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The long-term clinical outcomes after implantation of bioresorbable vascular scaffolds (BVS) in a real-world cohort were not well described. To identify factors associated with major adverse cardiovascular events (MACE) on long-term follow-up after implantation of BVS in patients undergoing elective percutaneous coronary intervention (PCI). This was an observational study based on a hospital registry of percutaneous coronary intervention. Participants were consecutive patients who underwent PCI and implanted with at least one everolimus-eluting BVS (Absorb®) in a single center between 2014 and 2017. Among the 170 cases analyzed (mean age 60.4 ± 10.7), a total of 203 Absorb BVS were implanted. MACE developed in 33 (19.4%) patients over a median follow-up period of 61 months, including 9 (5.3%) deaths, 13 (7.6%) non-fatal myocardial infarction and 19 (11.2%) ischemia driven target vessel revascularization. Definite or probable stent thrombosis developed in 4 (2.4%) patients. In crude analysis, history of smoking and initial presentation of non-ST elevation-acute coronary syndrome (NSTE-ACS) were predictors of long-term MACE. In adjusted analysis, presentation with NSTE-ACS was an independent predictor of long-term MACE [adjusted odds ratio (OR) 4.52; 95% confidence interval (95% CI) 1.50 to 13.6, P = 0.007]. Among patients receiving implantation of ABSORB BVS, presentation with NSTE-ACS was an independent predictor of MACE after a median follow-up period of 61 months. Future research is needed to confirm these findings and to determine the long-term safety of BVS in patients with NSTE-ACS.

The long-term clinical outcomes after bioresorbable vascular scaffold (BVS) implantation have been extensively compared with second-generation drug-eluting stent (DES) implantation, but not with bare-metal stent (BMS) or first-generation DES options.To compare the major adverse cardiovascular event (MACE) rates after implantation of BVS, first-generation DES, and BMS.This was a single-center observational study based on a registry of percutaneous coronary intervention (PCI). The primary endpoint was MACE at 3 years, defined as a composite endpoint of death, non-fatal myocardial infarction, and target-vessel revascularization.A total of 170 consecutive patients who underwent PCI with implantation of everolimus-eluting BVS (Absorb; Abbott Cardiovascular) between 2014 and 2017 were compared with a control group of 622 patients implanted with BMS and 604 patients implanted with first-generation DES from 2001 to 2005. In adjusted analysis, DES had a lower risk of MACE at 3 years compared with BMS (adjusted odds ratio [OR], 0.58; 95% confidence interval [CI], 0.41-0.81; P.01), while BVS had a similar risk of MACE compared with BMS (adjusted OR, 0.91; 95% CI, 0.55-1.52; P=.72). When compared with DES, BVS had a similar risk of MACE (adjusted OR, 1.45; 95% CI, 0.83-2.53; P=.19).In patients with BVS implantation, the risk of the composite outcome of MACE at 3 years was not significantly different when compared with patients with BMS or first-generation DES implantation.

IntroductionCurrent international guidelines recommend non-vitamin K oral anticoagulants (NOACs) for stroke prevention among patients with non-valvular atrial fibrillation (AF) at significant ischaemic stroke risk given the superior safety and comparable efficacy of NOACs over warfarin. Nonetheless, the safety and effectiveness of NOACs have not been evaluated in patients with AF with underlying moderate or severe mitral stenosis (MS), hence the recommended stroke prevention strategy remains warfarin therapy.Method and analysisMS remains disproportionately prevalent in Asian countries compared with the developed countries. This prospective, randomised, open-label trial with blinded endpoint adjudication aims to evaluate the safety and efficacy of dabigatran for stroke prevention in AF patients with moderate or severe MS. Patients with AF aged ≥18 years with moderate or severe MS not planned for valvular intervention in the coming 12 months will be randomised in a 1:1 ratio to receive dabigatran 110 mg or 150 mg two times per day or warfarin with international normalised ratio 2–3 in an open-label design. Patients with estimated creatinine clearance Ethics and disseminationThe study protocol has been approved by the Institutional Review Board of the University of Hong Kong and Hong Kong West Cluster, Hospital Authority, Hong Kong for Fung Yiu King Hospital, Grantham Hospital, Queen Mary Hospital and Tung Wah Hospital in Hong Kong. Results will be published in peer-reviewed journals.Trial registration numberClinicalTrials.gov Registry (NCT04045093); pre-results.

The long-term clinical outcomes after implantation of bioresorbable vascular scaffolds (BVS) in a real-world cohort were not well described. To identify factors associated with major adverse cardiovascular events (MACE) on long-term follow-up after implantation of BVS in patients undergoing elective percutaneous coronary intervention (PCI). This was an observational study based on a hospital registry of percutaneous coronary intervention. Participants were consecutive patients who underwent PCI and implanted with at least one everolimus-eluting BVS (Absorb

We report a case of stent reverse controlled antegrade and retrograde subintimal tracking (CART) in left anterior descending artery (LAD) chronic total occlusion. Reverse CART is the method used to make a connection between the retrograde wire and the antegrade true lumen by using a balloon to dilate the antegrade space and pushing the retrograde wire into this space. We successfully crossed the septal channel from right coronary to the LAD, and proceeded to reverse CART, which was unsuccessful. After demonstrating that both the retrograde and antegrade wires were in the same subintimal space by intravascular ultrasound (IVUS), we placed the distal stent edge at the connection point of the wires and deployed the stent. We could easily wire the stent lumen with the retrograde conquest 9 g wire. Afterwards we tried to push the retrograde corsair microcatheter through the CTO and into the antegrade guiding, but unfortunately, the retrograde corsair could not pass into the antegrade guiding and was stuck just outside the antegrade guiding ostium. At this point IVUS showed that the stent had been dislodged from the LAD and pushed into the aorta just outside the left main by the retrograde corsair because the retrograde wire passed into the stent lumen through a distal side strut opening and not through the true distal end of the stent. Due to unstable hemodynamics we had to remove the retrograde system and this led to stent embolism. The case illustrates stent dislodgement after stent reverse CART and stresses the importance of using IVUS to check fully the retrograde wire path before pushing the corsair. We discuss the role of stent reverse CART in the contemporary reverse CART era and conclude that it should be relegated to the very last resort after trying transit balloon technique. We conclude that stent reverse CART is mostly an unnecessary evil. Learning objective: The case illustrates the dangers of stent reverse controlled antegrade and retrograde subintimal tracking (CART) and discusses the alternative options to stent reverse CART, as well as how to perform stent reverse CART safely with the use of intravascular ultrasound both before stenting and after stenting to ensure correct wire passage through the stent.>

In the era of drug-eluting stents, the provisional stenting strategy has been established as the default strategy in percutaneous coronary intervention for bifurcation lesions. However, emerging evidence shows that, in selected situations, the complex strategy of stenting both vessels regardless could reduce side-branch restenosis without penalty. In particular, the double kissing crush technique has been proven to outperform the provisional strategy and other complex strategies in randomized trials. In this review, we present the evidence comparing the 2 strategies and individual stenting techniques and discuss the roles of other optimization techniques such as final kissing balloon inflation, proximal optimization technique, intravascular ultrasonography, and optical coherence tomography. Finally, we suggest a practical approach for choosing the optimal strategy for intervention with coronary bifurcation lesions.

Background— There is a paucity of data from large cohort studies examining the prognostic significance of obstructive sleep apnea (OSA) in patients with coronary artery disease. We hypothesized that OSA predicts subsequent major adverse cardiac and cerebrovascular events (MACCEs) in patients undergoing percutaneous coronary intervention. Methods and Results— The Sleep and Stent Study was a prospective, multicenter registry of patients successfully treated with percutaneous coronary intervention in 5 countries. Between December 2011 and April 2014, 1748 eligible patients were prospectively enrolled. The 1311 patients who completed a sleep study within 7 days of percutaneous coronary intervention formed the cohort for this analysis. Drug-eluting stents were used in 80.1% and bioresorbable vascular scaffolds in 6.3% of the patients, and OSA, defined as an apnea-hypopnea index of ≥15 events per hour, was found in 45.3%. MACCEs, a composite of cardiovascular mortality, nonfatal myocardial infarction, nonfatal stroke, and unplanned revascularization, occurred in 141 patients during the median follow-up of 1.9 years (interquartile range, 0.8 years). The crude incidence of an MACCEs was higher in the OSA than the non-OSA group (3-year estimate, 18.9% versus 14.0%; p =0.001). Multivariate Cox regression analysis indicated that OSA was a predictor of MACCEs, with an adjusted hazard ratio of 1.57 (95% confidence interval, 1.10–2.24; P =0.013), independently of age, sex, ethnicity, body mass index, diabetes mellitus, and hypertension. Conclusions— OSA is independently associated with subsequent MACCEs in patients undergoing percutaneous coronary intervention. Evaluation of therapeutic approaches to mitigate OSA-associated risk is warranted. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01306526.

The aim of the study was to evaluate the relation between tricuspid regurgitation (TR) severity and liver stiffness (LS) in patients with TR. A total of 131 patients with various degrees of TR secondary to left-sided heart valve disease were enrolled. Severity of TR was quantitatively assessed by proximal isovelocity surface area-derived effective regurgitant orifice (ERO). Patients were divided into 2 groups: 48 with mild-moderate TR (ERO0.4 cm(2)) and 83 with severe TR (ERO ≥0.4 cm(2)). Transient elastography was used to measure the level of LS, an established marker of liver fibrosis, with the threshold of significant LS set at ≥12.5 kPa. Patients with severe TR had a higher LS and prevalence of significant LS than those with mild-moderate TR. Furthermore, LS and significant LS independently correlated with TR-ERO, right atrial pressure and inferior vena cava (IVC) diameter. The presence of a large TR-ERO (≥0.4 cm(2)) and IVC diameter (2.15 cm(2)) provided a high specificity of 78% for significant LS. In conclusion, the present study demonstrates that TR-ERO, right atrial pressure, and IVC diameter are important parameters associated with LS in patients with TR.

Obstructive sleep apnea (OSA) has been shown to be associated with accelerated coronary atherosclerosis (1–3). In the multicenter Sleep and Stent Study, we found that OSA was an independent predictor of major adverse cardiac and cerebrovascular events (MACCE) and cardiovascular mortality after percutaneous coronary intervention (PCI), with adjusted hazard ratios (HR) of 1.57 (95% CI 1.10–2.24) and 2.11 (95% CI 0.91–4.91), respectively (4). Diabetes mellitus (DM) is an established risk factor of MACCE after PCI and was present in 42% of the patients in the Sleep and Stent Study (4). In this post hoc analysis, we hypothesized that patients with combined OSA and DM were at a particularly high risk of developing MACCE after PCI. The Sleep and Stent Study was an observational study evaluating the effects of OSA on cardiovascular outcomes in patients undergoing PCI. The detailed methodology and inclusion and exclusion criteria have been published previously (5). After an overnight sleep study, the recruited patients were classified as OSA(+) (apnea-hypopnea index ≥15 events per hour) or OSA(−) (

Objectives The aim of this study was to examine the angiographic result and its outcome predictors using the combination of paclitaxel-eluting balloon (PEB) and Genous stent. Background This approach to treat coronary stenoses is a logical strategy to strike a balance between minimizing restenosis and stent thrombosis. Methods From November 2010 to June 2012, 40 symptomatic patients with 44 de novo coronary lesions of diameter stenosis ≥50% were treated with the combination of PEB and Genous stents. Angiographic and clinical follow-up were intended at 6 and 9 months, respectively. Results The mean age of patients was 61 ± 11 years, with male predominance (83%). Diabetes mellitus and end-stage renal failure on peritoneal dialysis were found in 15 (38%) and 10 (25%) patients, respectively. Patients received dual antiplatelet therapy for 5.1 ± 1.5 months post procedure. The size and length of PEB used was larger than the stents (3.13 ± 0.46 mm and 28 ± 9 mm vs. 2.98 ± 0.36 mm and 23 ± 7 mm). Restudy angiography was performed on 41 (95%) lesions in 37 (93%) patients at 5.9 ± 1.7 months. Angiographic restenosis was seen in 5 (12%) lesions, and significantly associated with diabetes mellitus and dialysis dependency; the late lumen loss was 0.38 ± 0.37 mm. At 9-month follow-up, no stent thrombosis was observed. Conclusions The use of PEB combined with Genous stent is associated with a reasonably low restenosis and late lumen loss, whereas diabetes mellitus and renal failure with dialysis are poor predictors of angiographic restenosis.

A reliable stenting strategy for treating isolated side branch (SB) ostium stenosis is not well established. The purpose of this study was to examine the 6-month angiographic outcome of a novel technique, called the shoulder technique, on this lesion subtype. Symptomatic patients with isolated SB ostium stenosis, defined as ≥75% diameter stenosis at SB ostium and

The role of the second-generation zotarolimus-eluting stent RESOLUTE in small-vessel coronary artery disease is unclear. The aim of this study was examine the angiographic results of RESOLUTE in de novo coronary lesions of ≥50 % diameter stenosis in target vessels ≤2.5 mm. From August 2008 to April 2010, 142 symptomatic patients with 159 lesions who fitted the inclusion criteria were treated with RESOLUTE. The mean age of patients was 66 ± 10 years, with male predominance (66 %). Diabetes mellitus was found in 62 (43.7 %) patients, whereas multivessel disease was observed in 105 (73.9 %). The mean stent size and length used were 2.33 ± 0.13 and 22 ± 8 mm, respectively. Follow-up angiography was performed on 143 (89.9 %) lesions in 127 (89.4 %) patients at a mean of 10.3 ± 3.6 months. Angiographic restenosis was found in 9 (6.3 %) lesions; the late loss was 0.26 ± 0.34 mm. At 1-year follow-up there were four cardiovascular deaths, two nonfatal myocardial infarctions, and six repeated revascularizations. The resultant major adverse cardiac event rate was 8.5 %. The use of RESOLUTE to treat small-vessel disease is associated with good clinical and angiographic outcomes at 1 year.

Objectives The purpose of this study was to examine the angiographic and clinical results of stent full metal jacket in treating long lesions using everolimus-eluting stents (EES). Background Data are lacking regarding the use of EES for this lesion subgroup. Methods From 2007 to 2011, 77 symptomatic patients who had severe coronary stenoses necessitating implantation of stents with total length longer than 60 mm were treated with overlapping EES. Results The mean age of patient was 61 ± 11 years with male predominance (66%). Diabetes mellitus was seen in 35 (45.5%) patients. Majority of patients had class III angina with normal heart function. On average, 3.1 stents were implanted per lesion; the mean stent size and length were 2.70 ± 0.28 mm and 82 ± 16 mm. Restudy angiography was performed on 71 patients (72 lesions) at 8.9 ± 2.5 months. Angiographic restenosis was seen in 9 (12.5%) lesions; the lesion length and late loss were 67 ± 15 mm and 0.4 ± 0.6 mm, respectively. The use of intravascular ultrasound has been found to be a predictor of less restenosis (P = 0.02; HR: 0.02; CI: 0.01–0.59). The in-hospital and 1 year major adverse cardiac event rates were 7.8% and 13%. The annual cardiac death rates were 2.6%, 3.4%, and 5.3% in the first 3 years. Conclusions The use of EES full metal jacket for long lesions is only associated with good short-term clinical and angiographic outcomes. Long-term follow-up has revealed a high cardiac death rate which may necessitate prolongation of dual antiplatelet therapy. (J Interven Cardiol 2013;26:22–28)

In-stent restenotic bifurcation lesion (ISRB) is defined as an in-stent restenosis (ISR) with a sizeable side branch (SB) arises from within the disease segment (Fig. 1). Owing to a large volume of proliferating neointimal tissue and extracellularmatrix deposition [1,2], any intervention would readily predispose to SB occlusion, particularly if the SB ostium is diseased (true bifurcation lesions), which is very difficult to manage as the SB ostium is already covered with a layer of stent strut. Drugeluting stent (DES) implantation over the old stent (stent sandwich) is among one of the definitive treatments for ISR [3]. In this special lesion subgroup, however, stent implantation would bring more troubles by causingmore plaque extrusion in both radial and longitudinal direction after high-pressure stent deployment, and covering the SB ostiumwith 1more layer of stent strut. On the other hand, paclitaxel-eluting balloon (PEB) offers another platform of drug delivery without adding a new metal layer; its role has also been proven in ISR [4,5]. The advent of PEB, together with the current DES, provides many other alternatives to the treatment of this special bifurcation subgroup. A 67-year-oldmanwho got smoking, diabetesmellitus and hypertension as cardiovascular risk factors had known coronary artery disease with percutaneous coronary intervention to left anterior descending artery (LAD) bifurcation about 9 years ago. At that time, a sirolimuseluting stent (Cypher 2.5 × 18 mm) was deployed in mid LAD with kissing balloon inflation to LAD/diagonal bifurcation using 2.0 mm and

No data has been published on the management of in-stent restenotic bifurcation lesions. The aim of this small case series was to examine the angiographic and long-term clinical outcomes of using sleeve technique to treat this lesion subset.Six consecutive and symptomatic patients with MEDINA classification 1,1,1 in-stent restenotic bifurcation lesion were treated with drug-eluting stents using sleeve technique. Dual antiplatelet therapy was prescribed for an average of 13.5 ± 2.3 months.Most of the lesions (87%) were located at LAD/diagonal branch bifurcation. Kissing balloon inflation was performed successfully in all the patients. Follow-up angiography at nine months revealed a late loss of 0.35 ± 0.26 mm and 0.56 ± 0.56 mm in MV and SB, respectively. Angiographic restenosis was developed in 2 patients (33%), which were all located at the SB ostium. No in-hospital MACE was observed. One-year MACE was 17%, attributed by 1 patient with restenosis who needed revascularization. The mean follow up period was 50 ± 18 months, no stent thrombosis was detected.The use of sleeve technique to treat in-stent restenotic bifurcation lesions is associated with good acute procedural result, a fairly low one-year MACE and long-term clinical safety.

Background We examined the long term clinical outcomes after administration of intravascular brachytherapy (IVBT) for instent restenosis (ISR) and de novo coronary artery lesions in percutaneous coronary intervention (PCI). Methods and Materials From May 2000 to August 2004, 129 symptomatic patients with ISR and de novo coronary artery lesions were treated with intravascular beta radiation after successful PCI. The primary end-point was major adverse cardiac event (MACE), i.e., a composite of all-cause death, myocardial infarction and target lesion revascularization (TLR) within 5 years of follow-up. Results The mean age of patients was 64+10 years with a male predominance (78%). The majority of patients had diffuse bare metal instent restenotic lesions and 19 patients (15%) had de novo coronary artery lesions. From hospital discharge to follow-up at 5 years (mean follow-up period 75.3 + 17.7 months), the annual consecutive MACE rates were 16.3%, 13.4%, 8%, 12.2% and 6.6% respectively and were mainly driven by the need for TLR. Left anterior descending artery (LAD) as target vessel of PCI was an independent predictor of long term MACE (OR: 3.5; 95% confidence interval:1.2–10.6; P =.03). There were six cases of stent thrombosis (cumulative incidence of 4.7%) with case fatality rate of 33% (2/6). Conclusion MACE rates remained high post IVBT at 5 years of follow-up and were mainly driven by the need for TLR. LAD as target vessel of PCI was an independent predictor of long term MACE.

Summary Background Heart failure occurs in 6% of hyperthyroid patients. Nonetheless, only half of those with hyperthyroidism-related heart failure have impaired left ventricular (LV) systolic function. Thus, diastolic dysfunction may play an important role in the pathogenesis. Methods and results We performed serial echocardiographic examinations in 70 consecutive patients with hyperthyroidism (39 ± 2 years, 47 women) to determine their diastolic function and repeated the examinations 6 months after achieving a euthyroid state. All patients had normal LV systolic function, but diastolic dysfunction was detected in 22 cases (mild: 3, moderate: 15 and severe: 4). The prevalence of diastolic dysfunction increased with age from 17·9% in patients 60 years. Increasing age was the only independent predictor for diastolic dysfunction in hyperthyroid patients. After achievement of a euthyroid state, most patients (16/22, 72%) had completely normalized diastolic function: 100% of patients

Data of virtual histology (VH) acquired by intravascular ultrasound (IVUS) on saphenous vein graft (SVG) lesions is lacking. This study sought to report the VH IVUS findings in degenerative aortocoronary SVG lesions and correlate various types of plaque compositions (fibrous, fibro-fatty, dense calcium, and necrotic core) with different clinical and lesion characteristics. Virtual histology IVUS was performed on SVG in 38 symptomatic patients with a history of coronary artery bypass grafting, who underwent percutaneous coronary intervention on either native vessels or SVG. Measurements were made at the image slice with the smallest lumen. A total of 54 SVG lesions were analyzed; the mean graft age was 13.7 +/- 4.0 years. The mean vessel size was 5.0 +/- 1.0 mm; plaque area was 13.4 +/- 7.3 mm(2), and plaque burden was 63.0% +/- 15.0%. Fibrous tissue represented the major plaque component (62.1% +/- 17.1%). Lesions with a plaque burden ofor=70% were associated with positive remodeling, larger vessel size, higher percentage of fibro-fatty tissue, but lower percentage of dense calcium. Plaque burden was found to be positively correlated with remodeling index (r = 0.37, P = 0.01) and % fibro-fatty tissue (r = 0.49, P0.001) but negatively correlated with % dense calcium (r= -0.31, P = 0.03). The severity of SVG atherosclerosis paralleled with a proportional increase in fibro-fatty tissue. Unstable plaques in SVG were associated with positive remodeling, lipid-rich atheroma, and less calcium deposition, similar to the VH IVUS findings in native coronary arteries.

Background: Long-term β-blockade therapy is beneficial in post-myocardial infarct (MI) patients with left ventricular (LV) dysfunction; nevertheless, its benefit in post-MI patients with preserved LV function remains unclear. The objective of this study is to investigate the effects of long-term β-blockade therapy on the clinical outcomes in post-MI patients with preserved LV function. Hypothesis: The beneficial effects of long-term β-blockade therapy in post-MI patients with impaired LV function may extend to those with preserved LV function. Methods: Of 617 consecutive post-MI patients referred for cardiac rehabilitation program, 208 patients (age: 62.7 ± 0.8 years; male: 76%) with preserved LV function (ejection fraction ≥ 50%), negative exercise stress test, and on angiotensin-converting enzyme inhibition were studied. Results: Baseline characteristics were comparable between patients on β-blocker (n = 154) and not on β-blocker (n = 54). After a mean follow-up of 58.5 ± 2.7 months, 14 patients not on β-blocker (26%) and 14 patients on β-blocker (9%) died with hazard ratio (HR) of 2.5 (95% confidence interval [CI]: 1.25–6.42, P = 0.01). Likewise, patients not on β-blocker had a higher incidence of cardiac death (HR: 3.0, 95% CI: 1.07–12.10, P = 0.04), and non-sudden cardiac death (HR: 10.1, 95% CI: 1.82–89.65, P = 0.01), but not sudden cardiac death compared with patients on β-blocker (HR: 1.6, 95% CI: 0.34–7.61, P = 0.54). A Cox regression analysis revealed that only advanced age (≥75 years; HR: 2.55, 95% CI: 1.18–5.49, P = 0.02) and the absence of β-blocker (HR: 2.41, 95% CI: 1.14–5.09, P = 0.02) were independent predictors for mortality. Conclusion:β-blocker use was associated with a decrease in overall mortality and cardiac death in post-MI patients with preserved LV function. (PACE 2010; 33:675–680)

With the exception of contrast-enhanced cardiovascular magnetic resonance imaging, clear distinction of takotsubo cardiomyopathy from anterior wall myocardial infarction cannot be achieved currently by simple and noninvasive tests. The aim of this study was to examine the role of inferior ECG leads in distinguishing these two conditions. From January 2004 to June 2006, eight female patients suffering from takotsubo cardiomyopathy were identified by the Mayo Clinic criteria. The clinical and ECG features were compared with 27 consecutive sex- and age-matched patients with anterior wall myocardial infarction admitted to the Coronary Care Unit within the same period. The observed ECG features were then verified with that of 62 published cases of takotsubo cardiomyopathy. Takotsubo cardiomyopathy patients had similar left ventricular ejection fraction (35.0% +/- 5.7% vs 38.2% +/- 6.4%, P = 0.829), lower peak creatinine kinase level (461 +/- 330 U/l vs 2723 +/- 1826 U/l, P = 0.020), more ST-segment elevation in the inferior leads (50% vs 7.4%, P = 0.016), and virtually no ST-segment depression in inferior leads (0% vs 48.2%, P = 0.015) compared with patients who had anterior wall myocardial infarction. ST-segment elevation ofor=1.0 mm in lead II had 62.5% sensitivity and 92.6% specificity in detecting takotsubo cardiomyopathy. The observed ECG characteristics were comparable with those in the literature. In patients who present with anterior wall myocardial infarction, the absence of ST-segment depression or ST-segment elevation in inferior leads, especially if the ST-segment in lead IIor= III, is highly suggestive of takotsubo cardiomyopathy.

Hyperthyroidism is one of the most common reversible causes of atrial fibrillation (AF); nevertheless, the risk of ischemic stroke in patients with hyperthyroidism who present with new-onset AF is unclear.This study sought to investigate the clinical outcome of hyperthyroidism-induced AF with regard to risk of ischemic stroke risk.We prospectively studied the incidence, time course, and clinical predictors for ischemic stroke in patients with hyperthyroidism-induced AF (n = 160). They were compared with age- and sex-matched cohorts of hyperthyroid patients without AF (n = 160) and AF patients without hyperthyroidism (n = 160).Baseline characteristics were comparable among the 3 groups. At 1 year, 86 hyperthyroid patients with AF (54%) and 92 patients with nonthyroid AF (58%) had spontaneous or pharmacological sinus conversion (P = .20). Ischemic stroke was observed in 15 hyperthyroid patients with AF (9.4%) versus 5 patients with nonthyroid AF (3.1%, P = .02), and 1 hyperthyroid patient without AF (0.6%, P.001). Furthermore, the majority of ischemic stroke (70%) in patients with AF occurred within the first 30 days of presentation, whereas AF was still present. Cox regression analysis showed that hyperthyroidism (hazard ratio [HR]: 3.5, 95% confidence interval [CI]: 1.15 to 10.42, P = .03) and persistent AF (HR: 13.0, 95% CI: 2.88 to 58.80, P.01) predicted the occurrence of ischemic stroke; warfarin therapy reduced the risk of ischemic stroke (HR: 0.17, 95% CI: 0.04 to 0.79, P = .02).In hyperthyroid patients who presented with new-onset AF, there was an increased risk of ischemic stroke clustering during the initial phase of presentation. This should prompt early use of anticoagulation therapy in hyperthyroid patients with AF.

This study examined the 1-year clinical and angiographic follow-up results of implantation of paclitaxel-eluting stents (PES) in aortocoronary saphenous vein graft (SVG) lesions. Sixty-eight consecutive patients with 90 nonoccluded SVG lesions were treated with PES (Taxus), size ranging from 2.25 to 4.5 mm. Angiographic follow-up was performed on 63 patients (93%) and 83 lesions (92%) at 12 months; major adverse cardiac event (MACE) was recorded in all patients at 1 year. The mean age of patients was 71+/-8 years with predominance of men (75%); the mean graft age was 13+/-4 years. Glycoprotein IIb/ IIIa inhibitors were given in 21 patients (31%); embolic protection devices were used in 54 lesions (60%). On average, patients received 1.4 stents per lesion with a stent size of 3.4+/-0.6 mm and a length of 35.8+/-27.0 mm. Angiographic follow-up revealed a late loss of 0.36+/-0.66 mm with an in-segment binary restenosis rate of 7%. The in-hospital MACE was 7%, which was solely contributed by 5 patients with postprocedure non-Q myocardial infarction; the 1-year MACE was 15%, accounted by 1 noncardiac death and 9 patients with target vessel revascularization. Peripheral vascular disease and the use of glycoprotein IIb/ IIIa inhibitors were the independent predictors of MACE at 1 year. In conclusion, implantation of PES to treat degenerative aortocoronary SVG lesions is safe and associated with low late loss, angiographic restenosis, and MACE at 1-year follow-up.

Background: Amiodarone-induced thyrotoxicosis (AIT) is a clinical condition that is notoriously difficult to manage; the relative risk of adverse cardiovascular events in these patients compared with euthyroid patients is largely unknown. Objective: We compared the clinical characteristics and major adverse cardiovascular events (MACE) in AIT and euthyroid patients. Method: Patients at a tertiary referral center who had been prescribed amiodarone for at least 3 months were retrospectively analyzed. Baseline clinical characteristics, laboratory parameters, and outcome events were evaluated. MACE was defined as cardiovascular mortality, myocardial infarction, stroke and heart failure, or ventricular arrhythmias that required hospitalization. Results: A total of 354 patients (61.8 ± 14.1 yr; 64.7% male) with a mean follow-up of 48.6 ± 26.7 months were studied. AIT, euthyroid status, and amiodarone-induced hypothyroidism were identified in 57 (16.1%), 224 (63.3%), and 73 (20.6%) patients, respectively. No differences in baseline clinical characteristics were observed between AIT and euthyroid patients. Nonetheless AIT patients demonstrated a higher MACE rate (31.6 vs. 10.7%, P < 0.01), mostly driven by a higher rate of ventricular arrhythmias that required admission (7.0 vs. 1.3%, P = 0.03). Cox-regression multivariate analysis revealed that AIT (hazard ratio 2.68; confidence interval 1.53–4.68; P < 0.01) and left ventricular ejection fraction less than 45% (hazard ratio 2.52; confidence interval 1.43–4.42; P < 0.01) were independent predictors of MACE. Conclusion: In patients prescribed long-term amiodarone therapy, occurrence of AIT is associated with a 2.7-fold increased risk of MACE. Regular and close biochemical surveillance is thus advisable to identify and treat this high-risk group of patients.

Background: Atrial fibrillation (AF) that occurs as a frequent complication of myocardial infarction (MI) is associated with a poor clinical outcome. It nonetheless remains uncertain whether AF that occurs transiently during MI is associated with a subsequent increased risk of the development of AF and ischemic stroke. Methods: We retrospectively studied the impact of transient AF on the long-term risk of the occurrence of AF, ischemic stroke, and mortality in 431 consecutive patients (mean [± SEM] age, 64 ± 1 years; 75% men). All patients had experienced an acute inferior ST-segment-elevation MI and had preserved left ventricular ejection fraction (LVEF) [> 45%]. Results: All patients were in sinus rhythm on hospital admission, and transient AF was observed in 59 patients (13.7%) during their hospitalization for MI. On hospital discharge, all patients were in sinus rhythm and had been prescribed antiplatelet agents alone as antithrombotic therapy. Patients in whom transient AF developed during MI were older (mean age, 70 ± 1.4 vs 64 ± 0.7 years, respectively; p 65 years and transient AF during MI were independent predictors of the subsequent occurrence of AF and the development of ischemic stroke. Conclusion: Transient AF complicating acute inferior MI is associated with an increased future risk of AF occurrence and ischemic stroke in patients with preserved LVEF, despite the use of antiplatelet therapy.

Background Lead V4R faces the right ventricular free wall; it also reflects ischemia in the posterolateral wall lying opposite and manifests as ST-segment depression. Hypothesis The aim of this study was to evaluate the usefulness of V4R ST-segment depression in distinguishing proximal from distal left circumflex artery occlusion in acute inferoposterior wall myocardial infarction. Methods We retrospectively analyzed 239 patients who had first acute inferoposterior myocardial infarction, were admitted within 6 h from onset of symptom, and had coronary angiography performed within 4 weeks. Patients who had bundle-branch block or concomitant significant stenoses in the proximal and distal segments of the same vessel or of both vessels were excluded. The electrocardiographic and angiographic findings were reviewed by two independent groups of investigators. Results V4R ST-segment depression ≥1.0 mm was found in 8 of 46 patients (17.4%) with left circumflex artery occlusion but none (0%) with right coronary artery occlusion. Among the group with left circumflex artery occlusion, the mean magnitude of V4R ST-segment depression was greater in proximal than distal occlusion (0.82 ± 0.65 vs. 0.03 ± 0.12 mm, p < 0.0001). V4RST-segment depression ≥1.0 mm was found in 8 of 14 patients (57.1%) with proximal occlusion but none (0%) in 32 patients with distal occlusion. The sensitivity and specificity to predict proximal occlusion were 57.1 and 100%, respectively. Conclusions V4R ST-segment depression ≥1.0 mm was not useful for differentiating left circumflex and right coronary artery occlusion because of its low sensitivity. It is a fairly sensitive and very specific sign of proximal left circumflex artery occlusion. Copyright © 2007 Wiley Periodicals, Inc.

We report a modified crush technique with double kissing balloon inflation (the sleeve technique) in an attempt to increase the success rate of final kissing balloon inflation, which has been shown to improve the angiographic outcomes of side branch in bifurcation lesions. A stent was advanced across the side branch with protrusion of 3-5 mm of proximal stent segment into the main vessel. At the same time, a size-matched balloon with length long enough to cover the bifurcation as well as the protruding stent segment was placed in the main vessel. The side-branch stent is deployed first, the wire and stent balloon are removed. This is followed by balloon inflation in main vessel at high pressure to crush the protruding stent segment against vessel wall. The side branch is then rewired, two balloons are advanced to the main vessel and side branch, and the bifurcation is kissed with balloons the first time. The side branch is now like a new sleeve. The balloon and wire of the side branch are removed. Another stent was positioned and then deployed in the main vessel. The side branch is rewired the second time, two balloons are advanced to the main vessel and side branch again, followed by final (second) kissing balloon inflation of the bifurcation. The sleeve technique has been employed in six consecutive patients with 100% success rate of final kissing balloon inflation. There was no major adverse cardiac events or stent thrombosis encountered within 30 days of percutaneous coronary intervention.

There are only limited data on the prevalence and risk factors for postoperative atrial fibrillation (AF) after elective abdominal surgery. We retrospectively studied the clinical characteristics and hospital outcomes in 563 consecutive patients (mean age: 67 +/- 13 years, 245 men) with colorectal cancer who underwent elective colectomy. The baseline clinical characteristics of patients who underwent open (OC) versus laparoscopic colectomy (LC) were similar. Postoperative AF developed in 25 patients (4.4%). Patients who developed postoperative AF were older (P = 0.017), had a higher prevalence of hypertension (P = 0.05), more major postoperative events (P = 0.02), an elevated neutrophil count on postoperative day (POD) 1 (P = 0.007), longer hospitalizations (P = 0.02), and were more likely to undergo OC (P = 0.067). In multiple regression analysis, independent predictors of postoperative AF were OC (odd ratio: 3.3, 95% confidence interval: 1.3-8.0, P = 0.008), and an elevated neutrophil count on POD 1 (odd ratio: 3.2, 95% confidence interval: 1.3-7.8, P = 0.01). The incidence of postoperative AF after elective colorectal cancer surgery was approximately 4%. Postoperative AF was more commonly observed in patients with OC versus LC and in those with elevated postoperative neutrophil counts.

A 53-year-old man complained of chest pain during an exercise treadmill test. Electrocardiogram revealed transient giant R-wave, right-axis deviation, intraventricular conduction delay, and ST-segment elevation in the inferolateral leads. Subsequent coronary angiography showed an 80% lesion in mid part of a nondominant left circumflex artery, whereas the other coronary arteries had mild atherosclerosis only. Percutaneous coronary intervention and stenting was performed on the left circumflex artery lesion. A follow-up exercise thallium scan 3 months later still showed an intermediate-sized, mild reversible perfusion defect in the inferior and lateral wall but the giant R-wave ECG pattern was not inducible anymore. Restudy coronary angiography showed no in-stent restenosis, but there was disease progression in the midpart of the right coronary artery. The initial electrocardiographic pattern is typical of the “giant R-wave syndrome.” Severe coronary spasm superimposed on the underlying mild atherosclerotic lesion of the right coronary artery is hypothesized to be the cause of the initial event. Ad hoc direct stenting was performed on the right coronary artery lesion. The patient remained symptom-free with a normal thallium scan 9 months later.

Background: Obstructive sleep apnea (OSA) predicted major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing percutaneous coronary intervention (PCI) in the multi-center Sleep and Stent Study. In this post-hoc analysis, we determined the relative and combined prognostic

While long-term anticoagulation prevents ischemic stroke in high-risk patients with atrial fibrillation (AF), the optimal initial anti-thrombotic regime in acute AF is less well defined. We randomized 96 patients with new onset acute AF in an emergency admission ward to receive (1) once-daily preparation of low molecular weight heparin (LMWH), tinzaparin or (2) conventional intravenous unfractionated heparin (target APTT 50-70 s). 5 patients in unfractionated heparin group compared with no patients in LMWH group (0%, P = 0.04) developed ischemic stroke/transient ischemic attack during the first 48 h. An initial subcutaneous LMWH was safe and effective in ischemic stroke prevention in patients with acute AF.

Loo G et al. Clin Cardiol. 2014;37:261–269.

Introduction: The objective of this case report was to illustrate the diagnostic and intervention approach of anomalous right coronary artery (RCA). Clinical Picture: A 60-year-old man presented with acute inferior myocardial infarction. Cardiac catheterisation revealed an anomalous RCA arising from the posterior coronary sinus as the infarct-related artery. Treatment: Ad hoc percutaneous coronary intervention with stent implantation was performed using a few technical modifications. Outcome: Good angiographic result was achieved within 90 minutes, with 260 mL of contrast used. Conclusion: A high index of suspicion and logical diagnostic and intervention approach are required for the proper management of anomalous RCA. Key words: Acute myocardial infarction, Congenital coronary anomalies, Coronary interventions

A patient who had undergone bypass surgery 5 yr earlier, including left internal mammary artery (LIMA) grafting to the left anterior descending artery, underwent transvenous dual-chamber permanent pacemaker implantation for persistent advanced atrioventricular block. Intraoperative LIMA graft obstruction occurred, resulting in anterior myocardial infarction that was treated successfully by primary percutaneous transluminal coronary angioplasty and stenting. This is the first report of the occurrence of this complication during pacemaker implantation.

Normal coronary arteries were found in 22 (5.8%) of 379 patients presented with acute inferior myocardial infarction. These patients were significantly younger, had less cardiovascular risk factors, better systolic heart function, and lower cardiac enzymes level. Electrocardiography significantly showed more (1) ratio of ST-segment elevation in II/ III≥1; (2) isoelectric ST-segment in I; (3) ST-segment elevation in I; and less (4) paroxysmal atrial fibrillation; (5) ST-segment depression in I; and (6) ST-segment elevation in V4R. In conclusion, this subset of patients had clinical features suggestive of smaller infarct size compared with those suffering from atherosclerotic disease. They may have more left circumflex artery involvement and distal right coronary artery occlusion, as deduced from electrocardiography.

We report a rare case of Tako-Tsubo cardiomyopathy developed after excision of left atrial myxoma and adrenaline infusion given for blood pressure augmentation in a 56-year-old lady. Although the risk for developing Tako-Tsubo cardiomyopathy associated with adrenaline use has not been established, caution is still warranted.

Dabigatran was shown to be inferior to warfarin for patients with mechanical heart valves. However it was postulated that its inferiority was limited to early post-operative period where the valves had not been adequately endothelialized. We present a case where thromboembolic acute coronary syndrome developed in a patient six months after switching from warfarin to dabigatran, despite three years after mechanical mitral valve replacement. We propose an alternative explanation for dabigatran failure.

Idiopathic isolated ostial left main artery stenosis is a rare disease with uncertain etiology, clinical course and prognosis. We described a young woman with no cardiovascular risk factors, who developed the disease 3 years ago with a bare-metal stent implanted in the left main artery ostium. She presented again with severe angina of rapid onset. Coronary angiography revealed ostial left main artery in-stent restenosis. A drug-eluting stent was successfully deployed over the previous stent with good angiographic result. The etiology and management of this disorder were briefly discussed.

The aim of this study was to examine the mid-term angiographic result of T-stenting with small protrusion (TAP) as the bailout strategy for treating coronary bifurcation lesions. From 2009 to 2012, symptomatic patients who had severe coronary bifurcation stenoses were treated with one-stent strategy using drug-eluting stents, with kissing balloon inflation performed whenever side branch (SB) impingement occurred. TAP was performed if residual diameter stenosis of SB was ≥75 %, presence of ≥type B dissection or flow impairment was observed in the SB. Seventy-one patients (83 % male, mean age of 61 ± 12 years) were recruited into the study. MEDINA classification 1,1,1 lesions were observed in over 60 % of patients. The mean stent size and length in the main vessel (MV) and SB were 2.86 ± 0.43 and 30 ± 12, and 2.45 ± 0.26 and 16 ± 6 mm, respectively. Restudy angiography was performed on 64 (90 %) patients at 9.2 ± 3.9 months. Angiographic restenosis was observed in 8 (12.5 %) patients with late lumen loss in the MV and SB being 0.22 ± 0.19 and 0.34 ± 0.37 mm, respectively. The use of TAP as the bailout technique for treating coronary bifurcation lesions is associated with good angiographic outcomes, in terms of late lumen loss and restenosis, at 9 months.

The aim of this study was to examine the angiographic result and its outcome predictors using the combination of paclitaxel-eluting balloon (PEB) and Genous stent.This approach to treat coronary stenoses is a logical strategy to strike a balance between minimizing restenosis and stent thrombosis.From November 2010 to June 2012, 40 symptomatic patients with 44 de novo coronary lesions of diameter stenosis ≥ 50% were treated with the combination of PEB and Genous stents. Angiographic and clinical follow-up were intended at 6 and 9 months, respectively.The mean age of patients was 61 ± 11 years, with male predominance (83%). Diabetes mellitus and end-stage renal failure on peritoneal dialysis were found in 15 (38%) and 10 (25%) patients, respectively. Patients received dual antiplatelet therapy for 5.1 ± 1.5 months post procedure. The size and length of PEB used was larger than the stents (3.13 ± 0.46 mm and 28 ± 9 mm vs. 2.98 ± 0.36 mm and 23 ± 7 mm). Restudy angiography was performed on 41 (95%) lesions in 37 (93%) patients at 5.9 ± 1.7 months. Angiographic restenosis was seen in 5 (12%) lesions, and significantly associated with diabetes mellitus and dialysis dependency; the late lumen loss was 0.38 ± 0.37 mm. At 9-month follow-up, no stent thrombosis was observed.The use of PEB combined with Genous stent is associated with a reasonably low restenosis and late lumen loss, whereas diabetes mellitus and renal failure with dialysis are poor predictors of angiographic restenosis.