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Background: Little is known about the long-term risk of cardiovascular events after discharge among acute myocardial infarction (AMI) survivors living alone in Japan., Methods and Results: A large-scale prospective, observational study in the Osaka region involved consecutive patients with AMI from January 2002 through December 2010. We evaluated the association between living alone and longitudinal risk of cardiovascular events following discharge after AMI. A Cox proportional-hazards model was used to assess the association between living alone and the primary composite endpoint consisting of major adverse cardiovascular events and total deaths. During the study period, 5845 patients (4415 male patients, 1430 female patients) were registered. Living alone was found to be independently associated with a higher risk of composite endpoint consisting of major adverse cardiovascular events and total deaths [adjusted hazard ratio (HR) 1.32; 95% confidence interval (CI): 1.11-1.58]. Multivariate-adjusted HRs of composite endpoint were 1.34 (95% CI: 1.08-1.68) among male patients and 1.31 (95% CI: 0.95-1.81) in the female patients. AMI survivors living alone tend to have a higher adjusted HR of composite endpoint than those not living alone irrespective of age and gender groups., Conclusions: From this large AMI registry in Osaka, AMI survivors living alone after discharge had a higher risk of cardiovascular events and total deaths than those not living alone., (Copyright © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Although endovascular therapy (EVT) has been widely used for iliac lesions due to acceptable patency with stenting, EVT has not been established as primary treatment for aortic occlusion, partly because of uncertainty regarding long-term results. The purpose of this study was to investigate outcomes following EVT with stenting for chronic aortic occlusion. This study was a single-center retrospective analysis of a prospectively maintained database. Between September 2005 and May 2012, twenty-four lesions from 25 patients with a clinical diagnosis of chronic aortic occlusion (mean age, 71 years; 80 % male) were treated with EVT with stenting. Kaplan-Meier estimators were used to determine the patency rates according to Society for Vascular Surgery criteria. In results, lesion type was Trans Atlantic Inter-Society Consensus D in all patients. Mean lesion length was 145 mm. Initial success rate and procedural complication rate were 96 % (24/25) and 8 % (2/25), respectively. At 36 months, primary and secondary patency rates were 76 and 94 %, respectively. Restenosis was observed in 5 patients, all of whom underwent reintervention (four successful, one failure and intensity of medical treatment). EVT can be safely done in patients with chronic aortic occlusion. Procedural morbidity and mid-term durability were comparable to those of bypass surgery up to 3 years.

Background: The aim of this study was to investigate the efficacy and safety of paclitaxel-coated balloon (PCB) for the treatment of the bare-metal stent restenosis (BMS-ISR) and drug-eluting stent restenosis (DES-ISR)., Methods: This study was a prospective, multicenter, randomized (2:1) trial conducted in 208 patients with 213 in-stent restenosis lesions (BMS-ISR: 123 lesions, DES-ISR: 90 lesions) at 13 centers in Japan. Patients were randomly assigned to a PCB group (137 patients with 142 lesions) or a conventional balloon angioplasty (BA) group (71 patients with 71 lesions). The primary end point was target vessel failure at 6-month follow-up., Results: Clinical and angiographic follow-up 6 months after intervention was performed in 207 patients (99.5%) with 208 lesions (97.7%). Target vessel failure was noted in 6.6% of the PCB group and 31.0% of the BA group (P < .001). Recurrent restenosis occurred in 4.3% of the PCB group and 31.9% of the BA group (P < .001). Late lumen loss was lower in the PCB group than in the BA group (0.11 ± 0.33 mm vs 0.49 ± 0.50 mm, P < .001). In PCB-treated lesions, recurrent restenosis occurred in 1.1% of patients with BMS-ISR and in 9.1% of patients with DES-ISR (P = .04). Late lumen loss was lower in patients with BMS-ISR than in patients with DES-ISR (0.05 ± 0.28 mm vs 0.18 ± 0.38 mm, P = .03)., Conclusions: This randomized clinical study suggested that PCB provided much better clinical and angiographic outcomes than did conventional BA in patients with BMS-ISR and DES-ISR. Drug-eluting stent restenosis was associated with poorer outcomes compared with BMS-ISR after treatment with PCB., (© 2013.)

Purpose: In patients undergoing primary percutaneous coronary intervention (PCI) for the treatment of ST-segment elevation myocardial infarction (STEMI), coronary microvascular dysfunction is associated with poor prognosis. Coronary microvascular resistance is predominantly regulated by ATP-sensitive potassium (KATP) channels. The aim of this study was to clarify whether nicorandil, a hybrid KATP channel opener and nitric oxide donor, may be a good candidate for improving microvascular dysfunction even when administered after primary PCI., Methods: We compared the beneficial effects of nicorandil and nitroglycerin on microvascular function in 60 consecutive patients with STEMI. After primary PCI, all patients received single intracoronary administrations of nitroglycerin (250 μg) and nicorandil (2 mg) in a randomized order; 30 received nicorandil first, while the other 30 received nitroglycerin first. Microvascular dysfunction was evaluated with the index of microcirculatory resistance (IMR), defined as the distal coronary pressure multiplied by the hyperemic mean transit time., Results: As a first administration, nicorandil decreased IMR significantly more than did nitroglycerin (median [interquartile ranges]: 10.8[5.2-20.7] U vs. 2.1[1.0-6.0] U, p=0.0002).As a second administration, nicorandil further decreased IMR, while nitroglycerin did not (median [interquartile ranges]: 6.0[1.3-12.7] U vs. -1.4[-2.6 to 1.3] U, p<0.0001). The IMR after the second administration was significantly associated with myocardial blush grade, angiographic TIMI frame count after the procedure, and peak creatine kinase level., Conclusion: Intracoronary nicorandil reduced microvascular dysfunction after primary PCI more effectively than did nitroglycerin in patients with STEMI, probably via its KATP channel-opening effect.

It remains unclear whether severity of coronary artery disease (CAD) affects the prognosis of patients with peripheral artery disease (PAD). In this retrospective, multicenter study, we analyzed 537 consecutive patients with symptomatic PAD who underwent both peripheral artery revascularization and coronary angiography (CAG) prior to revascularization. We classified patients into 3 groups based on CAG: no-CAD group, intermediate CAD group (1-2 diseased vessels), and triple-vessel disease (TVD) group. We evaluated clinical outcome including all-cause death, major adverse cardiac events (MACEs), and amputation. The no-CAD, intermediate CAD, and TVD groups comprised 204, 268, and 65 patients, respectively. Mean follow-up duration was 952 ± 497 days. Freedom from any adverse outcome was highest in the no-CAD group and lowest in the TVD group (all-cause death: 86% vs 77% vs 65%, P = .043; MACE: 95% vs 87% vs 78%, P = .044; amputation: 96% vs 92% vs 83%, P = .0015). Severity of CAD affected prognosis of patients with PAD.

Rationale: Despite a recent decline of in-hospital mortality attributable to acute myocardial infarction (AMI), the incidence of ischemic heart failure (HF) in post-AMI patients is increasing. Although various microRNAs have been proposed as diagnostic indicators for AMI, no microRNAs have been established as predictors of ischemic HF that develops after AMI., Objective: We attempted to identify circulating microRNAs that can serve as reliable predictors of ischemic HF in post-AMI patients., Methods and Results: Using sera collected a median of 18 days after AMI onset, we screened microRNAs in 21 patients who experienced development of HF within 1 year after AMI and in 65 matched controls without subsequent cardiovascular events after discharge. Among the 377 examined microRNAs, the serum level of only miR-192 was significantly upregulated in AMI patients with development of ischemic HF. Because miR-192 is reported to be p53-responsive, the serum levels of 2 other p53-responsive microRNAs, miR-194 and miR-34a, also were investigated. Interestingly, both microRNAs were coordinately increased with miR-192, particularly in exosomes, suggesting that these microRNAs function as circulating regulators of HF development via the p53 pathway. Furthermore, miR-194 and miR-34a expression levels were significantly correlated with left ventricular end-diastolic dimension 1 year after AMI., Conclusions: In the sera of post-AMI patients who experienced development of de-novo HF within 1 year of AMI onset, the levels of 3 p53-responsive microRNAs had been elevated by the early convalescent stage of AMI. Further investigations are warranted to confirm the usefulness of these circulating microRNAs for predicting the risk of development of ischemic HF after AMI.

Background: Even mild paravalvular leakage (PVL) after transcatheter aortic valve replacement (TAVR) is associated with increased late mortality. Electrocardiogram-gated multi-slice computed tomography (MSCT) enables detailed aortic annulus assessment. We describe the impact of MSCT for PVL following TAVR., Methods: Congruence between the prosthesis and annulus diameters affects PVL; therefore, we calculated the OverSized AortiC Annular ratio (OSACA ratio) and OSACA (transesophageal echocardiography, TEE) ratio as prosthesis diameter/annulus diameter on MSCT or TEE, respectively, and compared their relationship with PVL ≤ trace following TAVR., Results: Of 36 consecutive patients undergoing TAVR (Group A), the occurrence of PVL ≤ trace (33.3%) was significantly related to the OSACA ratio (p = 0.00020). In receiver-operating characteristics analysis, the cutoff value of 1.03 for the OSACA ratio had the highest sum of sensitivity (75.0%) and specificity (91.7%; AUC = 0.87) with significantly higher discriminatory performance for PVL as compared to the OSACA (TEE) ratio (AUC = 0.69, p = 0.028). In nine consecutive patients (Group B) undergoing TAVR based on guidelines formulated from our experience with Group A, PVL ≤ trace was significantly more frequent (88.9%) than that in Group A (p = 0.0060)., Conclusions: The OSACA ratio has a significantly higher discriminatory performance for PVL ≤ trace than the OSACA (TEE) ratio, and aortic annular measurement from MSCT is more accurate than that from TEE., (© 2013 Wiley Periodicals, Inc.)

Percutaneous coronary intervention for chronic total occlusion remains a challenging field for interventional cardiologists because of inability to advance a wire beyond the occlusion. In case that the wire is not crossed to the distal main vessel but a side branch originated from distal end of the occlusion, we applied "reversed guidewire technique" which was initially proposed as a technique for extremely angulated bifurcations with utilizing hairpin shaped wire. In this case report, we describe application of this technique for chronic total occlusion in detail with potential limitations.

A 72-year-old man received an implantation of implantable cardioverter defibrillator with intracardiac electrogram (ICEG) monitoring because ventricular fibrillation occurred in a case of old myocardial infarction with reduced left ventricular function. A year later, he came to our hospital for a regular checkup. Unexpectedly, ST depression was recorded by ICEG monitoring. He had no significant symptoms at the time, but had had exertional chest discomfort about 3 or 4 weeks before. The patient subsequently underwent successful revascularization, which potentially prevented the recurrence of acute myocardial infarction. ST depression has not been recorded by ICEG monitoring since the revascularization.

Background: It remains unclear whether cilostazol, which has been shown to improve the clinical outcomes of endovascular therapy for femoropopliteal lesions, also reduces angiographic restenosis., Methods and Results: The Sufficient Treatment of Peripheral Intervention by Cilostazol (STOP-IC) study investigated whether cilostazol reduces the 12-month angiographic restenosis rate after percutaneous transluminal angioplasty with provisional nitinol stenting for femoropopliteal lesions. Two hundred patients with femoropopliteal lesions treated from March 2009 to April 2011 at 13 cardiovascular centers were randomly assigned 1:1 to receive oral aspirin with or without cilostazol. The primary end point was 12-month angiographic restenosis rate. Secondary end points were the restenosis rate on duplex ultrasound, the rate of major adverse cardiac events, and target lesion event-free survival. Researchers evaluated all follow-up data and assessed the end points in a blinded fashion. The mean lesion length and reference vessel diameter at the treated segment were 128±86 mm and 5.4±1.4 mm, respectively. The frequency of stent used was similar between groups (88% versus 90% in the cilostazol and noncilostazol group, respectively, P=0.82). During the 12-month follow-up period, 11 patients died and 152 patients (80%) had evaluable angiographic data at 12 months. The angiographic restenosis rate at 12 months was 20% (15/75) in the cilostazol group versus 49% (38/77) in the noncilostazol group (P=0.0001) by intention-to-treat analysis. The cilostazol group also had a significantly higher event-free survival at 12 months (83% versus 71%, P=0.02), although cardiovascular event rates were similar in both groups., Conclusions: Cilostazol reduced angiographic restenosis after percutaneous transluminal angioplasty with provisional nitinol stenting for femoropopliteal lesions., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00912756; and URL: https://www.umin.ac.jp. Unique identifier: UMIN000002091.

Background: Diabetes mellitus (DM) is a major risk factor for cardiovascular events. The study purpose was to compare DM and non-DM (nDM) patients in terms of statin-induced change of plaque characteristics using intravascular ultrasound (IVUS) and coronary angioscopy., Methods: Patients with coronary artery disease and hypercholesterolemia who were enrolled to the TWINS were selected and classified into two groups: DM group and nDM group. Eleven DM patients and 28 nDM patients were studied., Results: Low-density lipoprotein cholesterol levels decreased significantly to a similar extent at weeks 28 and 80 from baseline in DM and nDM (p<0.001). The mean angioscopic color grades of yellow plaques in DM and nDM were similar at baseline and significantly decreased at week 80 from baseline in both groups, however, the mean change of angioscopic color grade from baseline in DM were not significantly decreased and the mean angioscopic color was significantly higher than that in nDM (1.34 vs. 1.00, p<0.05) at week 28. IVUS showed plaque volume reduction in both groups (p<0.01) except at week 80 in DM group, which was not statistically significant different compared to the baseline., Conclusion: In DM patients, plaque volume regression by atorvastatin was shown to be attenuated, and its color improvement was significantly delayed. However, the yellowness became comparable between DM and nDM groups at week 80. These results indicate that patients with DM should be treated by intensive lipid-lowering therapy with atorvastatin for at least 80 weeks to stabilize vulnerable plaque., (Copyright © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

A 45-year-old male who had suffered from refractory non-ischemic heart failure treated with a left ventricular assist device received heart transplantation in February 2008. He underwent coronary angiography (CAG) and intravascular ultrasound (IVUS) at 3 months, and 1, 2, and 3 years after surgery. At 3 months, neither significant stenosis on CAG nor plaque on 3 coronary arteries, as assessed by IVUS were observed. However, focal eccentric plaque on proximal left anterior descending artery has developed up to 2 years, despite the fact that risk factors for cardiac allograft vasculopathy were well controlled. At 2 years, everolimus 2.5 mg/day was added to the patient's existing regimen consisting of corticosteroids, mycophenolate mofetil, and cyclosporine. Then mycophenolate mofetil was withdrawn. At 3 years, concomitant with plaque regression, a decreased plaque volume index, enlarged lumen volume index, and increased minimum lumen area were observed. We experienced a case with plaque regression associated with everolimus administration. Further investigations are needed to explore the mechanism of plaque regression associated with everolimus, as well as to confirm our observation in randomized controlled trials for patients after heart transplantation. < Learning objective: We experienced a case with plaque regression associated with everolimus administration. Further investigations are needed to explore the mechanism of plaque regression associated with everolimus, as well as to confirm our observation in randomized controlled trials for patients after heart transplantation.>.

Background: Recent technical advances have made endovascular treatment (EVT) an alternative first-line treatment for critical limb ischemia., Methods and Results: A prospective multicenter study was conducted to evaluate the clinical outcomes of 314 Japanese critical limb ischemia patients (mean age, 73±10 years) with infrainguinal arterial lesions who underwent EVT. Patients were enrolled from December 2009 to July 2011 and were followed-up for 12 months. The primary end point was amputation-free survival (AFS) at 12 months. Secondary end points were anatomic, clinical, and hemodynamic measures, including 12-month freedom from major adverse limb events. The 12-month AFS rate was 74%, with body mass index <18.5 (hazard ratio [HR], 2.22; P=0.008), heart failure (HR, 1.73; P=0.04), and wound infection (HR, 1.89; P=0.03) associated with a poor prognosis for AFS. The 12-month major adverse limb event-free rate was 88%, with hemodialysis (HR, 1.98; P=0.005), heart failure (HR, 1.69; P=0.02), and Rutherford classification 6 (HR, 2.25; P=0.002) associated with a poor prognosis for major adverse limb events. The median time for wound healing was 97 days, with body mass index <18.5 (HR, 0.54; P=0.03) and wound infection (HR, 0.60; P=0.04) being significant risk factors for unhealed wounds after EVT. At 12 months, 34% had undergone reintervention (bypass surgery, 2.6%; repeat EVT, 31.7%), and 73% were major adverse event-free., Conclusions: The high reintervention rate notwithstanding, EVT was an effective treatment for Japanese critical limb ischemia patients with infrainguinal disease, with satisfactory AFS and major adverse limb event-free rates. The results of this study will be helpful for the future evaluation of critical limb ischemia therapy., Clinical Trial Registration: URL: http://www.umin.ac.jp/ctr. Unique identifier: UMIN000002830.

Background: Little is known about the prognostic significance of elevated serum heart-type fatty acid-binding protein (H-FABP) in post-acute myocardial infarction (post-AMI) patients., Methods and Results: A total of 1,283 post-AMI patients with available serum samples collected in the convalescent stage were studied. During a median follow-up period of 1,785 days, 176 patients (14%) had adverse events (all-cause mortality, n=81; non-fatal MI, n=44; readmission for heart failure [HF], n=51). Patients were divided into 2 groups according to a serum H-FABP level of 6.08ng/ml, which was determined to be the optimal cut-off for discriminating all-cause mortality based on the maximum value of the area under the receiver operating characteristic curve. Patients with elevated H-FABP (>6.08ng/ml, n=224) had a significantly higher incidence of death (18.3% vs. 3.8%, P<0.001) and readmission for HF (10.3% vs. 2.6%, P<0.001), but not of non-fatal MI (4.5% vs. 3.2%, P=0.187), compared to those with H-FABP <6.08ng/ml. Multivariate Cox regression analysis indicated that elevated serum H-FABP was associated with an increased risk of mortality (hazard ratio [HR], 1.91; 95% confidence interval [CI]: 1.03-3.51, P=0.039) and readmission for HF (HR, 2.49; 95% CI: 1.15-5.39, P=0.020)., Conclusions: Elevated serum H-FABP during the convalescent stage of AMI predicted long-term mortality and readmission for HF after survival discharge in the post-AMI patients.

Background: Transcatheter aortic valve replacement (TAVR) is a new alternative treatment with acceptable early results for patients with aortic valve stenosis considered to be inoperable. The first TAVR was performed in Japan in October 2009, and a total of 51 have been performed up to February 2012., Methods and Results: Because it is not possible to disclose details for 36 patients at the time of writing due to ongoing clinical trials, the early and mid-term results of 15 patients are presented for the Edwards SAPIEN valves. Age was 83.4 ± 6.1 years. Mean pressure gradient and aortic valve area were 60.3 ± 21.1 mmHg and 0.64 ± 0.19 cm(2), respectively. Left ventricular ejection fraction was 55.5 ± 15.4%. The Logistic EuroSCORE, EuroSCORE II, and Society of Thoracic Surgeons score were 28.5 ± 21.5%, 11.1 ± 15.8%, and 10.0 ± 7.4%, respectively. All of the procedures were successful and did not require conversion to surgery. Perioperative stroke did not occur, although pacemakers were implanted in 2 patients (13.3%). At discharge, mean pressure gradient and aortic valve area were improved to 10.8 ± 4.4 mmHg and 1.77 ± 0.36 cm(2), respectively. Except for 1 patient who died of cancer 7 months after operation, all patients were alive at the time of writing (11-848 days after procedure; mean follow-up period, 184 days)., Conclusions: Satisfactory early and mid-term results have been achieved with TAVR, indicating that this is a good alternative to treat aortic valve stenosis.

Background: Although durable clinical outcomes have been reported, arterial repair after paclitaxel-coated nitinol drug-eluting stent (Zilver PTX) implantation in the superficial femoral artery (SFA) remains unclear., Methods and Results: Angioscopic evaluation was performed in SFA intra-stent surfaces 80±29 (range, 49-135) days or 84±18 (range, 52-112) days following Zilver PTX (20 stents in 10 patients; mean age, 72±8 years; 40% men) or bare metal stent (BMS; 14 stents in 9 patients; mean age, 70±7 years; 67% men) implantation, respectively. Neointimal coverage (NIC) was graded as 0, stent struts exposed; grade 1, struts bulging into the lumen, but still transparently visible although covered; grade 2, struts embedded in the neointima, but translucent; grade 3, struts fully embedded and invisible. NIC was defined as heterogeneous when the NIC grade variation was ≥1. Presence of yellow plaque and thrombus were investigated. Dominant NIC was significantly different between Zilver PTX (grade 0, 35%; grade 1, 20%; grade 2, 25%; grade 3, 20%) and BMS (grade 0, 7%; grade 1, 0%; grade 2, 14%; grade 3, 79%; P=0.001). NIC heterogeneity was less frequently observed in Zilver PTX (40% vs. 86%, P=0.009). Prevalence of yellow plaque or thrombus (75% vs. 79%, P=0.57) or thrombus (75% vs. 79%, P=0.57) were similar between Zilver PTX and BMS., Conclusions: Early phase arterial repair was different between Zilver PTX and BMS.

Background: Intake of long-chain n-3 polyunsaturated fatty acids (n-3 PUFA), including docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), is associated with a lower risk of atherosclerotic cardiovascular events, particularly acute myocardial infarction (AMI). However, limited data are available regarding the association between serum n-3 PUFA levels and heart failure (HF) events in survivors of AMI., Methods and Results: We evaluated whether serum DHA and EPA levels were associated with HF-free survival and HF hospitalization rates after AMI. A total of 712 patients were divided into 3 groups according to their tertile serum levels of DHA and EPA (Low, Middle, and High). Propensity-score-stratified Cox regression analysis revealed that DHA- and EPA-Low groups presented statistically significant worse HF-free survival (hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.03-2.72, P=0.0358, and HR 1.69, 95% CI 1.05-2.72, P=0.0280, respectively), with the EPA-Low group having a higher risk of HF hospitalization (HR 2.40, 95% CI 1.21-4.75, P=0.0097) than the DHA-Low group (HR 1.72, 95% CI 0.86-3.45, P=0.1224). The relationship between a low DHA or EPA level and decreased HF-free survival was almost common to all subgroups; however, the effect of low serum EPA on HF hospitalization was prominent in male patients, and those with low levels of high-density lipoprotein cholesterol or without statin therapy., Conclusions: Low levels of circulating n-3 PUFA are associated with decreased HF-free survival in post-AMI patients.

Background: Arterial repair in the early phase following implantation of a zotarolimus-eluting stent (ZES) remains unknown., Methods and Results: Following implantation of 49 Endeavor ZES in 33 patients, follow-up angioscopy was performed in 13 patients (26 ZES) in the early phase (EP; 123±24 days) and in 20 patients (23 ZES) in the middle phase (MP; 247±17 days). Neointimal coverage (NIC) was graded as follows: grade 0, stent struts exposed; grade 1, struts bulging into the lumen, although covered; grade 2, struts were embedded by the neointima but were seen translucently; grade 3, struts fully embedded and invisible. NIC was defined as heterogeneous for NIC grade variation≥1. The presence of thrombus and yellow plaque was also investigated. Although NIC heterogeneity tended to be more frequent in EP than in MP (50% vs. 22%, P=0.070), and yellow plaque significantly more frequent (58% vs. 13%, P=0.0025), the majority of stents were dominant NIC grade 3 at both follow-up periods (73% in EP vs. 78% in MP, P=0.75). There was no significant difference in thrombus (23% in EP vs. 4% in MP, P=0.10) between the follow-ups., Conclusions: Sufficient arterial repair may have occurred by 4 months after ZES implantation.

Background: In the percutaneous coronary intervention (PCI) era, little evidence exists regarding the incidence, predictors and long-term mortality of recurrent myocardial infarction (Re-MI) following discharge for acute myocardial infarction (AMI)., Methods and Results: A total of 7,870 patients who survived AMI were studied with a median follow-up period of 3.9 years: 353 patients (4.5%) experienced Re-MI, with 7 of those dying within 30 days, which was classified as fatal Re-MI. The incidence of Re-MI per year was 2.65% for the first year, and 0.91-1.42% thereafter up to 5 years. Multivariate Cox regression analyses revealed that predictors of Re-MI were diabetes mellitus (hazard ratio (HR): 2.079, P<0.001), history of MI (HR: 1.767, P=0.001), and advanced age (HR: 1.021, P=0.001). These 3 predictors remained significant when angiographic and procedural parameters were incorporated into the analyses. The incidence and adjusted risk of Re-MI increased when these variables were clustered (P<0.001). The all-cause mortality rate was significantly higher in patients with Re-MI than in those without (HR: 2.206, P<0.001)., Conclusions: In post-AMI patients treated in the PCI era, the incidence of Re-MI is low compared with that reported during the past 30 years. Patients' clinical factors of diabetes mellitus, history of MI, and advanced age appear to affect the occurrence of Re-MI after hospital discharge, and Re-MI still carries a risk for subsequent mortality.

We report a high-risk patient with severe symptomatic aortic stenosis who showed systolic anterior motion of the mitral valve (SAM) and severe mitral regurgitation immediately after transcatheter aortic valve replacement (TAVR). The patient did not have either SAM or mitral regurgitation, but showed significant septal hypertrophy on preoperative transthoracic echocardiography which could be associated with the occurrence of SAM. Caution should be exercised in patients with significant interventricular septal hypertrophy before TAVR.

Objectives: The aim of this randomized-controlled trial is to compare biolimus A9-eluting stent (Nobori) to sirolimus eluting stent (Cypher)., Background: The Nobori coronary stent is coated only abluminally with a biodegradable polymer, poly-lactic acid, and the antiproliferative agent biolimus A9. This stent has been studied in randomized trials versus Taxus Express and Taxus Liberte and showed noninferiority and superiority for in-stent late loss. This is the first randomized trial of Nobori stent versus Cypher stent., Methods: We conducted a randomized (3:2), controlled trial comparing Nobori and Cypher, in 335 patients (198 Nobori and 137 Cypher) at 15 centers in Japan. Patients with de-novo lesions in up to two native coronary arteries were considered for enrollment. The primary endpoint was freedom from target vessel failure (TVF), a composite of cardiac death, myocardial infarction, and target vessel revascularization at 9 months., Results: At 9 months, the primary endpoint of freedom from TVF was 92.6% in Nobori and 93.8% in Cypher arm (noninferiority test P < 0.001). As main secondary endpoints, the in-stent late loss was 0.12 ± 0.30 mm and 0.14 ± 0.34 mm in Nobori and Cypher stents, respectively. Target lesion revascularization was 0.5% in Nobori and 3.9% in Cypher treated patients (P = 0.04). Definite and probable stent thromboses were not recorded in any patient., Conclusions: Despite the relatively small number of patients, this well controlled clinical trial confirmed the primary hypothesis of non-inferiority of the Nobori biolimus A9-eluting stent to the Cypher sirolimus-eluting stent for freedom from TVF. Both stents showed excellent midterm results., (Copyright © 2011 Wiley Periodicals, Inc.)

To investigate the prognostic impact of circulating microRNAs (miRs) in patients who survived acute myocardial infarction (AMI), we compared the circulating miR signature at the time of survival discharge among samples in the serum bank of the Osaka Acute Coronary Insufficiency Study. Using a high-throughput array consisting of 667 miRs, 11 miRs were found to be differentially expressed in the serum among patients at high-risk for cardiac death. Real-time RT-PCR confirmed that the serum levels of miR-155 and miR-380* were approximately 4- and 3-fold higher, respectively, in patients who experienced cardiac death within 1 year after discharge. Accordingly, a subset of circulating miRs might be predictive for cardiac death in post-AMI patients., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Several studies showed durable long-term clinical benefit of endovascular therapy with stenting in aorto-iliac occlusive disease. Although in-stent restenosis is easily treated in routine practice, we experienced an uncommon case of failed reconstitution of in-stent total occlusion at the common iliac artery (CIA). The case was treated with nitinol stent implantation outside of the in-stent occlusion site, and good vessel patency was observed at 14 months after the procedure. Nitinol stent implantation outside of an in-stent occlusion in the CIA is a novel reconstitution strategy when the guide wire cannot pass the occlusion site within a previously implanted stent.

Objectives: The purpose of this study was to investigate the relationship between angiographic patterns of in-stent restenosis (ISR) after femoropopliteal (FP) stenting and the frequency of refractory ISR., Background: In-stent restenosis after FP stenting is an unsolved problem. The incidence and predictors of refractory restenosis remain unclear., Methods: This study was a multicenter, retrospective observational study. From September 2000 to December 2009, 133 restenotic lesions after FP artery stenting were classified by angiographic pattern: class I included focal lesions (≤50 mm in length), class II included diffuse lesions (>50 mm in length), and class III included totally occluded ISR. All patients were treated by balloon angioplasty for at least 60 s. Recurrent ISR or occlusion was defined as ISR or occlusion after target lesion revascularization. Restenosis was defined as >2.4 of the peak systolic velocity ratio by duplex scan or >50% stenosis by angiography., Results: Sixty-four percent of patients were male, 67% had diabetes mellitus, and 24% underwent hemodialysis. Class I pattern was found in 29% of the limbs, class II in 38%, and class III in 33%. Mean follow-up period was 24 ± 17 months. All-cause death occurred in 14 patients; bypass surgery was performed in 11 limbs, and major amputation was performed in 1 limb during the follow-up. Kaplan-Meier survival curves showed that the rate of recurrent ISR at 2 years was 84.8% in class III patients compared with 49.9% in class I patients (p < 0.0001) and 53.3% in class II patients (p = 0.0003), and the rate of recurrent occlusion at 2 years was 64.6% in class III patients compared with 15.9% in class I patients (p < 0.0001) and 18.9% in class II patients (p < 0.0001)., Conclusions: Restenotic patterns after FP stenting are important predictors of recurrent ISR and occlusion., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Previous studies showed that nicorandil can reduce coronary events in patients with coronary artery disease. However, it is unclear whether oral nicorandil treatment may reduce mortality following acute myocardial infarction (AMI)., Methods and Results: We examined the impact of oral nicorandil treatment on cardiovascular events in 1846 AMI patients who were hospitalized within 24 h after AMI onset, treated with emergency percutaneous coronary intervention (PCI), and discharged alive. Patients were divided into those with (Group N, n=535) and without (Group C, n=1311) oral nicorandil treatment at discharge. No significant differences in age, gender, body mass index, prevalence of coronary risk factors, or history of myocardial infarction existed between the two groups; however, higher incidences of multi-vessel disease, and a lower rate of successful PCI were observed in Group N. During the median follow-up of 709 (340-1088) days, all-cause mortality rate was 43% lower in Group N compared with Group C (2.4% vs. 4.2%, stratified log-rank test: p=0.0358). Multivariate Cox regression analysis revealed that nicorandil treatment was associated with all-cause death after discharge (Hazard ratio 0.495, 95% CI: 0.254-0.966, p=0.0393), but not for other cardiovascular events such as re-infarction, admission for heart failure, stroke and arrhythmia., Conclusions: The results suggest that oral administration of nicorandil is associated with reduced incidence of death in the setting of secondary prevention after AMI., (Copyright © 2011 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

A 19-year-old man who underwent bicaval orthotopic heart transplantation for idiopathic dilated cardiomyopathy complained of palpitations 2 weeks after the heart transplantation. An ECG revealed paroxysmal atrial tachycardia (AT) with a cycle length of 260 ms and the P wave morphology of the AT was similar to that during sinus rhythm. Echocardiography showed normal contraction. No rejection, vasculopathy, or infection was observed. An electrophysiologic study and catheter ablation guided by a noncontact mapping system were performed due to drug refractory AT. The AT was induced spontaneously by isoproterenol infusion. The activation sequence of the AT exhibited a focal pattern, and the breakout site of the AT into the donor right atrium was just 12 mm below the breakout site of the donor sinoatrial node. Radiofrequency catheter ablation eliminated this AT and resulted in an improvement in the symptoms.

Background: Previously the stabilization of coronary plaque with atorvastatin was demonstrated in the TWINS (evaluaTion With simultaneous angIoscopy and iNtravascular ultraSound) study. The influence of the low-density lipoprotein cholesterol (LDL-C) level on plaque stabilization was analyzed., Methods and Results: Patients (n=29) with hypercholesterolemia and coronary artery disease (CAD) were analyzed. They received atorvastatin (10-20mg/day) for 80 weeks and were divided into low (< 91 mg/dl) and high (≥ 91 mg/dl) LDL-C groups based on their 80-week LDL-C level. Angioscopy was performed before and after treatment. Yellow coronary plaques were classified into six grades (grades 0 to 5) and mean grade was determined for each patient. The LDL-C levels at week 28 and 80 were reduced in both low LDL-C groups (n=14, 140.3 to 77.9 and 75.9 mg/dl; P<0.001 both groups) and high LDL-C groups (n=15, 151.7 to 93.0 and 99.1mg/dl; P<0.001 both groups). Significant improvement in the mean grade was shown in the low LDL-C groups (1.44 to 1.00 and 1.05; P=0.003 both groups) at week 28 and 80 vs. no significant change in high LDL-C groups (1.43 to 1.23 and 1.28; P=0.032 and P=0.169 respectively)., Conclusions: Adequate reduction of LDL-C is important for the stabilization of coronary plaques.

Background: The addition of a mitral isthmus (MI) block line after pulmonary vein isolation could lead to a favorable outcome of catheter ablation in patients with atrial fibrillation (AF). However, it is sometimes tough to create a complete MI block line, and the cooling effect because of the local coronary flow may prevent the creation of a successful MI block line., Methods and Results: This study enrolled 81 AF patients in whom the creation of an MI block line was attempted in those with persistent or pacing-inducible AF after pulmonary vein isolation. A local coronary artery (LCA) across the MI block line was observed in 43 (53%) of 81 patients, and a bidirectional MI block was successfully accomplished in 53 (65%) of 81 patients, at the estimated MI line. The ratio of a successful MI block line was significantly lower in the patients with an LCA than in those without an LCA (42% versus 92%; P<0.001). The mean diameter of the coronary sinus (0.59 ± 0.18 versus 0.82 ± 0.22 cm; P<0.001) and length of the estimated MI line (33.4 ± 9.9 versus 29.4 ± 7.1 mm; P=0.032) were significantly shorter in the patients with a successful MI block line than in those without a successful MI block line. In the multivariable analysis, an LCA at the MI and a larger coronary sinus diameter were independent risk factors for an unsuccessful MI block line., Conclusions: Local coronary flow at the MI is associated with an increased incidence of an unsuccessful MI block line.

Purpose: To investigate the long-term outcomes of nitinol stenting in femoropopliteal lesions and to determine the factors associated with restenosis., Methods: Between December 2003 and December 2009, 861 patients (603 men; mean age 72 years) underwent nitinol stenting of the femoropopliteal segment in 1017 limbs. A quarter (26%) of the patients had critical limb ischemia. Mean lesion length was 152±93 mm. Stent patency was assessed by either duplex ultrasound or angiography and analyzed by Kaplan-Meier estimation. The determinants of restenosis were explored with Cox proportional hazard regression analyses; the results are presented as the hazard ratio (HR) and 95% confidence interval (CI). Risk stratification of primary patency was subsequently analyzed using a score based on the significant prognostic factors identified in the multivariate model., Results: Stent fracture occurred in 10% (104 limbs) of the lesions. At 1, 3, and 6 years, the primary patency rates were 77%, 67%, and 63%; secondary patency rates were 91%, 87%, and 87%; freedom from femoropopliteal bypass grafting was 99%, 97%, and 96%, respectively. Multivariate Cox regression analysis identified female gender (HR 1.899; 95% CI 1.318 to 2.737, p<0.001), ankle-brachial index <0.6 (HR 1.921; 95% CI 1.348 to 2.736, p<0.001), TASC II C/D lesion (HR 2.068; 95% CI 1.346 to 3.177, p = 0.0009), stent fracture (HR 1.937; 95% CI 1.203 to 3.118, p = 0.006), and the absence of cilostazol administration (HR 2.102; 95% CI 1.394 to 3.172, p<0.001) as strong independent factors associated with restenosis. After assigning a risk score based on the outcomes of the multivariate regression analysis (1 each for female gender, ABI <0.6, TASC II C/D, stent fracture, and absence of cilostazol therapy), primary patency was found to be lower in limb groups with a higher cumulative score (12-month primary patency: score 0: 93%, score 1: 80%, score 2: 73%, score 3; 47%, score 4: 0%, respectively; p<0.001)., Conclusion: Endovascular therapy using nitinol stents for FP lesions yielded acceptable outcomes up to 6 years. Risk stratification for patency can play an important role in estimating future occurrence of restenosis after nitinol stent implantation in FP lesions.

Background: Potential benefits of off-label cardiac resynchronization therapy (CRT) in end-stage heart failure (EHF) patients have not been fully investigated., Hypothesis: Some EHF patients who are dependent on intravenous inotropes can benefit from CRT., Methods: We retrospectively enrolled 14 EHF patients who were dependent on intravenous inotropes at the time of CRT implantation. Mean duration of inotropic support was 51 ± 47 days before CRT device implantation. To identify the efficacy of CRT, we assessed the successful withdrawal rate from inotropic support and survival estimates after device implantation. We also tried to identify possible predictors for withdrawal by comparing patient demographics between successful withdrawal (SW) and nonwithdrawal (NW) groups., Results: Successful withdrawal was achieved in 9 (64%) of 14 patients 46 ± 33 days after CRT device implantation. Event-free survival was longer in the SW group than in the NW group (810 ± 169 days vs 114 ± 34 days; P = 0.007). In addition, patients in the SW group showed a higher previous surgery rate (89% vs 20%; P = 0.010) and a lower grade of mitral regurgitation (median, 0 vs 2; P = 0.010) than those in the NW group., Conclusions: Our retrospective data showed potential benefits of CRT among EHFpatients. Treatment of mitral regurgitation might be an essential qualification for managing EHF patients with CRT., (© 2011 Wiley Periodicals, Inc.)

Objectives: We sought to investigate the timing of restenosis and the restenosis factors following nitinol stenting in the superficial femoral artery (SFA)., Background: Restenosis following nitinol stenting in the SFA remains unsolved., Methods: We analyzed 742 limbs in consecutive 585 patients who underwent successful endovascular therapy for de novo SFA lesions. Patency was assessed by duplex ultrasonography. Primary patency was defined as treated vessels without restenosis and secondary patency was defined as target vessels reopened by repeat revascularization. Receiver-operating characteristic (ROC) analysis was performed to delineate the timing of restenosis. Patients were subsequently classified into three groups: no restenosis, early restenosis, and late restenosis. Cox proportional hazard regression analyses were performed to explore the determinants of restenosis in each restenosis group., Results: Primary and secondary patency was 67 and 86% at 6 years, respectively. ROC curves indicated the 369th day was the best cutoff point distinguishing the early (144 limbs) and the late (42 limbs) restenoses. Sustained patency was observed in 556 limbs. After multivariate analysis, cilostazol (P = 0.0007) was negatively associated; female gender (P = 0.0071), diabetes mellitus (P = 0.0428), critical limb ischemia (P = 0.0435), and stent fracture (P = 0.0004) were positively associated with the early restenosis. Trans Atlantic Inter-Society Consensus II C/D was positively associated with both the early (P = 0.0017) and the late (P = 0.0359) restenoses., Conclusions: Restenosis predominantly occurred within a year following nitinol stenting in the SFA, and the factors associated with the early restenosis were different from those with the late restenosis., (Copyright © 2011 Wiley-Liss, Inc.)

Stent fracture with pseudoaneurysm formation in the femoropopliteal artery has uncommonly been reported. We present the case of a 72-year-old man with a fracture of self-expanding nitinol stent and a pseudoaneurysm formation in the suprageniculate popliteal artery. The popliteal artery was successfully reconstructed with a small saphenous vein graft interposition., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

The objectives of the present study were to determine predictors for target lesion revascularization (TLR) and to examine the clinical usefulness of the Driver(®) stent (a cobalt alloy, modular-type) in Japanese patients with coronary artery disease. Data on 631 Japanese patients including 241 with stable angina and 361 with acute coronary syndrome-who had been implanted with the Driver(®) stent (805 lesions) between August 2004 and February 2005-were collected retrospectively; 95.0 and 81.7% of these lesions were de novo and ACC/AHA classification B2/C type, respectively. Early angiography of 622 patients revealed 1) the preprocedural minimal lumen diameter (MLD) of 0.80 ± 0.51 mm, with lesion lengths of 17.1 ± 7.3 mm, and 2) the postprocedural MLD of 2.95 ± 0.55 mm, with MLD gains of 2.14 ± 0.68 mm. At 270 days of clinical follow-up, the incidences of major adverse cardiac events (MACE), TLR, and early stent thrombosis (ST) were 18.8, 14.7, and 0.2%, respectively; the TLR rate decreased statistically significantly to 5.3 and 5.9% when implanting the Driver(®) stent (3.5 and 4.0 mm) and by IVUS, respectively. Absence rate of diabetes mellitus, presence rate of AMI, presence rate of stent diameters of ≥3.5 mm, and presence rate of IVUS-guided PCI showed lower TLR rates, with statistically significant differences. Uni- and multivariate analyses revealed that AMI and stent diameter (≥3.5 mm) are significant predictors for TLR (0.048 and 0.047, respectively), indicating that physicians are recommended to consider these variables when selecting candidate real-world patients for IVUS-guided PCI.

Conventional aortic valve replacement (AVR) is the gold standard surgical treatment for symptomatic aortic valve stenosis. However, some patients are not referred for open surgical procedure because of their high risk due to complicated co-morbidities. We describe the first case in Japan of successful transcatheter aortic valve implantation (TAVI). An 81-year-old woman with severe interstitial pneumonia was referred for significant aortic valve stenosis. Conventional AVR might have been risky, so TAVI was planned after informed consent was obtained. Under general anesthesia was established, a 23-mm Edwards SAPIEN transcatheter heart valve was implanted through the common iliac artery. Postoperative echocardiographic assessment showed satisfactory hemodynamic function with a stable valve position, and she was discharged on day 7 without complications. At the 6-month follow-up, there had been no untoward events, and there was marked improvement in her functional status. TAVI for symptomatic aortic valve stenosis is a less invasive, alternative approach for high-risk patients.

Background: Sick sinus syndrome (SSS) is often complicated with the additional presence of atrial fibrillation (AF). Atrial septal pacing, compared with right atrial appendage (RAA) pacing, shortens the atrial conduction time and reduces the dispersion of the refractoriness. However, low atrial septal (LAS) pacing's efficacy for preventing AF in SSS remains controversial in Japan., Methods and Results: We analyzed 95 consecutive patients with SSS who underwent dual-chamber pacemaker implantations. Forty-two patients (44%) had a history of AF at the time of the pacemaker implantation. In the group without a history of AF, LAS pacing was performed in 17 patients, and RAA pacing in 36 patients. In the group with a history of AF, LAS pacing was performed in 15 patients, and RAA pacing in 27 patients. We evaluated whether LAS pacing prevented the development of de novo AF and the persistence of AF after pacemaker implantations. No significant differences were found in the baseline characteristics between the RAA and LAS groups regardless of an AF history. During a 1-year follow-up period, in the SSS patients without a history of AF, 19.0% (7/36) of the RAA group developed de novo AF, however, 5.9% (1/17) of the LAS group developed de novo AF (p=0.20). On the other hand, in the SSS patients with a history of AF, 22.0% (6/27) of the RAA group developed persistent AF, but none of the LAS group developed any persistent AF (p=0.049). There were no post-operative complications related to the LAS pacing., Conclusions: LAS pacing is safe and feasible. LAS pacing may prevent the progression to persistent AF in SSS patients with dual-chamber pacemakers., (Copyright © 2011 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Pulmonary vein thrombosis is rarely detected in patients with cancer, lung lobectomy, trauma and so on. We report the case of idiopathic pulmonary vein thrombosis complicated with coronary heart disease. A-57-year-old man with suspected coronary heart disease underwent computed tomography coronary angiography. He did not show any sign of malignancy in lung or other organs. Multi-detector row computed tomography demonstrated 3-dimensional images for the thrombi in bilateral lower pulmonary veins besides an old anterior myocardial infarction. Previously, few reports have described the detection of pulmonary vein thrombosis, however, multi-detector row computed tomography was thought to be useful for detecting and evaluating pulmonary vein thrombosis.

The initial and long-term result of coronary intervention has been improved by the newly developed technology year by year. High initial success rate of coronary intervention for patients with chronic total obstruction has been achieved with techniques devised by Japanese interventional cardiologist and good long-term patency with drug eluting stents. Technique established by coronary intervention has been broadly applied also to the treatment of a peripheral artery disease. MEGA trials of various interventions provide us high level of evidences to treat patients with atherosclerotic diseases adequately. Although there is not enough evidences in Japanese population because of poor infrastructures to run trials, the large-scale clinical trials about interventional therapy have been carried out in response to recognition of importance of EBM in these days.

Background: The nitinol stent has proven superior primary patency than balloon angioplasty in superficial femoral artery (SFA) lesions, but a systematic comparison of the patency of 2 different nitinol stents (S.M.A.R.T. and Luminexx) in patients with SFA lesions has not been done., Methods and Results: A multicenter, prospective database that included 511 consecutive patients who had undergone endovascular therapy with nitinol stenting for 638 limbs (S.M.A.R.T.: n=503; Luminexx: n=135) was retrospectively analyzed. Patency was assessed by duplex ultrasound. Outcomes were compared between the groups by the Kaplan-Meier and log-rank methods. To minimize the differences between each group, propensity-matched analysis was also performed. Stent fracture occurred in 11% (57/503) of the S.M.A.R.T. and 23% (31/135) of the Luminexx stents (P=0.0005). Despite a higher prevalence of chronic total occlusion (55% vs. 40%, P=0.002) and longer lesions (154±93mm vs. 135±71mm, P=0.03) in the S.M.A.R.T. group, there was no significant difference in patency for up to 5 years (P=0.50). When 119 lesions per group were assessed after propensity-matched analysis, the 5-year patency rate was 74% for the S.M.A.R.T. and 65% for the Luninexx stent (P=0.10)., Conclusions: Despite a different stent fracture rate, there was no significant difference in terms of patency between the S.M.A.R.T. and Luninexx stents for up to 5 years.

Background: Second-generation drug-eluting stents (DES) are expected to show better arterial repair than older DES. We angioscopically compared the biodegradable polymer-coated biolimus A9-eluting stent (BES) and durable polymer-coated sirolimus-eluting stent (SES) to explore differences in arterial repair., Methods and Results: Angioscopy was performed 9 ± 1 months after 15 BES and 16 SES were implanted initially in the native coronary artery. Heterogeneity of neointimal coverage (NIC) as well as the dominant NIC grade was examined. NIC was defined as: grade 0 = fully visible struts; grade 1 = struts bulging into the lumen, but covered; grade 2 = embedded, but translucent struts; grade 3 = invisible struts. Heterogeneity was judged when the NIC grade varied ≥ 1. In-stent late loss (0.06 ± 0.23 vs. 0.07 ± 0.18 mm, P = 0.80), and dominant NIC grade (1.5 ± 0.8 vs. 1.3 ± 0.7, P = 0.45) were similar for BES and SES. Within the stents, NIC was more heterogeneous in SES than in BES (P = 0.035). 80% of BES showed homogeneous NIC, while 56% of SES had heterogeneous NIC., Conclusions: BES showed limited late loss similar to that for SES. Nonetheless, the NIC with BES was more homogeneous than that with SES. Biodegradable polymer-coated BES may have an advantage in homogeneous NIC.

Background: The aim of this study was to compare the effect of atorvastatin treatment on high-grade yellow coronary plaques (grade ≥ 2, group H) vs. low-grade yellow plaques (grade ≤ 1, group L)., Methods and Results: Twenty-nine hypercholesterolemic patients with coronary heart disease were treated with atorvastatin (10-20mg/day) for 80 weeks and were divided into 2 groups by baseline plaque color grade. The angioscopic plaque grade and the vessel, plaque, and luminal volumes were measured by intravascular ultrasound at baseline and in weeks 28 and 80. The plaque color grade decreased significantly from baseline to weeks 28 and 80 in group H (2.27 ± 0.48, 1.47 ± 0.75, and 1.55 ± 0.86, respectively), but not significantly in group L (0.90 ± 0.31, 0.83 ± 0.61, and 0.89 ± 0.56, respectively). The plaque volume of group HP was greater than that of group LP (respectively 158.0 ± 45.8 vs. 107.5 ± 21.9 mm(3) at baseline, 144.5 ± 41.1 vs. 97.5 ± 24.8mm(3) in week 28, and 128.8 ± 31.5 vs. 87.9 ± 31.5mm(3) in week 80 (P < 0.001 by ANCOVA between groups)., Conclusions: The plaque-stabilizing effect of atorvastatin was stronger for more vulnerable plaques with a higher color grade, although regression of plaque during atorvastatin therapy was noted irrespective of plaque vulnerability.

Background: The use of a stent in the treatment of lesions of the superficial femoral artery (SFA) remains controversial. Although some reports have suggested that use of a nitinol stent in conjunction with aggressive medical management is effective for long SFA lesions, few long-term, large-scale studies have been done., Methods and Results: A retrospective analysis was conducted of data from a multicenter study in which the S.M.A.R.T. Control(TM) stent was used for treatment of de novo SFA lesions. A total of 528 lesions in 432 patients were included. Mean patient age was 72.5±9.1 years; mean stent length was 15.7±8.1cm; 259 lesions (49%) were classified as C/D according to the TransAtlantic Inter-Society Consensus (TASC) II classification. Primary and secondary patency at 4 years was 66% and 87%, respectively. No cilostazol administration (41% re-stenosis group vs. 29% no-restenosis group, P<0.01), female gender (42% vs. 26%, P<0.01), younger age (70.7±9.3 years vs. 72.9±9.0 years, P<0.05), and chronic total occlusion (CTO; 72% vs. 52%, P<0.01) were independent predictors of re-stenosis., Conclusions: The S.M.A.R.T. Control(TM) stent provided good long-term durability in the treatment of SFA lesions, and no cilostazol administration, female gender, younger age and CTO were associated with re-stenosis., (All rights are reserved to the Japanese Circulation Society.)

Skin perfusion pressure (SPP) is a measure of peripheral circulation; low SPP (<40 mm Hg) indicates poor wound healing. Cilostazol is used to alleviate symptoms and improve walking distance in patients with peripheral artery disease (PAD), but its effect on SPP is unknown. We enrolled patients whose symptoms were Rutherford class 3 or 4 and whose SPP was <40 mm Hg. We analyzed patient symptoms, ankle-brachial index (ABI), and SPP before and 1 month after treatment with cilostazol. We analyzed 20 legs of 14 patients. Cilostazol improved symptoms in 12 legs. The average heart rate increased from 76 ± 16 to 84 ± 20 beats/min (P < .05). Cilostazol did not increase the ABI but caused a significant increase in the SPP from 24.5 ± 8.88 to 42.8 ± 21.0 mm Hg (P < .01). Cilostazol increases microvascular circulation in severely ischemic limbs and may be useful in critical limb ischemia.

Left atrial roof line (LARL) can prevent the perpetuation of atrial fibrillation (AF) by delineation of the arrhythmogenic substrate, but it may be associated with an increased incidence of atrial tachycardia (AT). This study was performed to evaluate the characteristics and clinical implications of inducible AT after LARL.A total of 139 consecutive patients with AF who underwent catheter ablation were prospectively enrolled in this study. LARL was required to prevent the perpetuation of AF in 98 of 139 patients (71%). LARL significantly reduced the incidence of inducible AF (before versus after: 100% versus 44%, respectively, P < 0.01), whereas it significantly increased the incidence of AT (18% versus 63%, P < 0.01). ATs were observed after LARL in 62 of 98 patients (63%), and these circuits were determined in 99 of 112 stable ATs (88%), including tricuspid isthmus-dependent (n = 35), mitral annulus (n = 22), septal (n = 15), surrounding right pulmonary veins (PVs) (n = 12), coronary sinus (CS) ostium (n = 4), upper loop (n = 4), surrounding left PVs (n = 4), and LA anterior wall (n = 3). Catheter ablation (CA) successfully terminated 111 of 122 stable ATs (91%) during CA. The occurrence of AT after CA was significantly higher in patients with than in those without residual AT (26% versus 2%, P < 0.05).Induced AT with a stable circuit after LARL creation could be mapped, and delineation of the induced AT may lead to a favorable outcome.