 136.0 days for patients without intra-stent thrombi; P = 0.750). There were no significant differences between patients with and without intra-stent thrombi with regard to the incidence of aspirin resistance (13.8 vs. 11.1%, respectively; P = 0.630) or clopidogrel resistance (72.4 vs. 50.5%, respectively; P = 0.056). The percentage of uncovered struts was 17.9 ± 15.8% in patients with intra-stent thrombi and 12.7 ± 17.3% in patients without intra-stent thrombi (P = 0.098). Stent length was significantly longer in patients with intra-stent thrombi (22.9 ± 6.0 vs. 19.4 ± 5.0 mm, P = 0.006). Multivariate logistic regression analysis showed that stent length (odds ratio = 1.152, 95% confidential interval 1.025–1.295; P = 0.017) was the only independent risk factor for the presence of intra-stent thrombi on OCT. Conclusion This OCT study suggested that the presence of intra-stent thrombi may not be associated with aspirin/clopidogrel resistance in DES-treated patients. [ABSTRACT FROM PUBLISHER]

Objectives: The study evaluated serial quantitative and qualitative changes in vascular responses to drug-eluting stents (DES) using optical coherence tomography (OCT). Background: Serial changes in stent strut coverage and neointima characteristics in DES-treated lesions have not been sufficiently investigated using OCT. Methods: Serial OCT was performed in 72 patients with 76 DES-treated lesions at 9 months and 2 years after DES implantation (sirolimus-eluting stent, n = 23; paclitaxel-eluting stent, n = 20; zotarolimus-eluting stent, n = 25; everolimus-eluting stent, n = 8). Serial changes in quantitative parameters (neointimal thickness, stent strut coverage, and apposition at each strut) and qualitative characteristics of the neointima were evaluated. Results: Mean neointimal thickness significantly increased from 164 μm to 214 μm between 9 months and 2 years (p < 0.001), and the percentage of uncovered stent struts significantly decreased (from 4.4% to 2.3%, p < 0.001). Completely covered lesions were more frequently observed at 2 years (44.7% vs. 59.2%, p = 0.07). However, the percentage of malapposed struts (0.6% vs. 0.9%, p = 0.24) and incidence of intracoronary thrombi (10.5% vs. 9.2%, p > 0.99) were similar. On qualitative evaluation of neointimal morphology, lipid-laden neointima (27.6% vs. 14.5%, p = 0.009) and thin-cap neoatheroma (13.2% vs. 3.9%, p = 0.07) were more frequently detected at 2-year follow-up compared with 9 months. In matched cross-sectional evaluation, the change of neointimal morphology from homogeneous to heterogeneous or lipid-laden pattern was observed in 23 (30.3%) of 76 lesions. There was a significant increase in percent neointimal hyperplasia cross-sectional area in those lesions. Conclusions: This OCT study suggested that neointimal coverage improved from 9 months to 2 years without significant changes in the incidence of malapposed struts and intracoronary thrombus. Additionally, in-stent neoatherosclerosis including transformation to lipid-laden neointima might progress during extended follow-up periods after DES implantation. [Copyright &y& Elsevier]

Objectives: We performed this study to investigate the vascular response in early period after zotarolimus-eluting stent (ZES) (Endeavor Sprint, Medtronic CardioVascular, Minneapolis, Minnesota) implantation. Background: The ZES has different characteristics, with biocompatible polymer and rapid drug-elution, compared with the first-generation drug-eluting stents (DES). Methods: The ENDEAVOR OCT (Evaluation in 3 Months Duration of Neointimal Coverage after Zotarolimus-Eluting Stent Implantation by Optical Coherence Tomography) trial is a prospective, single-center study evaluating vascular healing patterns with optical coherence tomography (OCT) at 3 months after stent implantation. A total of 31 ZES in 30 patients underwent serial OCT at immediate post-intervention and 3 months. Neointimal growth and malapposition were analyzed at each stent strut of cross-sectional OCT images with 0.5-mm intervals. Results: The incidence of malapposition at post-intervention and 3 months was 6.0% and 0.2%, respectively. However, late acquired malapposition was not detected at 3 months. Of 31 stents, 27 stents (87.1%) were covered completely with neointima, but the remaining 4 stents had 2 (0.8%), 4 (0.9%), 4 (1.2%), and 6 (1.4%) uncovered struts. Overall mean percentage of covered stent struts was 99.9 ± 0.4%. This finding was consistent among groups with acute coronary syndrome and stable angina pectoris (99.9 ± 0.3% vs. 99.9 ± 0.4%, p = 0.92). Intracoronary thrombus was documented in 1 stent (3.2%) among 31 stents. Conclusions: Most of the stent struts were covered with neointima, and late acquired malapposition was not found at 3 months after ZES implantation. Therefore, the current study demonstrated that ZES might have a favorable in vivo vascular response at 3 months after stent implantation. (Evaluation of Zotarolimus Eluting Stent at 3 Months Using Optical Coherence Tomography [ENDEAVOR OCT]; NCT00815139) [Copyright &y& Elsevier]

Machine learning approaches using intravascular optical coherence tomography (OCT) to predict fractional flow reserve (FFR) have not been investigated. Both OCT and FFR data were obtained for left anterior descending artery lesions in 125 patients. Training and testing groups were partitioned in the ratio of 5:1. The OCT-based machine learning-FFR was derived for the testing group and compared with wire-based FFR in terms of ischemia diagnosis (FFR ≤ 0.8). The OCT-based machine learning-FFR showed good correlation (r = 0.853, P < 0.001) with the wire-based FFR. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the OCT-based machine learning-FFR for the testing group were 100%, 92.9%, 87.5%, 100%, and 95.2%, respectively. The OCT-based machine learning-FFR can be used to simultaneously acquire information on both image and functional modalities using one procedure, suggesting that it may provide optimized treatments for intermediate coronary artery stenosis. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text. Background: Using optical coherence tomography, we evaluated early follow-up findings of significant stent malapposition (SSM) in patients treated with second-generation drug-eluting stent. Methods and Results: From the DETECT-OCT randomized trial (Determination of the Duration of the Dual Antiplatelet Therapy by the Degree of the Coverage of the Struts on Optical Coherence Tomography From the Randomized Comparison Between Everolimus- Versus Biolimus-Eluting Stent), a total of 386 patients (390 lesions) who underwent both postintervention and 3-month follow-up optical coherence tomography examinations were included for the present analysis. SSM was defined as a stent that had a strut with a maximal wall-to-strut distance of ≥200 μm. Postintervention, SSM was detected in 175 lesions (44.9%), including 117 lesions with a maximal wall-to-strut distance of ≥200 to <400 μm and 58 lesions with a maximal wall-to-strut distance of ≥400 μm. As the implanted stent diameter-to-reference vessel diameter ratio grew, the risk of postintervention SSM dropped (odds ratio, 0.587; 95% CI, 0.367–0.941; P =0.0398). The optimal value that best separated SSM from non-SSM postintervention was a stent diameter-to-reference vessel diameter ratio of 1.0. At 3 months follow-up, the frequency of SSM decreased from 44.9% to 33.6% (131 lesions; P =0.0001), mainly driven by the decrease in lesions with a maximal wall-to-strut distance of ≥200 to <400 μm. As the maximal wall-to-strut distance on postintervention optical coherence tomography was larger, the risk of 3-month SSM increased (odds ratio, 1.607; 95% CI, 1.131–2.286; P =0.0284). The optimal value that best separated SSM from non-SSM at 3 months follow-up was a maximal wall-to-strut distance postintervention of 230 μm. Conclusions: A spontaneous decrease in SSM was observed early in this qualified study with a large number of study patients treated with second-generation drug-eluting stent. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01752894. [ABSTRACT FROM AUTHOR]

Functional assessment using fractional flow reserve (FFR) and anatomical assessment using optical coherence tomography (OCT) are used in clinical practice for patients with intermediate coronary stenosis. Moreover, coronary computed tomography angiography (CTA) is a common noninvasive imaging technique for evaluating suspected coronary artery disease before being referred for angiography. This study aimed to investigate the association between FFR and plaque characteristics assessed using coronary CTA and OCT for intermediate coronary stenosis. Based on a prospective multicenter registry, 159 patients having 339 coronary lesions with intermediate stenosis were included. All patients underwent coronary CTA before being referred for coronary angiography, and both FFR measurements and OCT examinations were performed during angiography. A stenotic lesion identified with FFR ≤0.80 was deemed diagnostic of an ischemia-causing lesion. The predictive value of plaque characteristics assessed using coronary CTA and OCT for identifying lesions causing ischemia was analyzed. Stenosis severity and plaque characteristics on coronary CTA and OCT differed between lesions that caused ischemia and those that did not. In multivariate analysis, low attenuation plaque on coronary CTA (odds ratio [OR]=2.78; P =0.038), thrombus (OR=5.13; P =0.042), plaque rupture (OR=3.25; P =0.017), and intimal vasculature on OCT (OR=2.57; P =0.012) were independent predictors of ischemic lesions. Increasing the number of these plaque characteristics offered incremental improvement in predicting the lesions causing ischemia. Comprehensive anatomical evaluation of coronary stenosis may provide additional supportive information for predicting the lesions causing ischemia. Prediction of lesions causing ischemia by plaque characteristics on coronary computed tomography angiography and optical coherence tomography. Based on a prospective multicenter registry, this study evaluated the association between the FFR and plaque characteristics assessed using coronary CTA and OCT in patients with intermediate coronary stenosis. In addition to stenosis severity on coronary CTA and OCT, plaque characteristics, including low attenuation plaque on coronary CTA and thrombus, plaque rupture, and intimal vasculature on OCT, were independent predictors for the lesions causing ischemia (FFR ≤0.80). CI, confidence interval; CTA, coronary computed tomography; FFR, fractional flow reserve; OCT, optical coherence tomography; OR, odds ratio. [Display omitted] • Plaque characteristics on coronary CTA and OCT were closely related with FFR-based functional assessment of coronary stenosis. • Low attenuation plaque on coronary CTA was independent predictor of ischemic lesions. • Thrombus, plaque rupture, and intimal vasculature on OCT were also independent predictors of ischemic lesions. • Comprehensive anatomical evaluation of coronary stenosis aids in predicting lesions causing ischemia. [ABSTRACT FROM AUTHOR]

Optical coherence tomography (OCT) was used to assess serial changes in severe acute stent malapposition (ASM) after drug-eluting stent (DES) implantation. The maximal depth and axial lengths of ASM after DES implantation were serially quantified at percutaneous coronary intervention (PCI), and at 3 and 12-month follow-up, for 100 lesions in 96 patients. Severe ASM was defined as a maximal malapposed depth ≥400 μm or maximal malapposed axial length ≥1 mm. Of the 100 lesions, 23 lesions (23%) had a severe ASM depth at PCI. At 3 months, the maximal depth decreased to <400 μm in 12 of 23 lesions (52%). At 12 months, the maximal depth further decreased to <400 μm in 8 of the remaining 11 lesions (73%). Similarly, of 53 lesions (53%) with a severe ASM length at PCI, the maximal length decreased to 0 mm in 26 (49%) but remained severe in 17 lesions (32%) at 3 months. At 12 months, 9 of the 17 remaining lesions (53%) further decreased to 0 mm. The cut-off values for the maximal malapposed depth and length to predict the absence of stent malapposition at 12 months were 565 μm at PCI and 165 μm at 3 months, and were 2.7 mm at PCI and 0.1 mm at 3 months, respectively. Half of the severe ASM cases resolved within 3 months, and another half resolved during 3–12 months of follow-up. Our findings provide a better understanding of the time-dependent natural course of severe ASM using OCT. • Severe ASM could be considered late persistent stent malapposition. • There are concerns about relation between late stent thrombus and severe ASM. • Most severe ASM resolved within 12 months of follow-up after DES implantation. [ABSTRACT FROM AUTHOR]

The impact of late drug-eluting stent (DES) malapposition detected by optical coherence tomography (OCT) on long-term clinical outcomes has not been clearly established. We evaluated long-term clinical outcomes of late stent malapposition (LSM) detected by OCT in a qualified study population. A total of 428 patients were selected from previous randomized OCT studies that evaluated the degree of strut coverage of different DESs at a 3–12-month follow-up OCT examination. These patients were assigned to one of two groups based on the presence (n = 136) or absence (n = 292) of LSM on follow-up OCT images (performed at 7.0 ± 3.4 months after DES implantation). The cumulative rates of composite events (cardiac death, target-vessel-related myocardial infarction, target-vessel revascularization, and stent thrombosis) were compared between the two groups. During 73.7 ± 18.3 months of follow-up, cardiac death or (very) late stent thrombosis did not occur in either group. The cumulative rate of composite events was similar among the patients in each group (6.2% in patients with LSM vs. 11.7% in those without LSM) [hazard ratio (HR) = 0.569, 95% confidence interval (CI) = 0.257–1.257, p = 0.163]. Target vessel-related myocardial infarction occurred in 0.7% of patients with LSM vs. 1.5% of those without LSM (HR = 0.521, 95% CI = 0.058–4.670, p = 0.560). Target-vessel revascularization was performed in 5.4% of patients with LSM vs. 10.2% of those without LSM (HR = 0.574, 95% CI = 0.246–1.343, p = 0.201). Cardiac death or (very) late stent thrombosis did not occur in patients with OCT-detected LSM during long-term follow-up. The presence of OCT-detected LSM was not associated with adverse clinical events. Image 1 • Although OCT-detected LSM is not rare, the relationship between this phenomenon and adverse events is still controversial. • In this study, cardiac death or (very) late stent thrombosis did not occur in patients with LSM during long-term follow-up. • LSM detected in follow-up OCT examination does not have to be corrected by additional interventions. [ABSTRACT FROM AUTHOR]

Objective Serial follow-up optical coherence tomography (OCT) was used to evaluate the effect of optimal lipid-lowering therapy on qualitative changes in neointimal tissue characteristics after drug-eluting stent (DES) implantation. Methods DES-treated patients (n = 218) who received statin therapy were examined with serial follow-up OCT. First and second follow-up OCT evaluations were performed approximately 6 and 18 months after the index procedure, respectively. Patients were divided into two groups, based on the level of low-density lipoprotein-cholesterol (LDL-C), which was measured at the second follow-up. The optimal lipid-lowering group (n = 121) had an LDL-C reduction of ≥50% or an LDL-C level ≤70 mg/dL, and the conventional group (n = 97). Neointimal characteristics were qualitatively categorized as homogeneous or non-homogeneous patterns using OCT. The non-homogeneous group included heterogeneous, layered, or neoatherosclerosis patterns. Qualitative changes in neointimal tissue characteristics between the first and second follow-up OCT examinations were assessed. Results Between the first and second follow-up OCT procedures, the neointimal cross-sectional area increased more substantially in the conventional group (0.4 mm 2 vs. 0.2 mm 2 in the optimal lipid-lowering group, p = 0.01). The neointimal pattern changed from homogeneous to non-homogeneous less often in the optimal lipid-lowering group (1.3%, 1/77, p < 0.001) than in the conventional group (15.3%, 11/72, p = 0.44). Optimal LDL-C reduction was an independent predictor for the prevention of neointimal pattern change from homogeneous to non-homogeneous (odds ratio: 0.05, 95% confidence interval: 0.01∼0.46, p = 0.008). Conclusion Our findings suggest that an intensive reduction in LDL-C levels can prevent non-homogeneous changes in the neointima and increases in neointimal cross-sectional area compared with conventional LDL-C controls. [ABSTRACT FROM AUTHOR]

Background: No randomized studies have been conducted to investigate serial changes in optical coherence tomography (OCT) analyses following implantation of biolimus-A9-eluting stents (BES) and sirolimus-eluting stents (SES). Methods: A total of 60 patients fulfilling the study criteria were randomly assigned into BES (n =30) and SES (n =30) implantation groups. Serial OCT evaluation at post-procedure, 3- and 12-month follow-up was performed in 46 patients [BES (n =22) and SES (n =24)]. OCT analyses were compared according to the type of stents and the follow-up time intervals. The percentage of uncovered struts was defined as the ratio of uncovered struts to total struts in all cross-sections. The primary endpoint was the percentage change (Δ) of uncovered struts in the 3- and 12-month follow-up samples. Results: The percentage of uncovered struts at the 3-month time period was not significantly different in the BES and SES groups; the median value (interquartile range) was 14.7% (0.0–23.4) versus 8.6% (0.7–21.5) (p =0.98), respectively. However, OCT at the 12-month follow-up showed a significantly lower percentage of uncovered struts [2.6% (0.8–5.6) versus 6.2% (1.7–14.7), (p =0.028), respectively] without significant difference of neointimal thickness. BES showed a greater reduction of percentage Δ of uncovered struts from 3–12months than that of SES [−17.2±14.5% versus −7.7±16.3%, respectively (p =0.043)]. Conclusions: Both drug-eluting stents showed a high percentage of incomplete strut coverage at 3months. However, BES showed a significantly lower percentage of uncovered struts at 12months compared to that of SES. This was achieved by superior strut coverage from 3 to 12months. [ABSTRACT FROM AUTHOR]

Abstract: Background: Acute coronary syndrome (ACS) is an independent risk factor for late stent thrombosis which might be related to the impaired vascular healing after drug-eluting stent (DES) due to the disruption of plaques and thrombus formation. Therefore, we investigated the vascular response after various DES implantations between ACS and stable angina pectoris (SAP) using optical coherence tomography (OCT). Methods: Ninety-one patients [49 ACS: 20 sirolimus-eluting (SES), 12 paclitaxel-eluting (PES) and 17 zotarolimus eluting stent (ZES) and 42 SAP: 15 SES, 12 PES and 15 ZES] underwent OCT at 9months after stent implantation. Neointimal coverage and malapposition were evaluated in 21,939 struts in 2269-mm stented segments. Results: In the ACS group, the incidence of uncovered and malapposed struts was significantly higher (8.9±13.7 vs 2.9±6.2%, p =0.01 and 2.2±5.6 vs 0.5±2.0%, p =0.02). Among the three DESs tested, SES showed a significantly higher rate of uncovered struts in the ACS group (17.3±13.4 vs 4.4±6.2%, p =0.003). PES had a trend toward higher rate of uncovered and malapposed struts in the ACS groups (6.7±7.6 vs 4.0±9.0%, p =0.13) while ZES was similar in both groups. Conclusion: The patterns of neointimal coverage and malapposition at 9months after DES implantation were different between ACS and SAP, and variable among the DES type between two groups. Therefore, the present study suggests that vascular response after DES implantation might be influenced by both clinical presentation and type of DES. [ABSTRACT FROM AUTHOR]

The status of neointimal coverage on the drug-eluting stent (DES) struts, which are placed across the side-branch vessels, remains unclear. The degree of neointimal coverage of stent struts crossing the side-branch vessel was evaluated according to the different types of DESs. Follow-up optical coherence tomography images at 9.3 months after the index procedure were identified in 51 patients who had undergone DES (sirolimus-eluting stents [SESs] in 22 patients, paclitaxel-eluting stents [PESs] in 15, and zotarolimus-eluting stents [ZESs] in 14) implantation with crossover of the side-branch vessels (size >2.0 mm). The enrolled patients were classified as a covered group if every unapposed strut showed neointimal coverage or an uncovered group if any struts lacked neointimal coverage. The neointimal hyperplasia thickness was also measured. The number of patients in the covered group was 15 (29%), with 36 patients in the uncovered group. Significant differences were found in the proportion of the covered group among the 3 DES types (6 [27%] of 22 with SESs, 1 [7%] of 15 with PESs, and 8 [57%] of 14 with ZESs; p = 0.011). The percentage of neointimal coverage in the overall stent struts was also significantly different among the 3 DES types (65% of 356 struts, 20% of 165 struts, and 83% of 143 struts for the SESs, PESs, and ZESs, respectively; p<0.001). The neointimal hyperplasia thickness in the PES group was significantly smaller than those of the ZES and SES groups (0.02 ± 0.02 mm vs 0.08 ± 0.06 mm and 0.04 ± 0.03 mm, respectively; p = 0.002). In conclusion, different patterns of neointimal coverage of the stent struts crossing the side branch vessels were observed according to the type of DES. [Copyright &y& Elsevier]

The introduction of optical coherence tomography has provided a new method for evaluating the vascular response to drug-eluting stents (DESs). We used optical coherence tomography to compare neointimal coverage and stent malapposition among DESs in patients with ST-segment elevation myocardial infarction. Optical coherence tomography was performed at 9 months after implantation of 3 types of DESs at the culprit lesions in 46 patients with ST-segment elevation myocardial infarction (16 sirolimus-eluting stents [SESs, Cypher Select], 11 paclitaxel-eluting stents [PESs, Taxus Liberte], and 19 zotarolimus-eluting stents [ZESs, Endeavor Sprint]). The neointimal thickness and apposition at each strut at each 1-mm interval and the presence of thrombi in each stent were evaluated. A total of 11,512 stent struts were analyzed. SESs had the thinnest neointimal thickness (SES 62 ± 43 μm vs PES 244 ± 142 μm vs ZES 271 ± 128 μm, p <0.001). The incidence of uncovered struts and malapposed struts were significantly greater in SESs and PESs than in ZESs (SES vs PES vs ZES, 16.2 ± 17.8% vs 4.7 ± 7.4% vs 0.6 ± 1.5%, respectively, p = 0.001; and 4.0 ± 8.2% vs 2.1 ± 4.5% vs 0 ± 0%, respectively, p = 0.001). Thrombus was also detected more often in SESs and PESs than in ZESs (SES, 6 [38%] vs PES, 3 [27%] vs ZES, 1 [5%], p = 0.02). In conclusion, the rate of stent strut coverage and malapposition were significantly different among the DES types in ST-segment elevation myocardial infarction. In particular, most stent struts in ZESs were covered with neointima and well-apposed. These findings imply that the type of DES might affect the vascular response in thrombotic lesions of ST-segment elevation myocardial infarction. [Copyright &y& Elsevier]

Objectives: Significant stent malapposition (SSM) is one of important mechanisms of drug-eluting stent (DES) thrombosis. Using optical coherence tomography (OCT), we evaluated early follow-up findings of SSM in patients treated with second-generation DES. Methods and Results: From the DETECT-OCT randomized trial, a total of 386 patients (390 lesions) who underwent both post-intervention and 3-month follow-up OCT examinations were included for the present analysis. SSM was defined as a stent that had a strut with a maximal wall-to-strut distance of ≥200μm. Post-intervention, SSM was detected in 175 lesions (44.9%), including 117 lesions with a maximal wall-to-strut distance of ≥200μm to <400μm and 58 lesions with a maximal wall-to-strut distance of ≥400μm. As the implanted stent diameter-to-reference vessel diameter ratio grew, the risk of post-intervention SSM dropped (odds ratio [OR]=0.587, 95% confidence interval [CI]=0.367-0.941, p=0.0398). The optimal value that best separated SSM from non-SSM post-intervention was a stent diameter-to-reference vessel diameter ratio of 1.0. At 3 months follow-up, the frequency of SSM decreased from 44.9% to 33.6% (131 lesions) (p=0.0001), mainly driven by the decrease in lesions with a maximal wall-to-strut distance of ≥200μm to <400μm. As the maximal wall-to-strut distance on post-intervention OCT was larger, the risk of 3-month SSM increased (OR=1.607, 95% CI=1.131-2.286, p=0.0284). The optimal value that best separated SSM from non-SSM at 3 months follow-up was a maximal wall-to-strut distance post-intervention of 230μm. Conclusions: A spontaneous decrease in SSM was observed early in this qualified study with a large number of study patients treated with second-generation DES. [ABSTRACT FROM AUTHOR]