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Background— The influences of antiplatelet therapy discontinuation on the risk of stent thrombosis and long-term clinical outcomes after drug-eluting stent implantation have not yet been addressed adequately. Methods and Results— In an observational study in Japan, 2-year outcomes were assessed in 10 778 patients undergoing sirolimus-eluting stent implantation. Data on status of antiplatelet therapy during follow-up were collected prospectively. Incidences of definite stent thrombosis were 0.34% at 30 days, 0.54% at 1 year, and 0.77% at 2 years. Thienopyridine use was maintained in 97%, 62%, and 50% of patients at 30 days, 1 year, and 2 years, respectively. Patients who discontinued both thienopyridine and aspirin had a significantly higher rate of stent thrombosis than those who continued both in the intervals of 31 to 180 days, 181 to 365 days, and 366 to 548 days after stent implantation (1.76% versus 0.1%, P P =0.02; and 2.1% versus 0.14%, P =0.004, respectively). When discontinuation of aspirin was taken into account, patients who discontinued thienopyridine only did not have an excess of stent thrombosis in any of the time intervals studied. Adjusted rates of death or myocardial infarction at 24 months were 4.1% for patients taking thienopyridine and 4.1% for patients not taking thienopyridine ( P =0.99) in the 6-month landmark analysis. Conclusions— Discontinuation of both thienopyridine and aspirin, but not discontinuation of thienopyridine therapy only, was associated with an increased risk of stent thrombosis. Landmark analysis did not suggest an apparent clinical benefit of thienopyridine use beyond 6 months after sirolimus-eluting stent implantation.

A 70-year-old woman was referred because of drug resistant and daily incessant palpitation attack. She had undergone two previous unsuccessful radiofrequency catheter ablations at another hospital. The physical examination, chest X-ray, and echocardiogram were all normal. The 12-lead ECG during tachycardia showed narrow QRS, short PR tachycardia and negative polarity of the P wave in leads I and aVL (Fig. 1A). The ECG monitor showed incessant tachycardia with warming-up phenomenon. Three dimensional electroanatomical map integrated with CT imaging (CARTOMERGE®, Biosense Webster Inc.) clearly revealed the radial activation pattern originating from the basalo-postero-inferior aspect of the left atrial appendage. Radiofrequency energy application at this site eliminated tachycardia permanently.

Background Optimal target vein selection for the pacing lead results in a better outcome, but left ventricular (LV) variability limits this selection. The aim of the present study was to investigate the efficacy of coronary venoplasty for insertion of a LV lead. Methods and Results Transvenous LV lead placement was attempted in 208 consecutive patients from November 2002 to January 2007, with success in 206 patients (99%). Retrospective analysis of the cardiac resynchronization therapy system implantation showed that 4 of the 206 patients (1.9%) required coronary venoplasty for insertion of the pacing lead implant. Using coronary balloon angioplasty catheters of 2.5 mm (2 patients), 3.0 mm (1 patient) and 4.0 mm (1 patient), each target vein was dilated. Of 4 patients, stenoses in 3 were dilated by balloon angioplasty only. However, focal stenosis of 1 patient was not able to be dilated due to severe stenosis. Therefore, part of the lesion was sharpened by rotational atherectomy and the stenosis was successfully dilated. The LV pacing lead could then be inserted and no complications occurred. Conclusion Venoplasty for stenosis was effective in allowing deployment of a LV lead into a target vein in some patients. The safety and complications of the procedure remain unclear. (Circ J 2007; 71: 1442 - 1445)

Background— There is a scarcity of long-term data from large-scale drug-eluting stent registries with a large enough sample to evaluate low-frequency events such as stent thrombosis (ST). Methods and Results— Five-year outcomes were evaluated in 12 812 consecutive patients undergoing sirolimus-eluting stent (SES) implantation in the j-Cypher registry. Cumulative incidence of definite ST was low (30 day, 0.3%; 1 year, 0.6%; and 5 years, 1.6%). However, late and very late ST continued to occur without attenuation up to 5 years after sirolimus-eluting stent implantation (0.26%/y). Cumulative incidence of target lesion revascularization within the first year was low (7.3%). However, late target lesion revascularization beyond 1 year also continued to occur without attenuation up to 5 years (2.2%/y). Independent risk factors of ST were completely different according to the timing of ST onset, suggesting the presence of different pathophysiological mechanisms of ST according to the timing of ST onset: acute coronary syndrome and target of proximal left anterior descending coronary artery for early ST; side-branch stenting, diabetes mellitus, and end-stage renal disease with or without hemodialysis for late ST; and current smoking and total stent length >28 mm for very late ST. Independent risk factors of late target lesion revascularization beyond 1 year were generally similar to those risk factors identified for early target lesion revascularization. Conclusion— Late adverse events such as very late ST and late target lesion revascularization are continuous hazards, lasting at least up to 5 years after implantation of the first-generation drug-eluting stents (sirolimus-eluting stents), which should be the targets for developing improved coronary stents.

Invasive coronary angiography is useful in patients with suspected variant angina to document an episode of coronary artery spasm with provocative test. Previous studies have demonstrated that atherosclerosis is present at the sites of vasospasm. The aim of this study was to clarify the relation between 64-row Multi-detector Computed Tomography (MDCT) findings of coronary artery and vasospasm. A total of 58 patients with suspected variant angina (32 females and 26 males, aged 49 to 87 years, mean 65 ± 9 years) who have no evidence of luminal narrowing in major coronary artery with MDCT and underwent ergonovine test to detect the presence of coronary artery spasm were enrolled in this study. Two patients were excluded because of poor images of MDCT. The criteria of positive ergonovine test was total occlusion or localized occlusive spasm associated with chest pain and ST segment elevation after administration of ergonovine into the left coronary artery. The existence of plaques and calcifications in major coronary artery were evaluated with MDCT. 23 of 56 (41.1%) patients were positive with ergonovine test. 9 of 23 (39.1%) were total occlusion and 14 of 23 (60.9%) were localized spasm. Using MDCT, atherosclerotic lesions were observed at all coronary spasm sites. Among the 33 patients with negative ergonovine test, 7 (21.2%) had no plaques in the coronary artery. Presence of plaques was significant factor for positive ergonovine provocation test (p = 0.03). Patients with positive ergonovine test had coronary artery plaques at the site of coronary spasm sites. Absence of coronary artery plaques with MDCT could rule out variant angina. Correlation between ergonovine provocation test and MDCT findings

Background: It’s well known that cardiac resynchronization therapy (CRT) is effective to reduce heart failure hospitalization. However, the impact of response to CRT on ventricular arrhythmic events is not well established. Methods: We investigated 216 pts received CRT in two institutions (age 69.3+/−10.8 years, NYHA class 3.1+/−0.5, LVEF 25.8+/−7.4%, LVEDD 62.1+/−8.3mm, pre QRS duration 158+/−32ms, AF 19.4%, ischemic heart disease 33.3%, CRT-D 51.3%) and divided into two groups, Responders (n=145, 67.1%) and Non-responders (n=71, 32.9%). CRT responder was defined as improvement of LVEF > or =5%, or reduction of LVEDD > or = 5mm at 3–6 month echo data. Long-term ventricular arrhythmic events (ventricular tachycardia: VT, ventricular fibrillation: VF and sudden cardiac death: SCD) were obtained. Kaplan-Meier curve were draw and Long-Rank test was used to compare event rates of two groups. Results: Mean follow up periods was 19.3 +/−12.7 months. Event free survival rates from ventricular arrhythmic events (VT, VF and SCD) were all significantly higher in Responders compared to Non-responders (VT: 89.2% vs. 77.8% at 2 year, Log-rank p=0.031, VF: 99.2% vs. 89.9% at 2 year, Log-rank p=0.0031, SCD: 98.6% vs. 89.2% at 2 year, Log-rank p=0.0038) and event free survival rate from combined VT, VF and SCD was also significantly higher in Responders (87.8% vs. 76.5% at 2 year, Log-rank p=0.0013). Conclusion: Response to CRT seems to reduce not only heart failure events, but also ventricular arrhythmic events. Figure: Adverse events in new onset AF vs no AF

This study aimed to examine the dynamic changes of the fibrinolytic system during coronary vasospasm. Tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor (PAI) and fibrinopeptide A (FPA) levels were measured in the great cardiac venous and arterial blood of 9 patients with clinically and angiographically proven vasospastic angina and 11 controls. Before ergonovine provocation, although there was no difference between the above 2 groups in t-PA levels in the aorta or the great cardiac vein, the PAI level in patients with variant angina was lower than in the controls both in the aorta (4.2±3.5 IU/ml vs 10.9±5.2 IU/ml) and in the great cardiac vein (2.3±2.9 IU/ml vs 11.9±4.9 IU/ml). During ergonovine-induced coronary vasospasm in patients with variant angina, the t-PA level in the great cardiac vein significantly increased from 3.4±0.7 ng/ml to 4.4±0.5 ng/ml (p

Background: The impact of mitral regurgitation (MR) on long-term clinical outcomes in patients (pts) undergoing cardiac resynchronization therapy (CRT) is not well established. Methods: We investigated 110 pts received CRT (age 71+/−10years, NYHA class 3.1+/−0.5, LVEF 26+/−7%, LVEDD 61+/−7mm, pre QRS duration 178+/−29ms) and divided into two groups, 40 pts with baseline MR grade 0 –1 (less MR group) and 70 pts with baseline MR grade 2– 4 (severe MR group). 1-year clinical data were obtained. Results: Baseline clinical and echocardiographic characteristics were similar between two groups without baseline MR grade (0.9+/−0.3 in less MR group vs.2.2+/−0.5 in severe MR group, p Conclusion: Pts with severe baseline MR had worse clinical outcomes even if received CRT compared to less MR pts.

Background Factors associated with patency of self-expandable stents placed in the superficial femoral artery (SFA) have not been clarified. In this study, we investigated the impact of stent diameter in patients who implanted self-expandable stents in the SFA. Methods Self-expandable stents were placed in SFA lesions in 80 patients (84 limbs) at our hospital between January 2003 and December 2005 and we investigated prospectively for 18 months. A total of 144 stents were used: The mean vascular diameter at sites proximal and distal to the stent-placement region on angiography was defined as the vessel diameter, and the stent diameter/vessel diameter (S/V) ratio was calculated. Results The age of the patients ranged from 44 to 88 years old (mean: 70.3 ± 6.8 years old), and 68 patients were male (85%). The mean diameter of the treated vessels was 5.1 ± 0.7 mm, the mean lesion length was 93.8 ± 43.8 mm, and 1.7 ± 0.6 stents were used per lesion. Chronic total occlusion was noted in 24 cases (30%). The primary (secondary) patency rates at 6, 12, and 18 months were 91.2% (97.5%), 74.5% (87.2%), and 63.6% (79.1%), respectively as estimated by the Kaplan-Meier method. An S/V ratio >1.3 was noted in 16 of the 80 patients (20%). There was a high percentage of patients with renal dysfunction and a smoking habit in this group, and the length of the treated lesion was long. In contrast, there were fewer patients with a high cholesterol level in this group. Other baseline parameters were similar between the two groups. A Kaplan-Meier estimate showed that the restenosis rate after 18 months was significantly higher in the S/V >1.3 group (87.5% vs. 35.5%, p100 mm (Hazard ratio (HR) 6.6, p=0.015), chronic total occlusion (HR 6.0, p=0.035), stent fracture(HR 17.5, p=0.022), and S/V >1.3(HR 29.0, p=0.0014) were independent predictors of primary patency at 18 months. conclusion The stent diameter of self-expandable stent was strongest predictor in primary patency at 18 months. The stent diameter of self-expandable stent can affect patency in the chronic phase.

Background: CAMELOT Study showed that the administration of amlodipine to diabetic patients with coronary artery disease (CAD) resulted in reduced adverse cardiovascular events, especially repeat coronary revascularization. Objective: To compare the effects of amlodipine versus placebo on restenosis and clinical outcome after percutaneous coronary intervention (PCI) for diabetic patients. Methods: In a prospective, double-blind design, 540 patients with 659 denovo lesions were randomized to receive 5–10mg of amlodipine or placebo. Diabetic patients were enrolled in171 patients (32%). The primary angiographic endpoint was minimal lume diameter (MLD) at 6 month assessed by follow-up (FU) quantitative coronary angiography (QCA). Clinical end points were death, myocardial infarction, coronary bypass surgery and repeat any PCI at 12 months. Results: Angioplasty was performed in all patients without complications ;461 patients (85%) had received coronary stent implantation.FU QCA was obtained in all patients. The MLD at FU was significantly larger in the amlodipine group (1.50±0.52mm in the amlodipine group versus 1.42±0.52mm in the placebo group: p=0.035). The loss index was tendency to be lower in the amlodipine group (0.54±0.66 in the amlodipine group versus 0.61±0.56 in the placebo group: p=0.076). The binary restenosis (defined as >50% diameter stenosis at FU) rate was 22.6% in the amlodipine group versus 28.5% in the placebo group (p=0.078). The composite incidence of clinical events were occurred in 89 patients (32%) in the amlodipine group versus 102 patients (39%) in the placebo group (p=0.103). The composite incidence of clinical events in diabetic patients were occurred in 30 patients (37%) in the amlodipine group versus 51 patients (57%) in the placebo group (p=0.007). Conclusion: Administration of amlodipine in diabetic patients resulted in reduced adverse cardiovascular events after PCI.

Ventricular tachycardia (VT), which causes hemodynamic instability, and ventricular fibrillation (VF) sometimes occur in patients with severe underlying cardiovascular disease such as myocardial ischemia or infarction, and are associated with high mortality. This report presents the efficacy of nifekalant hydrochloride (nifekalant), a pure class III antiarrhythmic agent, in treating life-threatening ventricular arrhythmia in such patients. From June 2000, when nifekalant became commercially available in Japan, to May 2003, 30 ischemic heart disease (IHD) patients with VT/VF resistant to direct-current (DC) countershock received nifekalant in our hospital. These 30 patients served as the nifekalant group in this study. As a control group, we also included 33 IHD patients with VT/VF that had been resistant to DC countershock upon or during hospitalization between January 1996 and May 2000 before nifekalant became commercially available. No significant differences were observed in patient background factors and treatments between the two groups. The rates of death within 48 hours of occurrence of VT/VF were significantly lower in the nifekalant group (7%, 2/30) than in the control group (27%, 9/33; P < 0.03). The rates of cardiac death during hospitalization were also significantly lower in the nifekalant group (40%, 12/30) than in the control group (67%, 22/33; P < 0.03). The rates of survival until hospital discharge were significantly higher in the nifekalant group (57%, 17/30) than in the control group (30%, 10/33; P < 0.03). Multivariate analysis of all 63 patients revealed nifekalant administration was the factor that significantly improved the mortality (odds ratio for cardiac death, 0.26; 95% confidence interval (CI), 0.07 to 0.95; P = 0.041). Nifekalant improves the prognosis for life-threatening ventricular arrhythmia in IHD patients.

Percutaneous transvenous mitral commissurotomy was performed in 106 consecutive patients. Significant symptomatic improvement was achieved in 97 patients (92%). Mean left atrial pressure decreased (from 18 +/- 8 to 11 +/- 8 mm Hg, p less than 0.00001), mean mitral diastolic pressure gradient decreased (from 12 +/- 7 to 7 +/- 6 mm Hg, p less than 0.00001), and mitral valve area increased (from 1.40 +/- 0.40 to 2.00 +/- 0.50 cm2, p less than 0.00001). Based on echocardiographic characteristics of the mitral apparatus, patients were grouped retrospectively in three categories: pliable (group 1, n = 37), semipliable (group 2, n = 59), and rigid (group 3, n = 10). Clinical success was achieved in 36 patients of group 1 (97%) and in 55 patients of group 2 (93%). Only six patients in group 3 (60%) improved symptomatically (p less than 0.001 vs. group 1, p less than 0.001 vs. group 2). The severity of mitral regurgitation increased in five patients of group 1 (14%), in 12 of group 2 (20%), and in three of group 3 (33%). Six patients had recurrent symptoms at 9 months after commissurotomy. Recurrence of symptoms was significantly more frequent in group 3 compared with the other two groups (group 1, 3%; group 2, 4%; and group 3, 50%; p less than 0.0001 vs. groups 1 and 2). Multiple regression analysis identified the previously mentioned echocardiographic characteristics of the mitral apparatus as the significant predictor for clinical outcome. Thus, percutaneous transvenous mitral commissurotomy can be considered a safe and effective treatment for patients with pliable valves. Patients with semipliable or with rigid valves should be selected for operation very carefully.