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Intake of hemoglobin by the hemoglobin-haptoglobin receptor CD163 leads to a distinct alternative non-foam cell antiinflammatory macrophage phenotype that was previously considered atheroprotective. Here, we reveal an unexpected but important pathogenic role for these macrophages in atherosclerosis. Using human atherosclerotic samples, cultured cells, and a mouse model of advanced atherosclerosis, we investigated the role of intraplaque hemorrhage on macrophage function with respect to angiogenesis, vascular permeability, inflammation, and plaque progression. In human atherosclerotic lesions, CD163+ macrophages were associated with plaque progression, microvascularity, and a high level of HIF1α and VEGF-A expression. We observed irregular vascular endothelial cadherin in intraplaque microvessels surrounded by CD163+ macrophages. Within these cells, activation of HIF1α via inhibition of prolyl hydroxylases promoted VEGF-mediated increases in intraplaque angiogenesis, vascular permeability, and inflammatory cell recruitment. CD163+ macrophages increased intraplaque endothelial VCAM expression and plaque inflammation. Subjects with homozygous minor alleles of the SNP rs7136716 had elevated microvessel density, increased expression of CD163 in ruptured coronary plaques, and a higher risk of myocardial infarction and coronary heart disease in population cohorts. Thus, our findings highlight a nonlipid-driven mechanism by which alternative macrophages promote plaque angiogenesis, leakiness, inflammation, and progression via the CD163/HIF1α/VEGF-A pathway.

Background Although a large isolated surface area of the left atrium (LA) may improve the success rate of catheter ablation (CA) for paroxysmal atrial fibrillation (AF), little is known about the relation between clinical outcomes and the amount of atrial mass reduction (AMR: ratio of total isolated and ablated areas to LA surface area) in different ablation strategies for patients with long-standing persistent AF (L-PeAF). Methods We randomly assigned 119 consecutive L-PeAF patients to adjunctive linear ablation ( n =60) or complex fractionated atrial electrogram (CFAE)-guided ablation ( n =59) after circumferential antral pulmonary vein isolation (PVI). Linear lesions included roof and anterior lines with conduction block. LA defragmentation was performed with an automated CFAE-detection algorithm. Cavotricuspid isthmus block was performed in all patients. Creatine kinase-MB (CK-MB) and troponin-T levels were measured 1day post-CA. Results CK-MB and troponin-T levels were higher, ablation time was longer, and AMR was greater in the CFAE-guided ablation group than in the linear ablation group. AF termination during CA was more frequently observed in the linear ablation group than in the CFAE-guided ablation group ( P =0.031). Twelve months after a single procedure, recurrence occurred in 16 (26.7%) patients with linear ablation and 27 (45.8%) patients with CFAE-guided ablation ( P =0.023). On multivariate analysis, LA volume and ablation method were the only independent risk factors for arrhythmia recurrence. Conclusion Conduction block through linear lines+PVI was an efficient ablation strategy for L-PeAF, whereas the AMR amount did not influence clinical outcomes.

PURPOSE Differences in the utility of routine angiographic follow-up (RAF) and clinical follow-up (CF) after percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) are not well understood. The present study aimed to compare the 3-year clinical outcomes of RAF and CF in AMI patients who underwent PCI with drug-eluting stents (DES). MATERIALS AND METHODS A total of 774 consecutive AMI patients who underwent PCI with DES were enrolled. RAF was performed at 6 to 9 months after index PCI (n=425). The remaining patients were medically managed and clinically followed (n=349); symptom-driven events were captured. To adjust for any potential confounders, a propensity score matched analysis was performed using a logistic regression model, and two propensity-matched groups (248 pairs, n=496, C-statistic=0.739) were generated. Cumulative clinical outcomes up to 3 years were compared between RAF and CF groups. RESULTS During the 3-year follow-up period, the cumulative incidences of revascularization [target lesion revascularization: hazard ratio (HR), 2.40; 95% confidence interval (CI), 1.18-4.85; p=0.015, target vessel revascularization (TVR): HR, 3.33; 95% CI, 1.69-6.58; p=0.001, non-TVR: HR, 5.64; 95% CI, 1.90-16.6; p=0.002] and major adverse cardiac events (MACE; HR, 3.32; 95% CI, 1.92-5.73; p

Emotional stimulation was reported to be related to coronary events, but, there is a lack of direct mechanistic evidence between metabolic activity of the amygdala, a neural stress center, and coronary artery disease (CAD) including acute coronary syndrome. In this study, we aimed to evaluate

Acute myocardial infarction (AMI) is associated with impaired long-term clinical outcomes. However, long-term clinical outcomes of AMI in younger patients age 45 years or younger is not clear. A total of 1,333 patients presenting with AMI who underwent percutaneous coronary intervention (PCI) were

Percutaneous coronary intervention (PCI) for multivessel disease has been widely used as a revascularization option for elderly patients with development of contemporary drug-eluting stents (DES). However, there are limited data regarding long-term clinical outcomes following successful PCI in

There are limited long-term outcome data comparing BioLinx polymer (B)-zotarolimus-eluting stents (ZES) with phosphorylcholine polymer (P)-ZES. The aim of this study was to compare the efficacy and safety of B-ZES with P-ZES in patients who underwent percutaneous coronary intervention (PCI) during a 3-year follow-up period.One thousand two hundred fifty four patients who underwent PCI with P-ZES (Endeavor [ZES-E] or Endeavor sprint [ZES-S], n = 356) or B-ZES (Endeavor resolute [ZES-R] or Resolute Integrity [ZES-I], n = 889) were enrolled. The primary endpoint was major adverse cardiac events (MACE); the composite of total death, non-fatal myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), non-target vessel revascularization (Non-TVR), and the secondary endpoint was stent thrombosis (ST).After PSM, 2 propensity-matched (PSM) groups (275 pairs, n = 550, C-statistic = 0.730) were generated. During the 3-year follow-up period, the cumulative incidence of MACE (hazard ratio [HR], 1.525; 95% confidence interval [CI], 0.920-2.526; P = .101) and ST (HR, 1.248; 95% CI, 0.335-4.4649; P = .741) were similar between P-ZES and B-ZES after PSM. However, TLR rate was significantly higher in ZES-S than ZES-I (11.3% vs 3.8%, log rank P = .029) and TVR rate was higher in ZES-S than ZES-R (14.1% vs 4.8%, log rank P = .025).In this single-center, all-comer registry, despite different polymers, P-ZES, and B-ZES showed comparable safety and efficacy during a 3-year follow-up period after PCI.

The impact of sarcopenia on atherosclerotic cardiovascular disease remains unclear. We aimed to investigate the prognostic impact of sarcopenia on coronary artery disease (CAD). A total of 475 patients with CAD who underwent successful percutaneous coronary intervention (PCI) and computed tomography (CT) were enrolled. The cross-sectional area of skeletal muscle at the first lumbar (L1) vertebral level was measured, and sex-specific cut-off values of L1 skeletal muscle index (L1 SMI, male &lt, 31.00 cm2/m2, female &lt, 25.00 cm2/m2) were obtained. The primary outcome was 3-year all-cause mortality and the secondary outcome was 3-year major adverse cardiovascular events (MACEs). Low L1 SMI was present in 141 (29.7%) of 475 patients. The incidence of all-cause mortality (23.7% vs. 5.9%, p &lt, 0.001) and MACEs (39.6% vs. 11.8%, p &lt, 0.001) was significantly higher in patients with low L1 SMI than in those with high L1 SMI. In multivariate analysis, low L1 SMI was an independent predictor of higher risk of all-cause mortality (hazard ratio (HR): 4.07, 95% confidence interval (CI): 1.95&ndash, 8.45, p &lt, 0.001) and MACEs (HR: 3.76, 95% CI: 2.27&ndash, 6.23, 0.001). These findings remained consistent after propensity score-matched analysis with 91 patient pairs (C-statistic = 0.848). CT-diagnosed low skeletal muscle mass is a powerful predictor of adverse outcomes in patients with CAD undergoing PCI.

Drug-eluting stents (DES) have improved the outcomes of acute myocardial infarction patients (AMI) patients; however, the risk of late stent thrombosis with DES due to delayed healing of the vessel wall is still considerable. The aim of this study was to compare the safety and efficacy of

Reduced left ventricular ejection fraction (LVEF) remains a strong predictor of adverse outcomes after percutanous coronary intervention (PCI). However, there are limited data about the impact of low LVEF on long-term outcomes after percutaneous transluminal angioplasty (PTA) for lower-extremity

Introduction The gold standard for evaluating stent expansion after percutaneous coronary intervention (PCI) is intravascular ultrasound (IVUS). However, the routine use of this modality is costly and time consuming. StentBoost is a new imaging technique that improves fluoroscopy-based assessments of stent expansion. The purpose of this study was to evaluate the effect of StentBoost imaging-guided PCI on mid-term angiographic and clinical outcomes. Methods and results A total of 870 consecutive patients were recruited (mean age: 64.34±11.61; men: 64.5%), all of whom underwent PCI with drug-eluting stents (DESs). The subjects were divided into a no StentBoost group (n=569 patients) and a StentBoost group (n=301 patients). The 6-month angiographic and 12-month clinical outcomes were compared between the two groups. At 1month, clinical outcomes were similar between the two groups. At 6months, the StentBoost group had significantly lower rates of late loss (0.32±0.40 vs. 0.48±0.59; p=0.005) and binary restenosis (1.2% vs. 8.3%; p=0.029) compared with the no-StentBoost group. At 12months, StentBoost group had significantly lower the incidence of target lesion revascularization (TLR) (1.7% vs. 7%; p=0.034) and TLR-major adverse cardiac events (6% vs. 13.2%; p=0.037) compared with the no-StentBoost group. Conclusion We conclude that the routine clinical use of StentBoost during PCI can be useful, and results in better medium-term angiographic and clinical outcomes.

Background The second-generation drug-eluting stents (DES) have shown superiority in many studies relating to safety and efficacy when compared with the first-generation DES. However, it is unclear whether there are differences in efficacy and safety among the second-generation DES after long-term follow-up. Methods This multicenter, prospective, randomized, open-labeled trial will directly compare the efficacy and safety among the patients treated with either everolimus-eluting stent (EES), zotarolimus-eluting stent with biolinx polymer (ZES-R), or biolimus-eluting stent (BES) with minimal exclusion criteria. The primary end point is a patient-oriented composite consisted of cardiac death, myocardial infarction not clearly attributable to a nontarget vessel and clinically indicated target lesion revascularization at 24-month clinical follow-up post-index procedure. With the hypothesis that “BES is non-inferior to EES” or “BES is non-inferior to ZES-R” in primary end point, approximately 2,600 patients will be assigned to one of the types of stents using a web-based randomization system. Conclusions The CHOICE trial will directly compare the efficacy and safety of EES, ZES-R, and BES in everyday clinical practice for long-term follow-up.

Extracellular fluid (ECF) is associated with blood pressure, but reports on the status of the ECF volume in hypertension have been inconsistent. The aim of this study was to assess the ECF volume status in hypertensives with regard to body size in a large cohort. We performed a single-center case-control observation study for patients who visited the outpatient hypertension clinic and health examination center. For all eligible participants, we examined the body composition, including fluid compartments, using a noninvasive bioimpedance analysis. Of 2934 subjects (women 1365, 57.5 ± 12.2 years), 1166 subjects were normotensive and 1768 subjects were hypertensive. The ECF volume was larger in female hypertensives than in normotensives but was not different between the male groups. However, the relative ECF, defined as the ratio of ECF to body mass index (BMI), was significantly lower in hypertensives of both genders (P

Background— Iatrogenic myocardial injury by radiofrequency catheter ablation (RFCA) releases proinflammatory substances from damaged myocardium, and these may contribute to endothelial dysfunction in systemic vascular structure. The aim of this study is to evaluate the effect of nonischemic myocardial damage on coronary microvascular function in patients undergoing atrial fibrillation (AF) ablation. Methods and Results— We included 49 patients who underwent AF ablation (paroxysmal AF=25, persistent AF=24) and 34 controls. Immediately before and after RFCA, index of microvascular resistance (IMR) was assessed at left anterior descending coronary artery, and blood samples were obtained for analyses of nitric oxide (NO), activated leukocyte cell adhesion molecule, and lipoprotein-associated phospholipase. Transthoracic echocardiography was performed at baseline, 1 day, 1 month, and 3 months after RFCA. Compared with baseline, IMR, activated leukocyte cell adhesion molecule, and lipoprotein-associated phospholipase increased and NO decreased after RFCA. In 36 subjects with increasing IMR, E/E′ ratio increased at 1 day and returned to baseline level at 3 months after RFCA. Changes in activated leukocyte cell adhesion molecule and lipoprotein-associated phospholipase between baseline and after RFCA were independently related to the increase in IMR. In 14 subjects (28.6%), arrhythmia recurred. Using a cutoff value of 9.3 mm Hg/s, sensitivity was 56.7% and specificity was 91.2% for IMR change in predicting AF recurrence ( P =0.028). Conclusions— Myocardial damage by RFCA provoked coronary microvascular dysfunction through systemic proinflammatory reaction that may contribute to transient diastolic dysfunction. This phenomenon may represent a mechanism for early recurrence of arrhythmia after RFCA. Clinical Trial Registration— URL: http://cris.nih.go.kr . Unique identifier: KCT0000030.

Background It has been shown that administration of lacidipine markedly reduces systolic blood pressure in elderly patients with hypertension without increasing the incidence of cardiovascular events and total mortality. But in Korea, there were no available data about the effectiveness and safety of lacidipine. Objectives The goal of our study was to compare the effect of lacidipine and amlodipine besylate on sitting systolic blood pressure (SBP) and edema regression time as primary parameters, and sitting diastolic blood pressure (DBP) and tolerability as a secondary parameter in patients with hypertension. Method This was a prospective, randomized, open-label, noninferiority study in which patients received 14 weeks of treatment with either lacidipine or amlodipine besylate. Patients aged 55 to 80 years having uncomplicated, mild-to-moderate essential hypertension (SBP 140 to 0.05). Because the 1-sided 95% CI for the difference in mean SBP changes between groups (−4.18 to 0.72) was within the pre-specified lower limit (−5 mm Hg), lacidipine was considered noninferior to amlodipine. There were no differences in mean edema regression time and in mean DBP changes. These results were consistent in the isolated systolic hypertension subgroup analysis. The overall incidence of clinical adverse events was comparable between the 2 groups (ie, 7.4% in the lacidipine group and 11.1% in the amlodipine group [P >0.05]). The most common adverse events were headache and facial flushing (5 out of 162 patients [3.1%] in the lacidipine group and 11 out of 153 patients [7.2%] in the amlodipine group]. Conclusions Fourteen weeks of lacidipine treatment significantly reduced blood pressure in older Korean patients with mild-to-moderate hypertension. The efficacy of lacidipine was not inferior to that of amlodipine besylate and tolerability was comparable between the 2 treatment groups. ClinicalTrials.gov identifier: NCT00460915.

Functional remodeling of left atrium (LA) after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) has not been fully elucidated. This study aimed to determine the impact of RFCA on LA transport function in patients who maintained sinus rhythm (SR) after AF ablation.A total of 96 patients (paroxysmal AF [PAF] = 52) who maintained SR during 1 year after AF ablation were enrolled. Multislice computed tomography was performed to determine LA volume (LAV) and LA emptying fraction (LAEF) at pre-RFCA and 1-year post-RFCA. Creatine kinase-MB (CK-MB) and troponin-T levels were analyzed 1-day post-RFCA. At 1-year post-RFCA, mean LAV and LAEF decreased in overall patients. Based on LAEF change (ΔLAEF) cutoff of 5.0%, LAEF reduced in 41 patients (worsened group) and improved or showed no change in 55 patients (preserved group). Compared with preserved group, worsened group had a higher proportion of PAF, higher levels of CK-MB and troponin-T, and additional LA ablation. ΔLAEF was inversely correlated with CK-MB and troponin-T levels. Subgroup analysis showed that LAEF significantly decreased in PAF patients who underwent additional LA ablation. Multivariate analysis revealed that high baseline LAEF and additional LA ablation were independent predictors for worsened LAEF.Although SR was maintained for 1 year after AF ablation, LAEF as well as LAV decreased. The extent of LAEF deterioration was significantly associated with the amount of iatrogenic myocardial damage. Our data indicate that extensive atrial ablation may lead to LA functional deterioration, especially in patients with PAF.

Background Coronary artery spasm ( CAS ) is a well‐known endothelial dysfunction, and a major cause of vasospastic angina ( VSA ). The renin–angiotensin system ( RAS ) is known to be closely associated with endothelial function. However, there are only a few studies that investigated the impact of RAS inhibitor on long‐term clinical outcomes in VSA patients. Methods and Results A total of 3349 patients with no significant coronary artery disease, diagnosed with CAS by acetylcholine provocation test were enrolled for this study. Significant CAS was defined as having ≥70% narrowing of the artery after incremental injections of 20, 50, and 100 μg of acetylcholine into the left coronary artery. Patients were divided into 2 groups according to whether the prescription included RAS inhibitor or not ( RAS inhibitor group: n=666, non‐ RAS inhibitor group; n=2683). To adjust for any potential confounders that could cause bias, propensity score matching ( PSM ) analysis was performed using a logistic regression model. After PSM analysis, 2 matched groups (524 pairs, n=1048 patients, C‐statistic=0.845) were generated and their baseline characteristics were balanced. During the 5‐year clinical follow‐up, the RAS inhibitor group showed a lower incidence of recurrent angina (8.7% versus 14.1%, P =0.027), total death (0.0% versus 1.3%, P =0.045), and total major adverse cardiovascular events (1.0% versus 4.1%, P =0.026) than the non‐ RAS inhibitor group. Conclusions Chronic RAS inhibitor therapy was associated with lower incidence of cardiovascular events in VSA patients in the 5‐year clinical follow‐up.

Background The self-expandable COMPLETE™ stent (Medtronic) has greater elasticity, allowing it to regain its shape after the compression force reduces, and has higher trackability, thus is easier to maneuver through tortuous vessels, whereas the balloon-expandable SCUBA™ stent (Medtronic) has higher radial stiffness and can afford more accurate placement without geographic miss, which is important in aortoiliac bifurcation lesions. To date, there have been no randomized control trials comparing efficacy and safety between the self-expanding stent and balloon-expandable stent in advanced atherosclerotic iliac artery disease. Methods/design The purpose of our study is to examine primary patency (efficacy) and incidence of stent fracture and geographic miss (safety) between two different major representative stents, the self-expanding nitinol stent (COMPLETE-SE™) and the balloon-expanding cobalt-chromium stent (SCUBA™), in stenotic or occlusive iliac arterial lesions. This trial is designed as a prospective, randomized, multicenter trial to demonstrate a noninferiority of SCUBA™ stent to COMPLETE-SE™ stent following balloon angioplasty in iliac arterial lesions, and a total of 280 patients will be enrolled. The primary end point of this study is the rate of primary patency in the treated segment at 12 months after intervention as determined by catheter angiography, computed tomography angiography, or duplex ultrasound. Discussion The SENS-ILIAC trial will give powerful insight into whether the stent choice according to deployment mechanics would impact stent patency, geographic miss, or stent fracture in patients undergoing stent implantation in iliac artery lesions. Trial registration National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier: NCT01834495), registration date: May 8, 2012 Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1435-9) contains supplementary material, which is available to authorized users.

Background: Alternative macrophages exist in human atherosclerosis but their role in atherogenesis remains uncertain. Intraplaque hemorrhage (IPH) is an important stimulus driving alternative macrophage polarization. Intake of hemoglobin (Hb) by the hemoglobin: haptoglobin receptor CD163 leads to a distinct non-foam cell phenotype termed M(Hb). These cells demonstrate upregulation of CD163, lack of lipid retention, and anti-oxidative properties, characteristics considered ‘atheroprotective’. Here we reveal an unexpected but important pathogenic role for M(Hb) in atherosclerosis. Objectives: To determine the role of M(Hb) macrophages in human intraplaque angiogenesis and vascular permeability. Methods: Using human atherosclerotic samples, cultured cells, and a mouse model of IPH, we investigated the role of IPH on macrophage function with respect to angiogenesis and vascular permeability. Results: Within M(Hb) activation of hypoxia-inducible factor-1 alpha (HIF-1) via inhibition of prolyl hydroxylases promotes intraplaque angiogenesis and vascular permeability. In human carotid plaques, alternative CD163 positive macrophages were found to be highly associated with plaque vascularity and expressed high levels of HIF1- and vascular endothelial growth factor-A (VEGF-A). Supernatants from hemoglobin:haptoglobin differentiated M(Hb) macrophages increased endothelial permeability and led to internalization of the endothelial barrier protein vascular endothelial cadherin (VE-cadherin) via activation of VEGF receptor 2 (VEGFR2). Areas of plaque demonstrating high density CD163 high macrophage subsets showed irregular VE-cadherin immunostaining and diffuse perivascular collections of von Willebrand factor suggesting microvessel incompetence. Finally, in brachiocephalic plaques of one-year-old apoE -/- and apoE -/- CD163 -/- mice, CD163 deficiency significantly reduced plaque progression, lesion size, and intraplaque hemorrhage, but had little effect on lesions uncomplicated by hemorrhage. Conclusions: Our findings provide a novel non-lipid driven mechanism by which alterative M(Hb) macrophages promote plaque neoangiogenesis and microvessel incompetence via a HIF-1/VEGF-A-dependent pathway.

An asymptomatic 31-year-old man with chronic hepatitis B and a 7-year history of lamivudine use was referred to our hospital for evaluation of a heart murmur. The patient had no family history of congenital heart disease or collagen vascular disease. Cardiac auscultation revealed a grade 3/6 continuous murmur at the right parasternal border. Transthoracic echocardiography revealed a round, tunnel-like structure from the left aortic sinus to the right atrium (RA; Figure 1A and 1B, arrows, and Movie IA and IB in the online-only Data Supplement) without any evidence of RA or right ventricular enlargement. Modified parasternal short-axis view (Figure 1C and Movie II in the online-only Data Supplement) of the aortic valve level demonstrated an anastomosis site to the RA with continuous turbulent flow on color Doppler examination. Continuous-wave Doppler obtained from the shunt indicated a high flow velocity with systolic and diastolic pattern at the anastomosis site to the RA (Figure 1D). Cardiac catheterization showed a normal pulmonary artery pressure (systolic/diastolic, 24/7 mm Hg) and normal mean RA pressure (4 mm Hg), and the Qp/Qs ratio was 1.3:1. Aortography confirmed a large tunnel beginning in the left aortic sinus and ending in the RA (Figure 2, asterisk, and Movie III in the online-only Data Supplement), with normal-looking left coronary arteries arising independently from different proximal portions of the tunnel. Importantly, no coronary myocardial branches originated from the tunnel, which is the …

Background Despite intensive anti-hypertensive treatment, overall control rates of only 30 ~ 50 % have been reported in patients with hypertension (HTN). However, clinical significance and angiographic characteristics of patients with uncontrolled HTN following Below-the-knee arteries (BTK) interventions in patients with critical limb ischemia (CLI) are not clarified yet as compared to those with controlled HTN. Methods A total 165 consecutive hypertensive patients with BTK lesions from August 2004 to November 2012 were enrolled for this study. Uncontrolled HTN was defined as a blood pressure of > 140 mmHg systolic and 90 mmHg diastolic under anti-hypertensive treatment. A total of 112 patients (67.8 %) had uncontrolled HTN. We compared the clinical and angiographic characteristics of patients with uncontrolled HTN following BTK interventions to those with controlled HTN at 12-month follow-up. Results The baseline characteristics are well balanced between the two groups. At 12 months, there was no difference in the incidence of mortality, target lesion revascularization (TLR), target extremity revascularization (TER), and limb salvage rate in both groups. However, amputation rates were higher in patients with controlled HTN (33.9 vs. 19.6 %, P = 0.045). Conclusion Regardless of blood pressure control, HTN itself was an independent risk factor for BTK lesions, suggesting more intensive medical therapy with close clinical follow up will be required for all BTK patients with HTN.

There have been some reports of iatrogenic coronary arteriovenous fistula (AVF) developing during percutaneous coronary intervention (PCI). PCI for chronic total occlusion (CTO) is more challenging due to a higher rate of procedural failure and increased risk of periprocedural complications. Recently, the coronary CTO guidewire has made rapid strides and revolutionized the procedure to increase high success rates for CTO revascularization. Simultaneously, as the number of CTO interventions increases, more complicated cases have also been reported.We report a case of huge iatrogenic left circumflex artery-to-posterior vein of left ventricle fistula resulting from unexpected penetration of CTO guidewire into cardiac vein during CTO intervention, which was successfully closed by a covered stent. Although controversies still exist concerning the closure of iatrogenic AVF in asymptomatic patients, especially when it drains into a third space including cardiac chambers or venous system, we decided to perform the closure of iatrogenic AVF by covered stent due to relatively bigger AVF size which was generated immediately following balloon angioplasty.

Objectives This study sought to compare everolimus-eluting stents (EES) with zotarolimus-eluting stents (ZES) in patients with acute myocardial infarction (AMI). Background There is a paucity of data to exclusively evaluate the safety and efficacy of second-generation drug-eluting stents (DES) in the setting of AMI. Methods The present study enrolled 3,309 AMI patients treated with ZES (n = 1,608) or EES (n = 1,701) in a large-scale, prospective, multicenter registry—KAMIR (Korea Acute Myocardial Infarction Registry). Propensity score matching was applied to adjust for differences in baseline clinical and angiographic characteristics, producing a total of 2,646 patients (1,343 receiving ZES, and 1,343 receiving EES). Target lesion failure (TLF) was defined as the composite of cardiac death, recurrent nonfatal myocardial infarction, or target lesion revascularization. Major clinical outcomes at 1 year were compared between the 2 propensity score-matched groups. Results After propensity score matching, baseline clinical and angiographic characteristics were similar between the 2 groups. Clinical outcomes of the propensity score-matched patients showed that, despite similar incidences of recurrent nonfatal myocardial infarction and in-hospital and 1-year mortality, patients in the EES group had significantly lower rates of TLF (6.5% vs. 8.7%, p = 0.029) and probable or definite stent thrombosis (0.3% vs. 1.6%, p Conclusions In this propensity-matched comparison, EES seems to be superior to ZES in reducing TLF and stent thrombosis in patients with AMI.

High-dose aspirin has been reported to aggravate coronary artery spasm (CAS). However, it is unknown whether low-dose aspirin (LDA; 100mg) has deleterious impact on CAS. We assessed the impact of LDA on CAS induced by intracoronary acetylcholine (ACh) provocation test. A total of 2789 consecutive patients without significant coronary artery disease who underwent ACh test between November 2004 and March 2010 were enrolled. The patients were divided into two groups: the aspirin group taking LDA before ACh test (n=221) and the no aspirin group not taking aspirin (n=2568). At baseline, the prevalence of old age, diabetes mellitus, hypertension, and hyperlipidemia were higher in the aspirin group. During the ACh test, the incidence of significant CAS, ischemic chest pain, as well as severe and multivessel spasm was higher in the aspirin group. The response rate to lower ACh dose was higher in the aspirin group. Multivariate analysis showed that the previous use of LDA was an independent predictor of CAS (adjusted odds ratio, 1.6, 95% confidence interval, 1.0–2.3; p=0.031). However, it is likely that the association of LDA and CAS that we have observed is not causal but may be hypothesis generating due to significant baseline differences. Further, male gender, old age, lipid-lowering drugs, baseline spasm, and myocardial bridge were independent predictors of CAS. LDA was more frequently associated with CAS and ischemic symptoms, as well as severe and multivessel spasm, suggesting the patients who have received LDA would require more intensive medical therapies and close follow up.

Background Although resistant hypertension (RH) is known to be associated with higher rates of cardiovascular events than is non-RH, there are no reported data on the prevalence of RH in Korean patients. We evaluated the prevalence and characteristics of RH among hypertensive patients treated at primary clinics in Korea. Methods Between August 2010 and January 2011, 247 primary care physicians enrolled 3088 patients with essential hypertension. We acquired demographic and anthropometric data using a questionnaire, evaluated blood pressure, and conducted a variety of laboratory tests using serum and urine. RH was defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg with the use of three antihypertensive agents of different classes, including a diuretic, or controlled hypertension with the use of four or more medications. Results We analyzed 3088 patients with hypertension, 48.3 % of whom were men. The mean age of patients was 64.3 ± 11.3 years and the prevalence of RH was 7.9 %. Patients with RH were more likely to be men, and to have higher waist circumference, increased blood levels of HbA1c, triglycerides, and serum creatinine, lower blood levels of high-density lipoprotein (HDL), and higher rates of current smoker, history of heart failure or coronary artery disease, and electrocardiographic left ventricular hypertrophy (LVH), than were patients with non-RH (all comparisons, P

Background: It is unclear whether the routine follow up (FU) coronary angiography (CAG) regardless of patient’s symptoms after successful percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) in patients (pts) with dyslipidemia is beneficial or not. Methods: The study population consisted of 554 consecutive dyslipidemia pts underwent PCI with unrestricted utilization of DESs from January 2004 to May 2011. Routine FU CAG was performed between 6 to 9 months following index PCI and was decided by individual physician’s discretion. Rests of the pts were clinically followed and ischemic driven events were captured. Clinical events including mortality, myocardial infarction and clinically driven PCI before 9 months were excluded in both groups. Cumulative clinical outcomes up to 3 years were compared between the Routine CAG group (n=329 pts) and the Clinical FU group (n= 225 pts). To adjust potential confounders, a propensity score matched (PSM) analysis was performed using the logistic regression model. Results: After PSM analysis, 2 propensity-matched groups (165 pairs, n = 330 pts, C-statistic=0.718) were generated and, the baseline characteristics of the two groups were balanced. At 3 years, the incidence of repeat revascularization and major adverse cardiac events (MACEs) was higher in the Routine CAG group than the control group (Table). Conclusions: Despite the expected beneficial effects, routine FU CAG following index PCI with DESs in dyslipidemia pts was associated with higher incidence of repeat PCI and MACE up to 3 years.

Background: It has been reported that a major cause of vasospastic angina is endothelial dysfunction of the coronary artery. However, it is controversial whether the uric acid level is associated with vasospastic angina, and can be a prognostic factor for vasospastic angina. Methods: A total 3828 patients (pts) underwent coronary angiography with acetylcholine (Ach) provocation test from Mar 2004 to Sep 2012 were enrolled. The definition of positive coronary artery spasm (CAS) was defined as transient luminal narrowing more than 70%. The uric acid level was categorized into 4 quartile groups; less than 3.8, 3.9~4.7, 4.8~5.7, and more than 5.8 mg/dL. Major adverse cardiovascular events (MACEs) defined as the composite of recurrent chest pain, cardiac death, myocardial infarction, and cerebrovascular accident were valuated up to 3 years. Results: The follow-up rate was the 61.1% (2340/3828). There was no difference in uric acid level between negative and positive CAS groups in female gender but in male gender, uric acid level was higher in negative CAS group (Table 1). However, when adjusted by age, the difference was disappeared (OR, 0.965; 95% CI, 0.898-1.037; P-value, 0.335). The incidence of MACE was 11.1% in male gender and 8.6% in female gender. In male gender, the serum uric acid level between the groups with and without MACE was similar but in female gender, the uric acid level was higher in the group with MACE. However, when adjusted by age, uric acid was not associated with MACE (Table 2). Conclusions: In our study, uric acid was neither the risk factor nor prognostic factor for 3-year clinical events in CAS patients regardless of gender.

Background: Although percutaneous transluminal angioplasty (PTA) is considered as an effective treatment strategy in patients (pts) with critical limb ischemia (CLI), below-the-knee (BTK) lesions with CLI is particularly challenging. This study sought to compare the 12-month outcomes following stenting versus standard plain old balloon angioplasty (POBA) alone in BTK lesions. Method: This study consisted of 339 consecutive lower extremity arterial disease pts (394 limbs, 1026 lesions included 716 BTK lesions) with BTK lesions from Sep 2004 to Dec 2013. All the enrolled pts were treated by stenting (bare metal stents, primary or provisional, 78 limbs in 73 pts) or POBA (316 limbs in 266 pts) with PTA. Procedural success, complications and clinical outcomes were compared between the two groups up to 12 months. To adjust potential confounders, a propensity score matched (PSM) analysis was performed using the logistic regression model. Results: After PSM analysis, 2 propensity-matched groups (56 pairs in pts, n= 112; 61 pairs in limbs, n=122, C-statistic=0.808) were generated, and the baseline & angiographic characteristics of the two groups were balanced. Procedural success, complication incidences were similar between the two groups. Six to 9-month CT or angiographic follow-up, there were similar incidence of binary restenosis, primary, and secondary patency. At 12 months, there were similar incidence of individual hard endpoints including mortality, myocardial infarction, limb salvage, and any extremity amputations except the target lesion and extremity revascularization. Repeat PTA incidence was higher in the stenting group than POBA group (table). Conclusion: Although the repeat PTA risk was increased with BTK stenting, other major individual clinical outcomes and limb salvage rates were similar between the POBA and stenting for the BTK lesions.

Our previous study showed that the long-term outcomes of coronary artery spasm (CAS) were good and did not differ depending on the vasomotion subtype in the acetylcholine (Ach) provocation test. we determined whether recurrent chest pain is really attributable to significant CAS in patients (pts)

Chronic total occlusion (CTO) intervention remains challenging because of the limited procedural success rate and higher target failure. Detailed real-world data on safety and efficacy of CTO intervention in acute coronary syndrome (ACS) patients from multicenter registry are limited. Korean

The Korean chronic total occlusion (CTO) registry was collected by retrospectively from 26 cardiovascular centers since May 2007. The aim of this study is to investigate the impact of a successful staged percutaneous coronary intervention (PCI) of CTO lesion in acute myocardial infarction (AMI)

Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin Receptor Blockers (ARB) are known to have similar effects on cardiovascular outcomes including total mortality in head-to-head trials, and ACE inhibitors, in particular, are recommended for diabetic patients. However, data is limited

Diabetes Mellitus (DM) can lead to cardiovascular morbidity and mortality. There are limited study of prognostic impact of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) patients with DM as compared with optimal medical therapy (OMT) alone. This is a retrospective single

Pitavastatin is a potent lipophilic statin and may play an important role in acute myocardial infarction (AMI) but there have been limited data on the safety and efficacy of pitavastatin in AMI. This study consisted of 1,039 consecutive patients with AMI (74.0% men, mean age 61.4 ± 12.6 years) who presented in 10 major percutaneous coronary intervention centers in Korea from February 2007 through September 2009. Pitavastatin 2 mg/day was routinely administered in patients with AMI from time of presentation. We investigated changes of lipid profiles, biochemical markers, adverse events, and clinical outcomes up to 12 months. During the study 318 events overall occurred in 220 patients (21.2%) who reported ≥1 treatment emergent adverse event, although 20 events in 14 patients (1.4%) were treatment-related adverse events. Low-density lipoprotein (LDL) cholesterol percent change was -25.6% and LDL cholesterol target attainment was 70.5% at 12-month follow-up. Levels of creatinine phosphokinase, serum glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, and high-sensitivity C-reactive protein decreased significantly during the first 1 month of pitavastatin treatment and were sustained to 12-month follow-up. Major adverse cardiac events occurred in 66 patients (7.3%). All-cause deaths occurred in 32 patients (3.5%) including 19 (2.1%) cardiac deaths and recurrent MIs occurred in 14 (1.6%) and target lesion revascularizations in 42 (4.7%). In conclusion, administration of pitavastatin 2 mg/day in patients with AMI showed 70.5% LDL cholesterol target attainment with good tolerance and was associated with favorable clinical outcomes up to 12 months.

1. Coronary artery spasm (CAS) is known to be a major cause of myocardial ischaemia. Multivessel coronary spasm (MVS) in particular is likely to induce more severe and prolonged myocardial ischaemia than single vessel spasm (SVS). 2. In the present study, a total of 1082 consecutive patients without significant coronary artery disease who underwent an acetylcholine (ACh) provocation test between March 2004 and April 2009 were investigated. Patients were divided into three groups: an MVS group (n = 275), an SVS group (n = 376) and a non-CAS group (n = 431). Differences in clinical and angiographic characteristics following the ACh provocation test were evaluated between the MVS, SVS and non-CAS groups. 3. At baseline, patients in the MVS group had the highest prevalence of peripheral artery disease (PAD), hyperlipidaemia, smoking and old age, as well as the highest triglyceride levels. Calcium channel blockers were most frequently prescribed in MVS patients before the ACh test. During the ACh test, the highest prevalence of chest pain, ischaemic electrocardiogram changes, baseline spasms and diffuse and severe spasms were observed in the MVS group. The response rate to lower ACh doses that induce CAS was also higher in the MVS group. Multivariate analysis showed that the presence of PAD (odds ratio (OR) 2.0; P = 0.006) and baseline spasm (OR 1.4; P = 0.045) were independent predictors of ACh-induced MVS. 4. In conclusion, ischaemic symptoms, diffuse and severe spasm and baseline spasm were more frequently associated with MVS patients, suggesting more intensive medical therapies and close clinical follow up would be required for this patient group.

BACKGROUND AND OBJECTIVES Angiotensin-receptor blockers (ARBs) have beneficial effects on cardiovascular, metabolic, and inflammatory parameters in addition to controlling blood pressure (BP). However, few comparative clinical studies have been conducted with different ARBs. We compared these effects in patients with uncomplicated hypertension who were receiving telmisartan or valsartan. SUBJECTS AND METHODS The subjects were patients with essential hypertension (48.4±9.6 years) who were randomly assigned to take either telmisartan (80 mg/day, n=30) or valsartan (160 mg/day, n=30) for 12 weeks. Their anthropometric, laboratory, vascular, and echocardiographic data were measured at baseline and at the end of the study. RESULTS Baseline characteristics were not significantly different between the two groups, except for the carotid-femoral pulse wave velocity (cfPWV; telmisartan group vs. valsartan group; 841.2±131.0 vs. 761.1±104.4 cm/s, p

Although left atrial volumes (LAVs) and transport function can be accurately measured by multi-slice computed tomography (MSCT) during sinus rhythm, limited data are available for in patients with atrial fibrillation (AF). The aims of our study were to compare LAVs and function assessed by MSCT and transthoracic echocardiography (TTE) during AF, and to validate a simplified method to determine LAVs and functions using MSCT. A total of 150 consecutive AF patients who were scheduled to undergo catheter ablation were enrolled in this study. All subjects underwent MSCT and TTE on the same day. LAVs were measured by MSCT at every 10% of the R-R interval (10-phase analysis). LA transport function was assessed by measuring changes in LAVs. LAVs and functions were also assessed by TTE using a modified Simpson's method and an area-length method. Fifty patients were in sinus rhythm (SR) and 100 were in AF during their examinations. Although TTE underestimated the maximal LAV (LAV(max), by 38.3%) and overestimated the total LA emptying fraction (LAEF(total), by 61.1%) compared with MSCT, there were excellent correlations between TTE and MSCT. LAV(max) and the minimal LAV (LAV(min)) based on MSCT were determined at relatively constant cardiac phases during AF as well as SR (LAV(max); 40%, LAV(min); 100% of R-R interval, fixed-phase analysis). LAVs and LAEF(total) assessed by 10-phase analysis showed good correlations with those assessed by fixed-phase analysis (P0.001). LAVs and function assessed by MSCT correlated well with LAVs and functions assessed by TTE, irrespective of the underlying rhythm. Our results indicate that in the context of MSCT, fixed-phase analysis is a simple and reliable method to determine LAVs and function in patients with AF.

Despite the widespread adoption of drug-eluting stent (DES) implantation, the optimal treatment of DES failures remains challenging. The present study evaluated the relation between quantitative angiography and the fractional flow reserve (FFR) in restenotic lesions after DES implantation and the efficacy of FFR in determining whether to treat these lesions. To assess their functional significance, the coronary pressure-derived FFR was measured in 50 DES restenotic lesions (49 patients). Additional intervention was performed in lesions with a FFR0.8. Major adverse cardiac events were assessed at 12 months after the reintervention procedure. The mean percent diameter stenosis (%DS) was 58 ± 13%. Of the 50 lesions, 20 (40%) were deferred without additional intervention. The FFR and %DS had a negative correlation (r = -0.61, p0.001). However, when only the lesions with diffuse-type restenosis (15 lesions) were analyzed, the degree of correlation decreased (r = -0.56, p = 0.12). Although most lesions (89%) with a %DS of ≥70 had significant functional ischemia, among 41 lesions with a %DS70, only 20 (49%) had demonstrated functional patency. The incidence of adverse events during the 12 months of follow-up after FFR-guided treatment was 18.0% (23.3% in the FFR0.80 group and 10.0% in FFR ≥0.80 group). In conclusion, a discrepancy was found between functional ischemia measured by the FFR and the angiographic %DS, in particular, in moderate- or diffuse-type restenotic lesions after DES implantation. The outcome of FFR-guided deferral in patients with DES in-stent restenosis seems favorable.

INTRODUCTION: As epicardial adipose tissue (EAT) is a metabolically active visceral fat, potential interaction between EAT and myocardium is strongly suggested. The aims of this study were to determine whether the amount and regional distribution of EAT are related to the chronicity of atrial fibrillation (AF) and left atrial (LA) remodeling. METHODS AND RESULTS: This study consisted of 40 subjects with paroxysmal AF (PAF) and 40 with persistent AF (PeAF). Eighty subjects with no history of AF were enrolled as controls. Total volume of EAT (EAT(total)), regional thickness of EAT, and LA volume (LAV) were measured by multislice computed tomography. In the AF group, blood samples were drawn from coronary sinus for analysis of inflammatory cytokines including adiponectin. RESULTS: Compared with controls, AF subjects had larger LAV, EAT(total), and the thicknesses of periatrial EAT including interatrial septum (IAS). However, the thicknesses of periventricular EAT were not different between the groups. The PeAF subjects had larger LAV, EAT(total), and periatrial EAT thicknesses, higher levels of inflammatory cytokines, and lower level of adiponectin than did the PAF subjects. Adiponection level was significantly associated with EAT(total) and IAS thickness. Multivariate analysis revealed that EAT(total) (P = 0.004) and IAS thickness (P = 0.016) were independently associated with LAV. CONCLUSION: EAT(total) and thickness of periatrial EAT were significantly larger in AF subjects compared to those of the matched controls and were closely related to the chronicity of AF. Moreover, EAT(total) and IAS thickness were independently associated with LAV in subjects with AF.