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There has been great effort to improve clinical outcome in percutaneous treatment for coronary artery disease. Complementary to coronary angiography, intravascular ultrasound (IVUS) provides in vivo tomographic anatomic information, enabling to evaluate from the lumen to the vessel wall. As a result, IVUS has had a pivotal role to understand pathophysiology of coronary artery disease and improve clinical outcome. It provides preprocedural information to evaluate stenosis severity and plaque characteristics and helps with optimal stent deployment, minimizing underexpansion and geographic miss that are the major mechanisms of stent failure. Recently, many large-scale clinical trials and meta-analyses with drug-eluting stents have shown the clinical benefits of IVUS-guided percutaneous coronary intervention. Some recent studies have also supported the cost-effectiveness of IVUS-guided PCI especially in high-risk patients. This article will discuss the clinical value of IVUS in contemporary practice.

During the 20 years since the introduction of intravascular ultrasound (IVUS) to catheterization laboratory, there has been growing evidence supporting the role of IVUS. In this article, we review clinical application of routine use of IVUS with recent evidences, a dominant strategy even in the era of drug-eluting stents. IVUS provides pre-procedural information to evaluate stenosis severity and plaque characteristics. In addition, IVUS helps optimal stent deployment, minimizing underexpansion and geographic miss, which are major mechanisms of stent failure. Large-scale clinical trials and meta-analyses have shown that the clinical benefits of IVUS guidance are maximized in complex lesions (left main coronary artery, long lesions and chronic total occlusion). Some recent studies have also supported the cost effectiveness of IVUS-guided PCI especially when there is a high risk of stent failure. IVUS provides valuable information about lesion severity, lumen and vessel size, lesion length, and plaque characteristics. By determining appropriate stent sizes and optimizing stenting procedures, IVUS-guided PCI improves clinical outcomes especially in patients with high-risk coronary lesions.

Objectives We report optical coherence tomography (OCT) findings in 33 patients who presented with very late stent thrombosis (VLST) after either drug-eluting stent (DES) or bare-metal stent (BMS) implantation. Background VLST is a potentially life-threatening complication, but the underlying mechanisms remain unclear. Methods In 33 patients (27 DES- and 6 BMS-treated lesions) with definite VLST, OCT images were acquired before either thrombus aspiration or intravascular ultrasonography (IVUS) imaging. Results The median duration from implantation was 61.5 months in the DES group and 109.1 months in the BMS group. In the overall cohort, combining DES and BMS, 94% showed intraluminal thrombi. VLST was associated with in-stent neointimal rupture in 23 patients (70%); 22 had thrombi near the site of neointimal rupture. Stent malapposition was observed in 14 (42%) lesions, but only 9 of them showed thrombi at the site of stent malapposition; moreover, 6 (18%) stented segments with malapposition also had neointimal rupture. Only 2 (6%) lesions had no evidence of neointimal rupture or malapposition. Stent fracture was detected in 3 DES-treated lesions, all with concomitant neointimal rupture. Compared with lesions without neointimal rupture, lesions with neointimal rupture showed a higher frequency of ST-segment elevation myocardial infarction (65% vs. 20%, respectively, p = 0.040) as well as a higher peak creatine kinase-myocardial band level (163.1 ng/ml vs. 15.7 ng/ml, respectively, p = 0.017). Conclusions OCT imaging indicated that advanced neoatherosclerosis with neointimal rupture and thrombosis was the most common mechanism of definite VLST and was associated with a high frequency of ST-segment elevation myocardial infarction.

Importance-Performance Analysis(IPA) is a well-known methodology to find the area for improvement. However, the IPA uses different strategies depending on an attribute falls in either `Concentrate`, `Keep up`, `Possible overkill`, or Low priority` quadrant. Problems can occur when attributes locate near the demarcation lines. To solve this problem of IPA, I suggest a modified importance-satisfaction analysis which integrates the Slack(1994)`s diagonal approach and Kano`s ASC(Jang et al., 2012) into Yang(2003)`s Importance-Satisfaction model. For this, I investigated 21 smartphone`s quality attributes, which adopted from Song and Park(2012)`s study, and conducted a survey of 280 university students for the results of Kano` model and the importance and satisfaction of the quality attributes. The results show that the proposed model enables the business managers to prioritize the quality attributes for improvement through the interpretation on the continuous diagonal line using the Kano`s questionnaire only, without acquiring any additional survey for importance of attributes. Accordingly, it is expected that the newly proposed method will diminish the limitation of the existing IPA. In addition, to test the validity of the ASC, this study conducts a comparative analysis between the Kano`s ASC and Tontini(2007)`s method to determine the relative importance of quality attributes.

Objectives We sought to define the clinical importance of an integrated classification of bicuspid aortic valve (BAV) phenotypes and aortopathy using multidetector computed tomography (MDCT). Background An association between BAV phenotypes and the pattern of valvular dysfunction or bicuspid aortopathy has yet to be definitely established. Methods The study cohort included 167 subjects (116 men, age 54.6 ± 14.4 years) who underwent both MDCT and transthoracic echocardiography from 2003 to 2010. Two BAV phenotypes—fusion of the right and left coronary cusps (BAV-AP) and fusion of the right or left coronary cusp and noncoronary cusp (BAV-RL)—were identified. Forty-five patients showed normal aortic dimensions and were classified as type 0. In the remaining patients, hierarchic cluster analysis showed 3 different types of bicuspid aortopathy according to the pattern of aortic dilation: type 1 (aortic enlargement confined to the sinus of Valsalva [n = 34]), type 2 (aortic enlargement involving the tubular portion of the ascending aorta [n = 49]), and type 3 (aortic enlargement extending to the transverse aortic arch [n = 39]). Results The prevalence of BAV-AP and BAV-RL was 55.7% and 44.3%, respectively. Comparing BAV-AP and BAV-RL, no differences in age or in the prevalence of male sex were determined. However, significant differences in the valvular dysfunction pattern were noted, with moderate-to-severe aortic stenosis predominating in patients with BAV-RL (66.2% vs. 46.2% in BAV-AP; p = 0.01), and moderate-to-severe aortic regurgitation in BAV-AP (32.3% vs. 6.8% in BAV-RL; p Conclusions The patterns of valvular dysfunction and bicuspid aortopathy differed significantly between the 2 BAV phenotypes, suggesting the possibility of etiologically different entities.

Functional lesion assessment for coronary tandem lesions and its clinical applications have not been thoroughly studied. The aim of this study was to test the hypothesis that the fractional flow reserve (FFR) gradient across an individual stenosis (ΔFFR) during pressure-wire pullback is a surrogate of the relative functional severity of each stenosis in coronary tandem lesions. For in vitro validation, computational flow dynamic modeling of coronary tandem lesion with various degree of stenosis was constructed. For clinical validation, a total of 52 patients (104 lesions) with coronary tandem lesions (2 stenoses along 1 coronary artery) were consecutively enrolled, and tailored stent procedures based on ΔFFR was performed, at first treating the lesion with large ΔFFR and then subsequently reassessing the FFR for the remaining lesion. The coronary stenosis was considered functionally significant and stenting was performed when the FFR of a lesion was ≤0.80. Using in vitro computational flow dynamic modeling, the lesion with the large ΔFFR of the coronary tandem lesion was indicated as the lesion with the greater degree of simulated diameter stenosis. In the clinical cohort, 28 patients (53.8%) had only single-lesion treatment, and stent implantation for 28 lesions (26.9%) was deferred according to the proposed strategy. During the 9-month follow-up period, only 1 repeat revascularization occurred among the deferred lesions. In conclusion, for the treatment of coronary tandem lesions, ΔFFR may be a useful index for prioritizing the treatment sequence and optimizing the stenting procedure. In this way, unnecessary stent implantation can be avoided, with the achievement of favorable functional and clinical outcomes.

This was designed to assess the outcomes of side branch (SB) stenosis after implantation of three drug-eluting stents (DES). From 2,645 patients in the ZEST (Comparison of the Efficacy and Safety of Zotarolimus-Eluting Stent with Sirolimus-Eluting and PacliTaxel-Eluting Stent for Coronary Lesions) Trial, 788 patients had 923 bifurcation lesions with SB ≥ 1.5 mm were included. SB was treated in 150 lesions, including 35 (3.8%) receiving SB stenting. Of untreated SB with baseline stenosis < 50%, the incidences of periprocedural SB compromise was similar in the zotarolimus (15.8%), sirolimus (17.2%), and paclitaxel (16.6%) stent groups (P = 0.92). At follow-up angiography, delayed SB compromise occurred in 13.9%, 3.2%, and 9.4% (P = 0.010) of these groups. When classified into four groups (< 50%, 50%-70%, 70%-99%, and 100%), 9.0% of untreated SB were worsened, whereas improvement and stationary were observed in 9.6% and 81.4%. In a multivariable logistic regression model, main branch (MB) stenosis at follow-up (%) was the only independent predictor of SB stenosis worsening (odds ratio, 1.03; 95% confidence interval, 1.01-1.04; P < 0.001). After MB stenting in bifurcation lesions, a minority of SB appears to worsen. DES with strong anti-restenotic efficacy may help maintain SB patency.

Background— Procedural and clinical outcomes still remain unfavorable for patients with long coronary lesions who undergo stent-based coronary interventions. Therefore, we compared the relative efficacy and safety of resolute zotarolimus-eluting stents (R-ZES) and sirolimus-eluting stents (SES) for patients with de novo long coronary lesions. Methods and Results— This randomized, multicenter, prospective trial, called the Percutaneous Treatment of LONG Native Coronary Lesions With Drug-Eluting Stent-IV (LONG-DES IV) trial, compared long R-ZES and SES in 500 patients with long (≥25 mm) native coronary lesions. The primary end point of the trial was in-segment late luminal loss at 9-month angiographic follow-up. The baseline characteristics were not different between R-ZES and SES groups, including lesion lengths (32.4±13.5 mm versus 31.0±13.5 mm, P =0.27). At 9-month angiographic follow-up, the R-ZES was noninferior to the SES with respect to in-segment late luminal loss, the primary study end point (0.14±0.38 mm versus 0.12±0.43 mm, P for noninferiority=0.03, P for superiority=0.68). In addition, in-stent late luminal loss (0.26±0.36 mm versus 0.24±0.42 mm, P =0.78) and the rates of in-segment (5.2% versus 7.2%, P =0.44) and in-stent (4.0% versus 6.0%, P =0.41) binary restenosis were not significantly different between the 2 groups. There were no significant between-group differences in the rate of adverse clinical events (death, myocardial infarction, stent thrombosis, target-lesion revascularization, and composite outcomes). Conclusions— For patients with de novo long coronary artery disease, R-ZES implantation showed noninferior angiographic outcomes as compared with SES implantation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01186094.

Objectives This study sought to evaluate the safety and efficacy of second-generation drug-eluting stents (DES) for patients with unprotected left main coronary artery (ULMCA) stenosis. Background The clinical benefit of second-generation DES for ULMCA stenosis has not been determined. Methods The authors assessed 334 consecutive patients who received everolimus-eluting stents (EES) for ULMCA stenosis between 2009 and 2010. The 18-month incidence rates of major adverse cardiac or cerebrovascular events (MACCE), including death, myocardial infarction (MI), stroke, or ischemia-driven target vessel revascularization (TVR), were compared with those of a randomized study comparing patients who received sirolimus-eluting stents (SES) (n = 327) or coronary artery bypass grafts (CABG) (n = 272). Results EES (8.9%) showed a comparable incidence of MACCE as SES (10.8%; adjusted hazard ratio [aHR] of EES: 0.84; 95% confidence interval [CI]: 0.51 to 1.40; p = 0.51) and CABG (6.7%, aHR of EES: 1.40; 95% CI: 0.78 to 2.54; p = 0.26). The composite incidence of death, MI, or stroke also did not differ among patients receiving EES (3.3%), SES (3.7%; aHR of EES: 0.63; 95% CI: 0.27 to 1.47; p = 0.29), and CABG (4.8%; aHR of EES: 0.67; 95% CI: 0.29 to 1.54; p = 0.34). However, the incidence of ischemia-driven TVR in the EES group (6.5%) was higher than in the CABG group (2.6%, aHR of EES: 2.77; 95% CI: 1.17 to 6.58; p = 0.02), but comparable to SES (8.2%, aHR of EES: 1.14; 95% CI: 0.64 to 2.06; p = 0.65). Angiographic restenosis rates were similar in the SES and EES groups (13.8% vs. 9.2%, p = 0.16). Conclusions Second-generation EES had a similar 18-month risk of MACCE for ULMCA stenosis as first-generation SES or CABG. (Evaluation of Outcomes of EES Implantation for Unprotected Left Main Coronary Artery Stenosis [PRECOMBAT-2]; NCT01348022 )

Objectives The purpose of this study was to determine the angiographic and optical coherence tomographic (OCT) characteristics of coronary lesions with recanalized thrombi. Background Although spontaneous recanalization of thrombi has been reported pathologically, it is rarely recognized in clinical practice. Methods Based on histopathologic features, recanalization of thrombi was defined by characteristics on OCT. Results Recanalization of thrombi was identified in 6 patients (3 male, 3 female; median age 63 years; age range 54 to 72 years). Based on symptoms, 3 patients were diagnosed with unstable angina; 2 were diagnosed with stable angina; and 1, who had mitral stenosis and huge left atrial thrombi, was diagnosed with post-infarct angina. All had normal serum concentrations of cardiac markers at admission. Angiography showed irregular linear filling defects and haziness. Two patients with near total occlusion had Thrombolysis In Myocardial Infarction (TIMI) flow grade 1 and collaterals, whereas 4 patients had TIMI flow grade 3 and no collaterals. All patients showed OCT findings consistent with recanalized thrombi, which consisted of signal-rich, high backscattered septa that divided the lumen into multiple small cavities communicating with each other. These structures, which had smooth inner borders, created a “Swiss cheese” appearance. Percutaneous coronary intervention was performed in 5 patients with angiographic slow flow or inducible-ischemia as documented by invasive or noninvasive stress tests. The remaining 1 patient with restored coronary flow underwent mitral valve surgery and left atrial thrombectomy. Conclusions OCT provided details on the characteristics of the organization of thrombi in both chronic total occlusion and subtotal narrowing. Coronary lesions containing recanalized thrombi were characterized by multiple small channels, with most showing functional significance.

ObjectivesThe aim of this study was to evaluate the impact of ischemia-guided (IG) revascularization.BackgroundThe importance of IG revascularization has not been well-determined.MethodsThe outcomes of IG revascularization, in which revascularization was performed in the matched coronary artery with the perfusion abnormality on myocardial perfusion image (MPI), were retrospectively compared with those of non-IG revascularization in a registry of 5,340 patients with multivessel coronary disease comprising 2,587 percutaneous coronary interventions (PCIs) with drug-eluting stents and 2,753 coronary artery bypass graft (CABG) surgeries after adjustment with inverse-probability-of-treatment weighting.ResultsThe MPI was performed in 42.3% of patients, and IG revascularization was performed in 17.3%, including 12.4% in PCI and 21.8% in CABG patients (p < 0.001). The incidence of major adverse cardiac and cerebrovascular events (MACCE) including death, myocardial infarction, stroke, or repeat revascularization was significantly lower in the IG than in the non-IG group (16.2% vs. 20.7%; adjusted hazard ratio [aHR]: 0.73; 95% confidence interval [CI]: 0.60 to 0.88; p = 0.001), primarily driven by the lower repeat revascularization rate (9.9% vs. 22.8%; aHR: 0.66; 95% CI: 0.49 to 0.90; p = 0.009). Subgroup analysis showed that IG reduced the risk of MACCE in PCI (17.4% vs. 22.8%; aHR: 0.59; 95% CI: 0.43 to 0.81; p = 0.001) but not in CABG (16.0% vs. 18.5%; aHR: 0.87; 95% CI: 0.67 to 1.14; p = 0.31) patients.ConclusionsIschemia-guided revascularization with MPI, particularly in PCI-treated patients, seems to decrease the risk of repeat revascularization and MACCE for patients with multivessel disease.

Diabetes mellitus is a major risk factor for coronary artery disease (CAD) and for diffuse and progressive atherosclerosis. We evaluated the outcomes of drug-eluting stent (DES) placement and coronary artery bypass grafting (CABG) in 891 diabetic patients (489 for DES implantation and 402 for CABG) and 2,151 nondiabetic patients (1,058 for DES implantation and 1,093 for CABG) with multivessel CAD treated from January 2003 through December 2005 and followed up for a median 5.6 years. Outcomes of interest included death; the composite outcome of death, myocardial infarction (MI), or stroke; and repeat revascularization. In diabetic patients, after adjusting for baseline covariates, 5-year risk of death (hazard ratio 1.01, 95% confidence interval 0.77 to 1.33, p = 0.96) and the composite of death, MI, or stroke (hazard ratio 1.03, 95% confidence interval 0.80 to 1.31, p = 0.91) were similar in patients undergoing DES or CABG. However, rate of repeat revascularization was significantly higher in the DES group (hazard ratio 3.69, 95% confidence interval 2.64 to 5.17, p

Objective To evaluate long-term patterns of luminal changes after implantation of different types of drug-eluting stents (DES), we analyzed the serial angiographic outcomes of patients implanted with zotarolimus-eluting stents (ZES), sirolimus-eluting stents (SES), or paclitaxel-eluting stents (PES). Background Little is known regarding long-term luminal changes after DES implantation. Methods As a subgroup analysis of the ZEST trial, we performed complete angiographic evaluation immediately after the procedure and at 9 months and 2 years in 111 patients with 165 lesions (36 patients with ZES, 40 with SES, and 35 with PES). Results Baseline clinical, angiographic, and procedural characteristics were similar among the three groups. Quantitative angiographic analysis revealed significant decreases in minimal luminal diameter 9 months after stent implantation in the ZES (from 2.71 ± 0.49 to 2.21 ± 0.42 mm, P < 0.001), SES (from 2.79 ± 0.49 to 2.58 ± 0.57 mm, P < 0.001), and PES (from 2.66 ± 0.45 to 2.19 ± 0.52 mm, P < 0.001) groups. However, significant late improvements with different degree in luminal diameter were observed between 9 months and 2 years in the ZES (from 2.21 ± 0.42 to 2.39 ± 0.58 mm, P = 0.001), SES (from 2.58 ± 0.57 to 2.66 ± 0.60 mm, P = 0.039), and PES (from 2.19 ± 0.52 to 2.43 ± 0.52 mm, P < 0.001) groups. Conclusion Serial angiographic follow-up study revealed a biphasic luminal response after DES implantation, characterized by an early progression phase for the first 9 months and a late regression phase from 9 months to 2 years. © 2012 Wiley Periodicals, Inc.

Little is known about the intravascular ultrasound (IVUS) minimal lumen area (MLA) criteria and their accuracy in lesion subsets assorted according to vessel type, lesion location, vessel size, and clinical settings. We therefore assessed the accuracy of subgroup-specific cut-off values in predicting fractional flow reserve (FFR)0.80. In total 692 consecutive patients with 784 coronary lesions were assessed by IVUS and FFR before intervention. All patients had ≥1 target vessel with a de novo lesion (30% to 90% diameter stenosis). For prediction of FFR0.80 in the group overall, the best cut-off value of MLA was 2.4 mm(2) (sensitivity 84% and specificity 63%). Overall diagnostic accuracy was only 69%. In the subgroup analysis, the MLA cutoff was 2.4 mm(2) for the left anterior descending coronary artery, 1.6 mm(2) for the left circumflex coronary artery, and 2.4 mm(2) for the right coronary artery. By lesion location, the optimal cutoff was 2.6 mm(2) for proximal, 2.3 mm(2) for mid, and 1.9 mm(2) for distal segments. Furthermore, the cutoffs were 3.2 mm(2) in lesions with a larger RLD3.5 mm and 1.9 mm(2) in lesions with a smaller RLD2.75 mm. Nevertheless, diagnostic accuracies of all subgroup-specific criteria were80%. In conclusion, because IVUS-measured MLA is only 1 of many factors affecting coronary flow hemodynamics, even subgroup-specific criteria were inaccurate in identifying ischemia-inducible stenosis. In conclusion, direct functional assessment is therefore essential in guiding treatment strategies for coronary lesions.

Objectives This study compared everolimus-eluting stents (EES) and sirolimus-eluting stents (SES) for long coronary lesions. Background Outcomes remain relatively unfavorable for stent-based coronary intervention of lesions with long diseased segments. Methods This randomized, multicenter, prospective trial compared the use of long EES with SES in 450 patients with long (≥25 mm) native coronary lesions. The primary endpoint of the trial was in-segment late luminal loss at 9-month angiographic follow-up. Results The EES and SES groups had similar baseline characteristics. Lesion length was 34.0 ± 15.4 mm in the EES group and 34.3 ± 13.5 mm in the SES group (p = 0.85). Nine-month angiographic follow-up was performed in 80% of the EES group and 81% of the SES group (p = 0.69). In-segment late loss as the primary study endpoint was significantly larger in the EES group than in the SES group (0.17 ± 0.41 mm vs. 0.09 ± 0.30 mm, p for noninferiority = 0.96, p for superiority = 0.04). The in-segment binary restenosis rate was also higher in the EES group than in the SES group (7.3% vs. 2.7%, p = 0.046). However, in-stent late loss (0.22 ± 0.43 mm vs. 0.18 ± 0.28 mm, p = 0.29) and in-stent binary restenosis rate (3.9% vs. 2.7%, p = 0.53) were similar among the 2 groups. The incidence of any clinical outcomes (death, myocardial infarction, stent thrombosis, target lesion revascularization, and composite outcomes) was not statistically different between the 2 groups. Conclusions For patients with long native coronary artery disease, EES implantation was associated with greater angiographic in-segment late loss and higher rates of in-segment restenosis compared with SES implantation. However, clinical outcomes were both excellent and not statistically different. (Percutaneous Treatment of LONG Native Coronary Lesions With Drug-Eluting Stent-III [LONG-DES-III]; NCT01078038 )

Background— This study sought to evaluate the clinical impact of angiographic complete revascularization (CR) after drug-eluting stent implantation or coronary artery bypass graft surgery for multivessel coronary disease. Methods and Results— A total of 1914 consecutive patients with multivessel coronary disease undergoing drug-eluting stent implantation (1400 patients) or coronary artery bypass graft surgery (514 patients) were enrolled. Angiographic CR was defined as revascularization in all diseased segments according to the Synergy Between PCI With Taxus and Cardiac Surgery classification. The outcomes of patients undergoing CR were compared with those undergoing incomplete revascularization (IR) after adjustments with the inverse-probability-of-treatment weighting method. Angiographic CR was performed in 917 patients (47.9%) including 573 percutaneous coronary intervention (40.9%) and 344 coronary artery bypass graft (66.9%) patients. CR patients were younger and had more extensive coronary disease than IR patients. Over 5 years, CR patients had comparable incidences of death (8.9% versus 8.9%; adjusted hazard ratio, 1.04; 95% confidence interval, 0.76 to 1.43; P =0.81), the composite of death, myocardial infarction, and stroke (12.1% versus 11.9%; adjusted hazard ratio, 1.04; 95% confidence interval, 0.79 to 1.36; P =0.80), and the composite of death, myocardial infarction, stroke, and repeat revascularization (22.4% versus 24.9%; adjusted hazard ratio, 0.91; 95% confidence interval, 0.75 to 1.10; P =0.32) compared with IR patients. However, 368 patients (19.2%) with multivessel IR had a greater tendency toward higher risk of death, myocardial infarction, stroke, or repeat revascularization (30.3% versus 22.1%; adjusted hazard ratio, 1.27; 95% confidence interval, 0.97 to 1.66; P =0.079) than those without multivessel IR. Conclusions— Angiographic CR with drug-eluting stent implantation or coronary artery bypass grafting did not improve long-term clinical outcomes in patients with multivessel disease. This finding supports the strategy of ischemia-guided revascularization.

ObjectivesThe aim of this study was to assess the impact of early and late bleeding on subsequent mortality after drug-eluting stent (DES) implantation.BackgroundLittle is known about the impact of late bleeding after DES implantation.MethodsWith a time-updated Cox model, the impact of bleeding and myocardial infarction (MI) on 3-year mortality was analyzed in 3,148 consecutive patients who underwent DES implantation for coronary disease.ResultsBleeding, defined according to STEEPLE (Safety and Efficacy of Enoxaparin in PCI Patients, an International Randomized Evaluation) minor or major criteria, occurred in 6.5% of patients over 3 years. Patients with bleeding were older; were more likely to be female; had higher rates of diabetes mellitus, hypertension, and extensive coronary disease and lower ventricular function; and underwent more complex procedures than those without bleeding. The 3-year adjusted hazard ratios (HRs) for mortality were 5.81 (95% confidence interval [CI]: 3.92 to 8.60; p < 0.001) for patients with bleeding and 2.53 (95% CI: 1.62 to 3.96; p < 0.001) for patients with MI. When the timings of events were separated, the HRs for mortality were 4.89 (95% CI: 3.08 to 7.78; p < 0.001) and 7.81 (95% CI: 4.39 to 13.89; p < 0.001) for patients with bleeding within and after 30 days, respectively. By contrast, the HRs for mortality were 1.85 (95% CI: 1.09 to 3.14, p = 0.022) and 10.33 (95% CI: 4.91 to 21.75, p < 0.001) for patients with MI within and after 30 days, respectively.ConclusionsBleeding is closely associated with mortality during both the early and late periods after DES implantation. Therefore, in addition to carefully assessing bleeding after stenting, evidence-based treatment should be implemented to offer the best balance of benefit and harm.

Objectives We performed the long-term (5-year) follow-up of a large cohort of patients who underwent drug-eluting stent (DES) or coronary artery bypass graft (CABG) surgery for multivessel revascularization. Background Limited information is available on very long-term outcomes after multivessel DES treatment relative to CABG. Methods We evaluated 3,042 patients with multivessel disease who received DES (n = 1,547) or underwent CABG (n = 1,495) between January 2003 and December 2005, and for whom complete follow-up data were available for a median 5.6 years (interquartile range: 4.6 to 6.3 years). We compared adverse outcomes (death; a composite outcome of death, myocardial infarction, or stroke; and repeat revascularization). Results After adjustment for differences in baseline risk factors, 5-year risk of death (hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.76 to 1.32, p = 0.99) and the combined risk of death, myocardial infarction, or stroke (HR: 0.97; 95% CI: 0.76 to 1.24, p = 0.81) were similar between the DES group and the CABG group. However, the rates of revascularization were significantly higher in the DES group (HR: 2.93; 95% CI: 2.20 to 3.90, p Conclusions For patients with multivessel disease, DES treatment, compared with CABG, showed similar rates of mortality and of the composite safety outcomes, but higher rates of revascularization up to 5 years.

Background Atrial tachyarrhythmias (ATA) frequently develop during catheter ablation of atrial fibrillation (AF), but the mechanism of ATA during combined pulmonary vein isolation (PVI) and complex fractionated electrogram-guided ablation (CFEA) has not been reported. Methods and results This study involved 105 patients with symptomatic, drug-refractory AF. After PVI, CFEA was performed in the left/right atrium if AF remained inducible in paroxysmal AF (PAF) or persisted in persistent AF (PeAF). For the 70 PAF patients, PVI alone rendered AF non-inducible in 29 patients (41.4%), and converted inducible AF into inducible atrial flutter (AFl) in 10 patients (14.3%). For the remaining 31 PAF patients, additional CFEA rendered AF non-inducible in 11 patients (15.7%), whereas only AFl was inducible in 11 patients (15.7%). For 35 PeAF patients, PVI and CFEA converted AF into sinus rhythm in 2 (5.7%) and into AFl in 21 (60.0%) patients, while AF persisted in 12 patients (34.3%). The mechanism of ATA was focal (20/114, 17.5%), roof-dependent (20/114, 17.5%), peri-mitral (33/114, 28.9%), cavotricuspid isthmus-dependent (34/114, 29.8%) AFl or unknown (7/114, 6.1%). Successful ablation was achieved in 93/114 (81.6%) tachycardias. Conclusions The major mechanism of ATA during the combined approach of PVI and CFEA is macroreentry around large anatomic obstacles such as the pulmonary vein or the mitral or tricuspid annuli.

Background— Coronary artery bypass grafting and percutaneous coronary intervention (PCI) are alternative treatments for complex multivessel or left main disease. However, the relative treatment effects in diabetic and nondiabetic patients remain uncertain. Methods and Results— We performed a pooled analysis of 5775 patients from 3 clinical studies comparing PCI and coronary artery bypass grafting for multivessel or left main disease and compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and repeat revascularization) according to the diabetic status. Over a median follow-up of 5.5 years, risk-adjusted mortality after PCI relative to coronary artery bypass grafting was not different in diabetic (hazard ratio [HR], 1.15; 95% CI, 0.88–1.51) and nondiabetic (HR, 1.15; 95% CI, 0.88–1.50) patients. The adjusted risks of the composite outcome of death, Q-wave myocardial infarction, or stroke were also not different in diabetic (HR, 1.00; 95% CI, 0.79–1.26) and nondiabetic (HR, 0.99; 95% CI, 0.78–1.26) patients. However, PCI was significantly associated with higher risk of repeat revascularization both in diabetic (HR, 3.56; 95% CI, 2.62–4.83) and in nondiabetic (HR, 3.55; 95% CI, 2.61–4.83) patients. Significant interactions were absent between diabetic status and revascularization strategies for death ( P =0.27), composite outcome of death, Q-wave myocardial infarction, or stroke ( P =0.97), and repeat revascularization ( P =0.08). Conclusions— For multivessel or left main disease, the long-term risks of mortality and composite serious outcomes were not different between PCI and coronary artery bypass grafting in diabetic and nondiabetic patients, but PCI was associated with higher risk of repeat revascularization. These relative treatment effects were not modified by diabetic status. These results are hypothesis generating and should be addressed in a randomized trial.

ObjectivesThe goal of this study was to identify clinical and lesion-specific local factors affecting visual-functional mismatch.BackgroundAlthough lesion severity determined by coronary angiography has not been well correlated with physiological significance, the mechanism of the discordance remains poorly understood.MethodsThe authors assessed quantitative coronary angiography, intravascular ultrasound (IVUS), and fractional flow reserve (FFR) in a prospective cohort of 1,000 patients with 1,129 coronary lesions. Three-dimensional computational simulation studies were performed.ResultsLesions with angiographic diameter stenosis (DS) ≥50% and FFR >0.80 (“mismatches”) were seen in 57% of non–left main lesions and in 35% of the left main lesions, respectively (p = 0.032). Conversely, among the lesions with DS

Background— It remains unclear whether there are differences in the safety and efficacy outcomes between everolimus-eluting stents (EES) and sirolimus-eluting stents (SES) in contemporary practice. Methods and Results— We prospectively enrolled 6166 consecutive patients who received EES (3081 patients) and SES (3085 patients) between April 2008 and June 2010, using data from the Interventional Cardiology Research In-Cooperation Society-Drug-Eluting Stents Registry. The primary end point was a composite of death, nonfatal myocardial infarction (MI), or target-vessel revascularization (TVR). At 2 years of follow-up, the 2 study groups did not differ significantly in crude risk of the primary end point (12.1% for EES versus 12.4% for SES; HR, 0.97; 95% CI, 0.84–1.12, P =0.66). After adjustment for differences in baseline risk factors, the adjusted risk for the primary end point remained similar for the 2 stent types (HR, 0.96; 95% CI, 0.82–1.12, P =0.60). There were also no differences between the stent groups in the adjusted risks of the individual component of death (HR, 0.93; 95% CI, 0.67–1.30, P =0.68), MI (HR, 0.97; 95% CI, 0.79–1.18, P =0.74), and TVR (HR, 1.10; 95% CI, 0.82–1.49, P =0.51). The adjusted risk of stent thrombosis also was similar (HR, 1.16; 95% CI, 0.47–2.84, P =0.75). Conclusions— In contemporary practice of percutaneous coronary intervention procedures, the unrestricted use of EES and SES showed similar rates of safety and efficacy outcomes with regard to death, MI, sent thrombosis, and TVR. Future longer-term follow-up is needed to better define the relative benefits of these drug-eluting stents. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01070420.

High on-treatment platelet reactivity (HTPR) after clopidogrel is associated with a higher risk of cardiovascular events after percutaneous coronary intervention (PCI). However, it remains unclear whether HTPR is of similar prognostic value for different clinical presentations.We compared the prognostic impact of HTPR, measured by the VerifyNow P2Y12 assay (Accumetrics, San Diego, CA), on outcomes between 1,095 patients with acute coronary syndromes (ACS) and 1,329 patients with stable coronary artery disease (CAD) who were treated with PCI. Before PCI, patients received optimal clopidogrel treatment (75 mg daily for at least 5 days or if5 days, 300-600 mg loading), and platelet reactivity was measured at 24 to 48 hours after PCI. The primary end point was a composite of death, myocardial infarction, stent thrombosis, or stroke.During follow-up (median, 22.0 months), HTPR was independently associated with higher risks of the primary end point (hazard ratio [HR] 2.03, 95% CI 1.30-3.18, P = .002) and mortality (HR 3.46, 95% CI 1.18-10.18, P = .02) in patients with ACS. By contrast, for patients with stable CAD, HTPR was not associated with adjusted risks of the primary end point (HR 1.00, 95% CI 0.71-1.39, P = .98) or mortality (HR 0.74, 95% CI 0.36-1.51, P = .41). Significant interactions were present between HTPR status and clinical presentations for the primary end point (P = .02) and mortality (P = .04).There was a substantial interaction between platelet reactivity on clopidogrel and clinical presentations on cardiovascular events after PCI. High on-treatment platelet reactivity was significantly associated with higher risks of cardiovascular events in ACS patients, whereas this association was absent in stable CAD patients.

The global risk classification (GRC) was created to incorporate clinical variables into angiographic SYNTAX score by combination with EuroSCORE. This study aimed to validate the ability of the GRC score to predict long-term outcome in patients underwent unprotected left main coronary artery (ULMCA)

This study sought to evaluate the safety and efficacy of second-generation drug-eluting stents (DES) for patients with unprotected left main coronary artery (ULMCA) stenosis.The clinical benefit of second-generation DES for ULMCA stenosis has not been determined.The authors assessed 334 consecutive patients who received everolimus-eluting stents (EES) for ULMCA stenosis between 2009 and 2010. The 18-month incidence rates of major adverse cardiac or cerebrovascular events (MACCE), including death, myocardial infarction (MI), stroke, or ischemia-driven target vessel revascularization (TVR), were compared with those of a randomized study comparing patients who received sirolimus-eluting stents (SES) (n = 327) or coronary artery bypass grafts (CABG) (n = 272).EES (8.9%) showed a comparable incidence of MACCE as SES (10.8%; adjusted hazard ratio [aHR] of EES: 0.84; 95% confidence interval [CI]: 0.51 to 1.40; p = 0.51) and CABG (6.7%, aHR of EES: 1.40; 95% CI: 0.78 to 2.54; p = 0.26). The composite incidence of death, MI, or stroke also did not differ among patients receiving EES (3.3%), SES (3.7%; aHR of EES: 0.63; 95% CI: 0.27 to 1.47; p = 0.29), and CABG (4.8%; aHR of EES: 0.67; 95% CI: 0.29 to 1.54; p = 0.34). However, the incidence of ischemia-driven TVR in the EES group (6.5%) was higher than in the CABG group (2.6%, aHR of EES: 2.77; 95% CI: 1.17 to 6.58; p = 0.02), but comparable to SES (8.2%, aHR of EES: 1.14; 95% CI: 0.64 to 2.06; p = 0.65). Angiographic restenosis rates were similar in the SES and EES groups (13.8% vs. 9.2%, p = 0.16).Second-generation EES had a similar 18-month risk of MACCE for ULMCA stenosis as first-generation SES or CABG.

Background— We assessed the optimal intravascular ultrasound (IVUS) stent area to predict angiographic in-stent restenosis (ISR) after sirolimus-eluting stent implantation for unprotected left main coronary artery (LM) disease. Methods and Results— A total of 403 patients treated with single- or 2-stent strategies (crushing and T-stent) had immediate poststenting IVUS and 9-month follow-up angiography. Poststenting minimal stent area (MSA) was measured in each of 4 segments: ostial left anterior descending (LAD), ostial left circumflex (LCX) polygon of confluence (POC, confluence zone of LAD and LCX), and proximal LM above the POC. Overall, 46 (11.4%) showed angiographic restenosis at 9 months: 3 of 67 (4.5%) nonbifurcation lesions treated with a single-stent, 14 of 222 (6.3%) bifurcation lesions treated with single-stent crossover, and 29 of 114 (25.4%) of bifurcation lesions treated with 2 stents. The MSA cutoffs that best predicted ISR on a segmental basis were 5.0 mm 2 (ostial LCX ISR), 6.3 mm 2 (ostial LAD ISR), 7.2 mm 2 (ISR within the POC), and 8.2 mm 2 (ISR within the LM above the POC). Using these criteria, 133 (33.8%) had underexpansion of at least 1 segment. Angiographic ISR (at any location) was more frequent in lesions with underexpansion of at least 1 segment versus lesions with no underexpansion (24.1% versus 5.4%, P P P =0.001). Conclusions— With these criteria, IVUS optimization during LMCA stenting procedures may improve clinical outcomes.

To evaluate long-term patterns of luminal changes after implantation of different types of drug-eluting stents (DES), we analyzed the serial angiographic outcomes of patients implanted with zotarolimus-eluting stents (ZES), sirolimus-eluting stents (SES), or paclitaxel-eluting stents (PES).Little is known regarding long-term luminal changes after DES implantation.As a subgroup analysis of the ZEST trial, we performed complete angiographic evaluation immediately after the procedure and at 9 months and 2 years in 111 patients with 165 lesions (36 patients with ZES, 40 with SES, and 35 with PES).Baseline clinical, angiographic, and procedural characteristics were similar among the three groups. Quantitative angiographic analysis revealed significant decreases in minimal luminal diameter 9 months after stent implantation in the ZES (from 2.71 ± 0.49 to 2.21 ± 0.42 mm, P0.001), SES (from 2.79 ± 0.49 to 2.58 ± 0.57 mm, P0.001), and PES (from 2.66 ± 0.45 to 2.19 ± 0.52 mm, P0.001) groups. However, significant late improvements with different degree in luminal diameter were observed between 9 months and 2 years in the ZES (from 2.21 ± 0.42 to 2.39 ± 0.58 mm, P = 0.001), SES (from 2.58 ± 0.57 to 2.66 ± 0.60 mm, P = 0.039), and PES (from 2.19 ± 0.52 to 2.43 ± 0.52 mm, P0.001) groups.Serial angiographic follow-up study revealed a biphasic luminal response after DES implantation, characterized by an early progression phase for the first 9 months and a late regression phase from 9 months to 2 years.

The impact of underexpansion and minimal stent area (MSA) criteria in the second generation drug-eluting stents (DES) has not been addressed yet.Using intravascular ultrasound (IVUS), we assessed the optimal cut-off values of post-stenting MSA to prevent in-stent restenosis (ISR). Poststenting IVUS data and 9-month follow-up angiography were available in 912 patients with 990 lesions: 541 sirolimus-eluting stents (SES), 220 zotarolimus-eluting stents (ZES) and 229 everolimus-eluting stents (EES).For the prediction of angiographic ISR, the MSA of each DES was measured. The poststenting MSA was 6.4 ± 1.8 mm(2) in SES, 6.2 ± 2.1 mm(2) in ZES and 6.2 ± 2.1 mm(2) in EES. At the 9-months follow-up, the incidence of angiographic ISR was similar between SES (3.3%) vs. ZES (4.5%) vs. EES. (4.4%), (P = 0.53). Multivariable logistic regression analysis identified the post-stenting MSA as the only independent predictor of angiographic ISR in ZES (Odds ratio 0.722, 95% confidence interval 0.581-0.897, P = 0.001) and in EES (Odds ratio 0.595, 95% confidence interval 0.392-0.904, P = 0.015). The best MSA cut-off value was 5.5 mm(2) for the prediction of SES restenosis (sensitivity 72.2% and specificity 66.3%). For ZES, the optimal MSA predicting ISR was 5.3 mm(2) (sensitivity 56.7% and specificity 61.8%). For EES, the MSA5.4 mm(2) predicted ISR (sensitivity 60.0% and specificity 60.0%).As a preventable mechanism of ISR, smaller stent area predicted angiographic restenosis of the second generation DES as well as the first generation. The optimal cut-off values of post-stenting MSA for preventing restenosis were similar between ZES vs. EES vs. SES.

ObjectivesThis study was designed to assess the functional significance of side branches after stent implantation in main vessels using fractional flow reserve (FFR).BackgroundLittle is known about the functional significance of side branches after stent implantation in main vessels in coronary bifurcation lesions.MethodsBetween May 2007 and January 2011, 230 side branches in 230 patients after stent implantation in main vessels were assessed by FFR and were consecutively enrolled.ResultsMedian FFR at the side branch was 0.91 (interquartile range: 0.85 to 0.95). There was a negative correlation between the diameter stenosis (DS) by quantitative coronary angiography (QCA) and FFR of side branch (r = −0.21, p = 0.002), but only 41 (17.8%) side branches were functionally significant after stent implantation in the main vessel. Among 67 side branches with >50% DS by QCA, 19 (28.4%) had FFR ≤0.80, and among 163 side branches with ≤50% DS by QCA, 22 (13.5%) had FFR ≤0.80 after stent implantation in main vessels. On the basis of receiver-operating characteristic curves, the optimal cutoff value of DS by QCA of the side branch was 54.9%, and the area under the curve was 0.64 (95% confidence interval [CI]: 0.58 to 0.71, p < 0.001) with a 41.5% sensitivity, an 83.1% specificity, a 34.7% positive predictive value, an 86.3% negative predictive value, and a 75.7% accuracy. Multivariate binary logistic regression analysis identified DS by QCA (odds ratio [OR]: 1.04, 95% CI: 1.02 to 1.06, p = 0.001) and reference vessel diameter (OR: 0.28, 95% CI: 0.10 to 0.77, p = 0.014) before stent implantation as independent predictors of the side branches with FFR ≤0.80 after stent implantation.ConclusionsMost side branch lesions do not have functional significance after stent implantation in the main vessel, and quantitative coronary angiography is unreliable in assessing the functional severity of these lesions.

Objectives The purpose of this study is to compare the efficacy of the treatment strategies for in-stent restenosis (ISR) of drug-eluting stents (DES) according to the morphologic pattern of restenosis. Background Optimal treatment strategies for ISR within DES have not been adequately addressed yet. Methods Patients with ISR of DES were randomized according to the lesion length to compare outcomes of sirolimus-eluting stent (SES) versus cutting balloon angioplasty for focal type (≤10 mm) and SES versus everolimus-eluting stent (EES) for diffuse type (>10 mm). The primary endpoint was in-segment late loss at 9 months. Overall 162 patients, 96 with focal ISR and 66 with diffuse ISR, were enrolled. Results In focal lesions, in-segment late loss was significantly higher in the cutting balloon group (n = 48) than in the SES group (n = 48; 0.25 mm, interquartile range [IQR]: −0.01 to 0.68 mm vs. 0.06 mm, IQR: −0.08 to 0.17 mm; p = 0.04). Consequently, in-segment restenosis rate tended to be higher in the cutting balloon group than in the SES group (20.7% vs. 3.1%, p = 0.06) with comparable incidences of the composite of death, myocardial infarction, or target vessel revascularization at 12 months of clinical follow up (6.3% vs. 6.3%, p > 0.99). In 66 cases of diffuse ISR, in-segment late loss (0.11 mm, IQR: −0.02 to 0.30 mm; vs. 0.00 mm, IQR: −0.08 to 0.25 mm; p = 0.64), in-segment restenosis rate (5.0% vs. 14.3%, p = 0.32), and the composite incidence of death, myocardial infarction, or target lesion revascularization (9.6% vs. 8.8%, p > 0.99) did not differ between SES group (n = 32) and EES group (n = 34). Conclusions For lesions of focal DES restenosis, repeat implantation of SES is more effective in reducing late luminal loss and subsequent restenosis rate than cutting balloon angioplasty. For diffuse DES restenosis, implantation of SES or EES is comparably effective in terms of angiographic and clinical outcomes.

Percutaneous coronary intervention (PCI) is increasingly used to treat unprotected left main coronary artery stenosis, although coronary-artery bypass grafting (CABG) has been considered to be the treatment of choice.We randomly assigned patients with unprotected left main coronary artery stenosis to undergo CABG (300 patients) or PCI with sirolimus-eluting stents (300 patients). Using a wide margin for noninferiority, we compared the groups with respect to the primary composite end point of major adverse cardiac or cerebrovascular events (death from any cause, myocardial infarction, stroke, or ischemia-driven target-vessel revascularization) at 1 year. Event rates at 2 years were also compared between the two groups.The primary end point occurred in 26 patients assigned to PCI as compared with 20 patients assigned to CABG (cumulative event rate, 8.7% vs. 6.7%; absolute risk difference, 2.0 percentage points; 95% confidence interval [CI], -1.6 to 5.6; P=0.01 for noninferiority). By 2 years, the primary end point had occurred in 36 patients in the PCI group as compared with 24 in the CABG group (cumulative event rate, 12.2% vs. 8.1%; hazard ratio with PCI, 1.50; 95% CI, 0.90 to 2.52; P=0.12). The composite rate of death, myocardial infarction, or stroke at 2 years occurred in 13 and 14 patients in the two groups, respectively (cumulative event rate, 4.4% and 4.7%, respectively; hazard ratio, 0.92; 95% CI, 0.43 to 1.96; P=0.83). Ischemia-driven target-vessel revascularization occurred in 26 patients in the PCI group as compared with 12 patients in the CABG group (cumulative event rate, 9.0% vs. 4.2%; hazard ratio, 2.18; 95% CI, 1.10 to 4.32; P=0.02).In this randomized trial involving patients with unprotected left main coronary artery stenosis, PCI with sirolimus-eluting stents was shown to be noninferior to CABG with respect to major adverse cardiac or cerebrovascular events. However, the noninferiority margin was wide, and the results cannot be considered clinically directive. (Funded by the Cardiovascular Research Foundation, Seoul, Korea, and others; PRECOMBAT ClinicalTrials.gov number, NCT00422968.).

We performed the long-term (5-year) follow-up of a large cohort of patients who underwent drug-eluting stent (DES) or coronary artery bypass graft (CABG) surgery for multivessel revascularization.Limited information is available on very long-term outcomes after multivessel DES treatment relative to CABG.We evaluated 3,042 patients with multivessel disease who received DES (n = 1,547) or underwent CABG (n = 1,495) between January 2003 and December 2005, and for whom complete follow-up data were available for a median 5.6 years (interquartile range: 4.6 to 6.3 years). We compared adverse outcomes (death; a composite outcome of death, myocardial infarction, or stroke; and repeat revascularization).After adjustment for differences in baseline risk factors, 5-year risk of death (hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.76 to 1.32, p = 0.99) and the combined risk of death, myocardial infarction, or stroke (HR: 0.97; 95% CI: 0.76 to 1.24, p = 0.81) were similar between the DES group and the CABG group. However, the rates of revascularization were significantly higher in the DES group (HR: 2.93; 95% CI: 2.20 to 3.90, p0.001). Similar results were obtained in comparisons of DES with CABG for high-risk clinical and anatomic subgroups with diabetes mellitus, abnormal ventricular function, age 65 years or more, and 3-vessel and left main disease. However, mortality benefit with DES implantation relative to CABG was noted in patients with 2-vessel disease (HR: 0.57; 95% CI: 0.36 to 0.92, p = 0.02).For patients with multivessel disease, DES treatment, compared with CABG, showed similar rates of mortality and of the composite safety outcomes, but higher rates of revascularization up to 5 years.

Pet industry is anticipated to be growing at a high speed and relative pet policies will be in place soon as the Korean population is ageing. However, there has been no scientific approach to assess the pet industry and to improve it. For this, the authors propose a Service Quality Improvement (SQI) gap model with the improvement of quality attributes as a priority, which takes into consideration the two gaps between the satisfaction levels of employees and customers and between those of the own company and the competitors. The current study empirically analyses Korea's leading animal hospital and derives seven service quality attributes for the hospital. This paper surveys 56 regular customers and 36 internal employees. The results show that service quality attributes can be prioritised for improvement by using the proposed model. A validity test is conducted and suggestions for successful pet industry in Korea are also presented in this paper.

Adenosquamous carcinoma of the papilla of Vater is a rare tumor and only a few cases have been reported so far. Here, we report a case of adenosquamous carcinoma in a 76-year-old male who presented with jaundice and right upper quadrant abdominal pain. Ultrasonography and enhanced abdominal CT scans showed dilated common bile duct (CBD) and intrahepatic bile duct (IHD) with a suspicious obstructing mass in distal CBD. On endoscopy, obstructing and ulcerated mass was noted on the papilla of Vater. Histopathological inspection of the biopsied specimens from mass showed adenosquamous cell carcinoma of the papilla of Vater. Since the patient refused operation, we inserted a self-expandable metallic stent in distal CBD. This is the first case report on adenosquamous carcinoma of the papilla of Vater in Korea.