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Background: In the setting of the Acute Coronary Syndrome (ACS), differences in response to prasugrel and ticagrelor between East Asian and European patients have not been investigated yet. Methods: This is a sub-analysis of the "BleeMACS registry". Patients admitted for ACS and underwent PCI from between 2012 and 2014 were stratified first according to their provenance, Europe vs. East Asia (China and Japan), and then by country. The adjusted rate of 1-year serious bleeding - safety end-point-and 1-year death/re-infarction -effectiveness endpoint-of the new P2Y12r inhibitors were compared. Results: Data of 10004 patients in Europe and 2332 patients in East Asia were collected. At baseline prior stroke (6% vs 9%, p

Bleeding events after an acute coronary syndrome have a negative impact on prognosis. Available risk scores are limited by suboptimal accuracy, prediction of only in-hospital events and absence of patients treated with new antiplatelet agents in the current era of widespread use of percutaneous coronary intervention. The BleeMACS (Bleeding complications in a Multicenter registry of patients discharged after an Acute Coronary Syndrome) project is a multicenter investigator-initiated international retrospective registry that enrolled more than 15 000 patients discharged with a definitive diagnosis of acute coronary syndrome and treated with percutaneous revascularization. The primary end point is the incidence of major bleeding events requiring hospitalization and/or red cell transfusion concentrates within 1 year. An integer risk score for bleeding within the first year after hospital discharge will be developed from a multivariate competing-risks regression. The BleeMACS registry collaborative will allow development and validation of a risk score for prediction of major bleeding during follow-up for patients receiving contemporary therapies for acute coronary syndrome

Background. Benefits of beta-adrenergic receptor blockers (BB) following ST-elevation myocardial infarction (STEMI) are based on data before primary percutaneous coronary intervention (PCI) became the therapeutic first choice. This study examined the relationship between BB dose and magnitude of left ventricular ejection fraction (LVEF) improvement in STEMI following primary PCI. Methods and Findings. A total of 235 STEMI patients following primary PCI who underwent echocardiography during the acute phase and over 6 months from onset were studied retrospectively. Serial LVEFs were assessed for three groups: no BB (n=33), carvedilol (n=163), and bisoprolol (n=42). Left ventricular reverse remodeling (RR) was defined as LVEF improvement ≥10%. All patients received fixed doses of BB and renin-angiotensin system inhibitor during observation. The median interval between echocardiographs was 526 days. The mean LVEF change was +2.6% (acute: 53.9±9.9%, chronic: 56.4±10.6%). Carvedilol and bisoprolol groups showed LVEF improvement, but none was seen in the no BB group (+3.7±6.5%, +3.8±6.9%, -4.2±5.0%, P

Very late stent thrombosis (VLST) is a major unresolved problem of drug-eluting stent (DES) implants. However, its actual incidence with respect to the distribution of DES-target vessel and accuracy of adjudicating stent thrombosis according to the ARC definition has not been yet adequately evaluated. We studied 720 patients who had completed over 1 year from elective DES implantation. In this cohort, we extracted patients who present acute coronary syndrome (ACS) (n = 3, 0.4%). The timing of ACS events was 17, 19, and 24 months after DES implantation. At the time of presentation, VLST was strongly suspected as the initial diagnosis, however, coronary angiography (CAG) confirmed the different culprit lesion from DES and clearly no thrombus within the DES. According to ARC definition, three probable stent thromboses in this cohort before CAG, however, no stent thrombosis was confirmed after the CAG. Thus, no stent thrombosis was confirmed among this study population. In the very late phase after DES implantation, new onset ACS is not at all extraordinary occurrence in the target vessels of previous DES implantation. However, stent thrombosis is often assumed without angiographic confirmation. The clinical possibility that non-stent thrombosis is incidentally diagnosed with stent thrombosis without angiographic confirmation should be considered within the current accepted definition of stent thrombosis.

It is well known that percutaneous coronary intervention in hemodialysis (HD) patients is associated with higher rates of in-stent restenosis (ISR) compared to non-HD patients. However, little is known about lesion morphologies that may contribute to ISR in this population. Therefore, this study

Background The aim of this study was to investigate the accuracy of optical frequency domain imaging (OFDI) in lipid-rich plaque detection and determine the causes of "misinterpretation," and evaluate whether these limitations can be overcome with intravascular ultrasound (IVUS) using ex-vivo human coronaries. Methods and results The OFDI images and corresponding 218 histological segments were evaluated. Segments with a poor signal and diffuse borders on OFDI, classified as lipid-rich plaques, were compared with the histological segments and IVUS images. Using histological images as the gold standard, the sensitivity, specificity, positive predictive value, and negative predictive value of OFDI for the detection of lipid-rich plaques were 93%, 93%, 85%, and 97%, respectively. The causes of false-positive diagnosis of lipid-rich plaque (11 segments) were superficial macrophage infiltration causing signal attenuation (8/11 segments, 73%) and tangential signal dropout of light (3/11 segments, 27%), whereas the cause of false-negative diagnosis was thickening of the fibrous cap (5 segments, 100%). Simultaneous IVUS helped to correct the misinterpretation of OFDI results and improved the diagnostic accuracy; the sensitivity, specificity, positive predictive value, and negative predictive value of OFDI with adjunct use of IVUS were 96%, 99%, 99%, and 98%, respectively. Conclusions OFDI occasionally over- or underestimates the existence of lipid-rich plaques, which may be overcome with adjunctive usage of IVUS.

As altered blood flow in the cerebral perforating arteries (PA) might be related to development of cerebral white matter hyperintensities, we examined whether the hemodynamic relationship of the PA and middle cerebral artery (MCA) is altered in rat models of diabetes, compared with normal rats and a rat model of sinoatrial denervation (blood pressure fluctuation model).We used microangiography with monochromatic synchrotron radiation to measure the diameters of the PA and MCA at 4.5 μm resolution in five groups of rats: (i) Long-Evans Tokushima Otsuka (LETO); (ii) Otsuka Long-Evans Tokushima Fatty (a model of type 2 diabetes with obesity); (iii) LETO with sinoaortic denervation (LETO + SAD); (iv) F344; and (v) F344 + streptozotocin (a model of type 1 diabetes).Compared with LETO, Otsuka Long-Evans Tokushima Fatty rats showed a significant reduction in the diameter of both PA and MCA, though the PA/MCA diameter ratio was unchanged. In contrast, compared with LETO, LETO + SAD rats showed an increased MCA diameter, and the PA/MCA diameter ratio was decreased. Compared with F344 rats, the MCA diameter was increased in F344 + streptozotocin rats, and the PA/MCA diameter ratio was decreased. Scatter diagrams showed that the diameters of the PA and MCA were essentially independent of each other in the two types of diabetic models.PA were consistently visualized at high resolution by means of microangiography using synchrotron radiation. The present results show that rat diabetic models exhibit changes in PA diameter and PA/MCA diameter ratio, which might be related to the development of diabetes-associated cerebral white matter hyperintensities.

The spatial resolution of conventional angiographic systems is not enough to predict diabetic microangiopathy in arterioles (20-200 µm).To determine whether fingertip synchrotron (SR) radiation microangiography has enough spatial resolution to quantitate arteriolar diameter changes, and whether an arteriolar paradoxical vasoconstriction is a characteristic observation for diabetic microangiopathy, diameter reduction as arteriolar branching and difference of the diameter changes induced by acetylcholine between control (n = 5) and diabetic rats (n = 5) were analyzed.Fingertip SR microangiography visualized the arterioles with a diameter range of 30-300 µm and demonstrated vascular diameter reduction as branching with a fixed ratio (r = 0.93, P0.004 and r = 0.73, P0.001). A vasodilatory reaction was induced by acetylcholine in the control (142.4 ± 61.9 to 190.9 ± 73.5, P0.05, n = 25), in contrast, paradoxical vasoconstriction in diabetic rats (201.6 ± 83.0 to 16 0.4 ± 67.9, P0.05, n = 37). Histological angiopathy was noted only in the diabetic rats.In conclusion, the fingertip SR microangiography is useful to predict diabetic micrangiopahty.

Routine use of distal protection for ST-segment elevation myocardial infarction (STEMI) is not recommended. The purpose of this study was to analyze the impact of slow flow on mortality after STEMI, and the efficacy of adjunctive distal protection following primary thrombus aspiration. We retrospectively analyzed 414 STEMI patients who underwent primary PCI. Distal protection was used following primary thrombus aspiration only when the operator judged the patient to be at high risk of slow flow. Patients were divided into 3 groups: those receiving no thrombus aspiration (A- Group), thrombus aspiration without distal protection (A+/D- Group) or a combination of aspiration with distal protection (A+/D+ Group). Slow flow/no reflow was characterized as transient or persistent. The A-, A+/D-, and A+/D+ Groups consisted of 28.5 % (n = 118), 44.4 % (n = 184), and 27.1 % (n = 112) of patients, respectively. All-cause mortality at 180 days was 6.8 % without slow flow, 14.1 % with transient and 44.4 % with persistent slow flow (P < 0.0001), but was similar whether or not distal protection was used among these groups complicated without slow flow (A-, 8.7 %; A+/D-, 6.3 %; A+/D+, 4.3 %; P = 0.5854). However, in cases complicated with transient or persistent slow flow, distal protection reduced all-cause mortality to 38.5 % (A-), 23.3 % (A+/D-), and 10.8 % (A+/D+) at 180 days (P = 0.0114). Our data confirm that routine distal protection is not to be recommended. However, it is suggested that it could reduce mortality of patients with slow flow. Predicting slow flow accurately before PCI, however, remains a challenge.

Risk stratification is important in the management of Brugada syndrome (BrS). Late potentials (LPs) and T-wave amplitude variability (TAV) in high-resolution ambulatory electrocardiography (ECG) were retrospectively investigated.One hundred and twenty-seven patients diagnosed with BrS on 12-lead ECG were classified into 3 groups: documented ventricular fibrillation (VF)/asystole (n=19), episodes of syncope alone (n=30), and asymptomatic (n=78). Healthy volunteers were enrolled as controls (n=25). In the BrS patients, LPs showed appreciable circadian periodicity; filtered QRS duration (fQRS) and duration of the terminal low-amplitude signal40 μV (LAS40) increased, whereas root mean square voltage of the terminal 40 ms of the fQRS (RMS40) decreased at night compared with the day. TAV did not have such a circadian periodicity. LP-positive incidence (night-time) and peak TAV were as follows: VF/asystolesyncope/asymptomaticcontrol (P0.001). VF/asystole was discriminated from control at a ratio of 81-84% by night-time LPs (fQRS116 ms, LAS4035 ms, RMS4025 μV) or peak TAV (54 μV); VF/asystole was discriminated from syncope/asymptomatic at a ratio of 60-69%, by night-time LPs (fQRS122 ms, LAS4042 ms, RMS4018μV) or peak TAV (58 μV). Combined analysis of LPs and peak TAV increased the discriminant ratio up to 93% and 77%, respectively.Analysis of both LPs and TAV (taking circadian periodicity into account) is useful in identification of high-risk BrS patients.

Diabetic microangiopathy causes acetylcholine-induced paradoxical vasoconstriction in arterioles (20-200 μm). Because conventional angiographic systems lack sufficient spatial resolution (100-200 μm), they are not useful for prediction of diabetic microangiopathy and for the prevention of lethal cardiovascular diseases.

Upper-limb arterial anomalies are sometimes encountered during transradial coronary procedures. These anomalies may contribute to procedural failure or to vascular complications, and are a major reason why many operators tend to avoid transradial procedures. We investigated the frequency of right upperlimb arterial anomalies using antegrade arteriography in patients undergoing transbrachial coronary angiography or intervention, and discuss the potential impact of these anomalies on the transradial procedure.We prospectively studied 163 consecutive patients who underwent right transbrachial coronary angiography or intervention for the first time during the period from May 2007 to December 2007. Following the transbrachial procedure, we performed antegrade transbrachial arteriography of right upper-limb arteries in these patients and investigated the frequency and anatomy of arterial anomalies.A total of 40 upper-limb arterial anomalies were observed in 38 patients (23.3%). These included 8 abnormal origins (4.9%), 2 radio-ulnar loops (1.2%), 25 tortuosities (15.3%), 4 stenoses (2.5%) and 1 loop (0.6%). In patients with congenital lesions (8 patients; 4.9%), abnormal origin of the radial artery was the most common anomaly encountered, and in the acquired group (25 patients; 15.3%), tortuosity was the most common abnormality.Even with a 23.3% incidence of right upper-limb arterial abnormalities, 98.8% of patients were acceptable for transradial coronary intervention except for 1.2% of radio-ulnar loops.

The aim was to examine the efficacy of the simple technique that reduces tangling of the guidewires by utilizing wet gauze during percutaneous coronary intervention with multiple guidewires. We defined "Critical tangle of the guidewires" as occurring when it became impossible to insert balloon catheters into the bifurcation lesion due to tangling of the guidewires without withdrawing and reinserting one of the guidewires. We compared the rate of the critical tangle of the guidewires between the group taking no special tangle precaution ("NP Group"), and the group taking the tangle precaution with the wet gauze ("Gauze Group"). Eighty-four patients were enrolled in the study and randomly assigned to either NP Group (n = 43) or Gauze Group (n = 41). The kissing balloon technique success was 42/43 (97.7%) versus 40/41 (97.6%), in NP Group and Gauze Group, respectively. The rate of critical tangle of the guidewires was significantly lower in Gauze Group (27.9 vs. 7.3%, p = 0.014). The manipulation of several guidewires utilizing gauze method will be a useful technique for reducing tangle of the guidewires during the procedure of kissing balloon technique.

To determine the optimal radial puncture point, we analyzed the anatomy and luminal diameter of the right radial artery (RA) by quantitative angiography.Difficulty of radial puncture has impeded the establishment of the transradial approach as the standard procedure for cardiac catheterization.Antegrade angiography was performed from the right brachial artery in 135 patients who underwent coronary angiography. Presence and location of a bifurcation in the area of the RA puncture were analyzed. Furthermore, inner luminal diameter of the RA was quantitatively measured. We used the line between the styloid process and the ulnar styloid process (R-U line) as an anatomical reference point.Radial arterial bifurcation with a superficial palmar branch was angiographically observed in 66 patients (48.9%). The inner luminal diameter was significantly larger at the proximal point to the point of bifurcation. The bifurcation level was located at a median of -3.33 mm (interquartile range: -5.60 to 4.69 mm) below the R-U line. Radial puncture at 10 mm proximal to the R-U line could avoid bifurcation in 91.9% of all cases. Mean radial, ulnar and brachial arterial inner diameters were 2.94 +/- 0.52 mm, 2.51 +/- 0.49 mm and 4.53 +/- 0.62 mm. The RA size within 10-60 mm above the R-U line was nearly invariable throughout the range. CONCLUSION The radial puncture level should be proximal to the radial bifurcation because of its lumen size. The ideal puncture point was found to be at least 10 mm proximal to the R-U line.

Radiocontrast-induced nephropathy (CIN) is one of the most serious complications of percutaneous coronary interventions (PCI). The prevention of PCI-related CIN for chronic kidney disease (CKD) patients has not been established yet. The intravascular ultrasound (IVUS) is commonly used as an imaging device during PCI. We performed IVUS-guided PCI while only using fluoroscopic imaging and without administering any routine contrast dye injection during the procedures. All patients underwent a baseline coronary angiography prior to the elective PCI. During the PCI, all the following procedures were done with X-ray fluoroscopic imaging without or with a minimized contrast dye injection: the engagement of the guiding catheter, insertion of the coronary guidewire, insertion of the IVUS catheter, the stent deployment and the post-dilatation. The diameter and the length of the balloon and the stent were determined according to the pre-procedural IVUS findings, and the end point of the stent dilatation was also judged according to the acquired minimal cross-sectional area of the stent. Here we report our findings from two cases representative of IVUS-guided minimum contrast PCI in which the volumes of contrast dye during the procedure were 5 and 4 ml, respectively. No CIN occurred after either procedure. The IVUS-guided minimum contrast PCI could be a promising option for the prevention of CIN after PCI.

近年、中枢神経系遠心路の客観的評価法として、磁気刺激による誘発筋電図が注目を集めている。今回我々は、健常成人12名について、その誘発筋電図記録を短母指外転筋に限定して磁気刺激を行い、その臨床応用について検討した。磁気刺激の強度を上昇させる事によりMEPの振幅増大および潜時短縮を認めたが、これは強い刺激を加えることにより被刺激部位が広範囲になり、かっ深部まで波及するためと考えられた。CMCTは、身長との相関を認めなかった。測定筋、拮抗筋の随意収縮運動は、MEPの増強作用を認めることが分かった。短母指外転筋にて誘発筋電図を記録することが出来る頭皮上刺激部位のMappingは、かなり広範囲に及んでいたが、F3，Fz、C3、Czを中心とするものであった。

✓ A patient is described with an orbital varix arising from the right superior ophthalmic vein, associated with ophthalmoplegia and severe pain, and without proptosis. The varix was detected using computerized tomography and orbital phlebography, and at surgery was verified as a venous aneurysm. During the operation, a pearly phlebolith was found. Histological examination of the varix revealed multiple ectatic venous channels. The etiology of this unusual clinical manifestation and the treatment of the patient are briefly discussed.

Dense particles of hydroxyapatite (HAP) were consolidated in the frontal sinus of dogs, and bone formation with time was observed in undecalcified ground sections using Cole's HE stain. In the HAP mass on the experimental side, a small amount of newly generated bone was seen around the inner wall of the sinus after 3 months. Even after 12 months, bone formation was still limited to the surrounding region and did not extend to the central region of the sinus. In the sinus opened area, bone formation was seen from both ends of the bone along the HAP particles, and ossiferous closing was observed without leaving a recess at 12 months. On the control side, yellow bone marrow tissue, pneumatic spaces or cyst formation were seen, and a recess was left in the sinus opened area in all cases.

Recently, T-wave variability (TWV) has been notified by Dr. Zareba et al., as attractive marker of repolarization abnormalities. Differing from T-wave alternans which merely observes alternative beat-to beat changes of the amplitude of T-waves, TWV reflects morphological changes of the entire component aspect of ST-T waves by dividing ST-T segment into 40 ms duration for each beat. This method was useful for identifying the high risk patients in myocardial ischemia or dilated cardiomyopathy, however until now there are still few reports about the utility. TWV was measured by the ambulatory monitoring, and therefore a clinical significance might be a great role to capture the repolarization changes during sleep at night. We investigated the longitudinal fluctuations of TWV in the two kinds of disease to stratify risks for fatal arrhythmia. One is Brugada syndrome and the other is sleep apnia syndrome. We used high-resolution ambulatory ECG (2.5 µV, 1000 Hz) manufactured by the Ela Medical company for 24-hours continuously. The data of TWV were analyzed and other electrocardiographic parameters including late potentials (LP), heart rate variability (HRV), heart rate turbulence (HRT), and QT/RR slope were also analyzed using same data. In this symposium, we will report the results of these analyses.

The present paper reports two cases of calcifying odontogenic eyst, including a review of previously reported cases of the lesion in Japan.Case 1: A 24-year-old woman had a painless swelling in the right maxillary incisor region. The radiographic examination showed an ovoid radiolucent area containing several small radiopaque spots. The lesion was enucleated. Histopathological findings from the specimens showed the presence of ghost cells and calcified tissues in the connective tissue around the cyst wall. The patient had an uneventful postoperative course and the follow-up radiographs were not available for study.Case 2: A 32-year-old man was referred complaining a mental mandibular swelling which had been present for one year. The radiographic examination showed two cystic radiolucent area from the right incisor to the left second premolar area, and tooth-like appearance could be found in the left one. These cysts were enucleated and HAP was consolidated into the bone defect occurred postoperatively. Histopathological findings revealed that the epithelium of the right side cyst contained ghost cells, calcified tissues, and foreign body giant cells. The left one was complex odontoma. Postoperative courses were uneventful and no relapse was found.

Background Reducing total ischemic time is important in achieving better outcome in ST-segment elevation myocardial infarction (STEMI). Although the onset-to-door (OTD) time accounts for a large portion of the total ischemic time, factors affecting prolongation of the OTD time are not established. Purpose The purpose of this study was to determine the impact of transport pathways on OTD time in patients with STEMI. Methods and subjects We retrospectively studied 416 STEMI patients who were divided into 4 groups according to their transport pathways; Group 1 ( n = 41): self-transportation to percutaneous coronary intervention (PCI) facility; Group 2 ( n = 215): emergency medical service (EMS) transportation to PCI facility; Group 3 ( n = 103): self-transportation to non-PCI facility; and Group 4 ( n = 57): EMS transportation to non-PCI facility. OTD time was compared among the 4 groups. Essential results Median OTD time for all groups combined was 113 (63–228.8) min [Group 1, 145 (70–256.5); Group 2, 71 (49–108); Group 3, 260 (142–433); and Group 4, 184 (130–256) min]. OTD time for EMS users (Groups 2 and 4) was 138 min shorter than non-EMS users (Groups 1 and 3). Inter-hospital transportation (Groups 3 and 4) prolonged OTD by a median of 132 min compared with direct transportation to PCI facility (Groups 1 and 2). Older age, history of myocardial infarction, prior PCI, shock at onset, high Killip classification, and high GRACE Risk Score were significantly more frequent in EMS users. Principal conclusions Self-transportation without EMS and inter-hospital transportation were significant factors causing prolongation of the OTD time. Approximately 35% of STEMI patients did not use EMS and 21% of patients were transported to non-PCI facilities even though they called EMS. Awareness in the community as well as among medical professionals to reduce total ischemic time of STEMI is necessary; this involves educating the general public and EMS crews.

Intravenous amiodarone (AMD) induces multiple antiarrhythmic effects via blocking of Na(+), Ca(2+), and IKr channels, and beta receptors. A patient on chronic dialysis was administered AMD for nonsustained ventricular tachycardia after successful cardiopulmonary resuscitation. QT prolongation occurred 5 h after AMD administration. AMD was withdrawn at 24 h because of prolonged QTc interval (716 ms), which persisted for a further 48 h (661 ms). Ventricular premature contraction (VPC) was significantly decreased at 7h; however, VPC increased again after discontinuing AMD. Depolarization changes induced by the Na(+)-channel blocking action of AMD were analyzed. There was increasing filtered QRS-duration and duration of low-amplitude signals at voltage40 µV, and decreasing root-mean-square voltage of signals in the last 40 ms of ventricular late potentials (LPs) within 7 h. However after stopping AMD, LPs were reversed. The blood concentration of AMD reached the effective level within 10 min but decreased immediately to an ineffective level. Onset and disappearance of the VPC-inhibiting effect corresponded to the depressive effect on depolarization but not with the increase in the prolonged repolarization effect and blood concentration. Even if the QT interval is sufficiently prolonged, the Na(+)-channel blocking action is required for AMD to induce the antiarrhythmic effect.