The Role of Index of Microcirculatory Resistance in Left Anterior Descending Artery ST Segment Elevation Myocardial Infarction Patients after Primary Percutaneous Coronary Intervention

Background: Our aim was to assess the relationship of the index of microvascular resistance (IMR) in left anterior descending (LAD) artery involved STEMI patients. Methods: Data of 316 STEMI patients who had undergone primary percutaneous coronary intervention (PCI) were collected from three cardiovascular centers from 2005 to 2015. In total, 246 patients with LAD STEMI were enrolled for IMR evaluation. Patients were divided into two groups respective of the cut-off IMR value of 30. All-cause mortality, left ventricular function, improvement of systolic function, and cardiac biomarkers were analyzed and compared. Results: A total of 246 patients were enrolled. The number of patients in the IMR above 30 group was 93 and below 30 was 153. The mean ages for each group were 57.91 ± 11.99 and 54 ± 10.63, respectively. The peak creatinine kinase (CK) (3936.85 ± 2827.32 IU/L vs. 2218.08 ± 2310.41 IU/L, p < 0.001) and CKmb (336.15 ± 195.08 mg/mL vs. 231.53 ± 179.53 mg/mL, p < 0.001) levels were higher for an IMR above the 30 group. The left ventricular ejection fraction (LVEF) (44.57 ± 6.685% vs. 47.35 ± 8.17%, p = 0.006) and improvement of LVEF (2.81 ± 7.135% vs. 5.88 ± 7.65%, p = 0.004) was lower in the IMR above 30 group. All-cause mortality (7.5% vs. 1.3%, p = 0.012) was higher in the IMR above 30 group, and a Cox regression analysis showed that an IMR above 30 was a poor prognostic factor regarding all-cause mortality (HR: 5.151, 95% CI 1.062-24.987, p = 0.042) even after adjusting for classical clinical risk factors. Conclusions: An elevated IMR value represented larger infarct size, more severe LV dysfunction, and higher mortality in LAD STEMI patients after successful PCI.

P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy After Deployment of a Drug-Eluting Stent: The SHARE Randomized Clinical Trial

Importance

P2Y12 inhibitor monotherapy after dual antiplatelet therapy (DAPT; a P2Y12 inhibitor plus aspirin) for a brief duration has recently emerged as an attractive alternative for patients undergoing percutaneous coronary intervention (PCI) with a drug-eluting stent.

Objective

To investigate whether P2Y12 inhibitor monotherapy after 3 months of DAPT was noninferior to 12 months of DAPT following PCI with a drug-eluting stent.

Design, Setting, and Participants

The Short-Term Dual Antiplatelet Therapy After Deployment of Bioabsorbable Polymer Everolimus-Eluting Stent (SHARE) open-label, noninferiority randomized clinical trial was conducted from December 15, 2017, through December 14, 2020. Final 1-year clinical follow-up was completed in January 2022. This study was a multicenter trial that was conducted at 20 hospitals in South Korea. Patients who underwent successful PCI with bioabsorbable polymer everolimus-eluting stents were enrolled.

Interventions

Patients were randomly assigned to receive P2Y12 inhibitor monotherapy after 3 months of DAPT (n = 694) or 12 months of DAPT (n = 693).

Main Outcomes and Measures

The primary outcome was a net adverse clinical event, a composite of major bleeding (based on Bleeding Academic Research Consortium type 3 or type 5 bleeding) and major adverse cardiac and cerebrovascular events (cardiac death, myocardial infarction, stent thrombosis, stroke, or ischemia-driven target lesion revascularization) between 3 and 12 months after the index PCI. The major secondary outcomes were major adverse cardiac and cerebrovascular events and major bleeding. The noninferiority margin was 3.0%.

Results

Of the total 1452 eligible patients, 65 patients were excluded before the 3-month follow-up, and 1387 patients (mean [SD] age, 63.0 [10.7] years; 1055 men [76.1%]) were assigned to P2Y12 inhibitor monotherapy (n = 694) or DAPT (n = 693). Between 3 and 12 months of follow-up, the primary outcome (using Kaplan-Meier estimates) occurred in 9 patients (1.7%) in the P2Y12 inhibitor monotherapy group and in 16 patients (2.6%) in the DAPT group (absolute difference, -0.93 [1-sided 95% CI, -2.64 to 0.77] percentage points; P < .001 for noninferiority). For the major secondary outcomes (using Kaplan-Meier estimates), major adverse cardiac and cerebrovascular events occurred in 8 patients (1.5%) in the P2Y12 inhibitor monotherapy group and in 12 patients (2.0%) in the DAPT group (absolute difference, -0.49 [95% CI, -2.07 to 1.09] percentage points; P = .54). Major bleeding occurred in 1 patient (0.2%) in the P2Y12 inhibitor monotherapy group and in 5 patients (0.8%) in the DAPT group (absolute difference, -0.60 [95% CI, -1.33 to 0.12] percentage points; P = .10).

Conclusions and Relevance

In patients with coronary artery disease undergoing PCI with the latest generation of drug-eluting stents, P2Y12 inhibitor monotherapy after 3-month DAPT was not inferior to 12-month DAPT for net adverse clinical events. Considering the study population and lower-than-expected event rates, further research is required in other populations.

Trial Registration

ClinicalTrials.gov Identifier: NCT03447379.

Stopping Aspirin Within 1 Month After Stenting for Ticagrelor Monotherapy in Acute Coronary Syndrome: The T-PASS Randomized Noninferiority Trial

BACKGROUND

Stopping aspirin within 1 month after implantation of a drug-eluting stent for ticagrelor monotherapy has not been exclusively evaluated for patients with acute coronary syndrome. The aim of this study was to investigate whether ticagrelor monotherapy after <1 month of dual antiplatelet therapy (DAPT) is noninferior to 12 months of ticagrelor-based DAPT for adverse cardiovascular and bleeding events in patients with acute coronary syndrome.

METHODS

In this randomized, open-label, noninferiority trial, 2850 patients with acute coronary syndrome who underwent drug-eluting stent implantation at 24 centers in South Korea were randomly assigned (1:1) to receive either ticagrelor monotherapy (90 mg twice daily) after <1 month of DAPT (n=1426) or 12 months of ticagrelor-based DAPT (n=1424) between April 24, 2019, and May 31, 2022. The primary end point was the net clinical benefit as a composite of all-cause death, myocardial infarction, definite or probable stent thrombosis, stroke, and major bleeding at 1 year after the index procedure in the intention-to-treat population. Key secondary end points were the individual components of the primary end point.

RESULTS

Among 2850 patients who were randomized (mean age, 61 years; 40% ST-segment-elevation myocardial infarction), 2823 (99.0%) completed the trial. Aspirin was discontinued at a median of 16 days (interquartile range, 12-25 days) in the group receiving ticagrelor monotherapy after <1 month of DAPT. The primary end point occurred in 40 patients (2.8%) in the group receiving ticagrelor monotherapy after <1-month DAPT, and in 73 patients (5.2%) in the ticagrelor-based 12-month DAPT group (hazard ratio, 0.54 [95% CI, 0.37-0.80]; P<0.001 for noninferiority; P=0.002 for superiority). This finding was consistent in the per-protocol population as a sensitivity analysis. The occurrence of major bleeding was significantly lower in the ticagrelor monotherapy after <1-month DAPT group compared with the 12-month DAPT group (1.2% versus 3.4%; hazard ratio, 0.35 [95% CI, 0.20-0.61]; P<0.001).

CONCLUSIONS

This study provides evidence that stopping aspirin within 1 month for ticagrelor monotherapy is both noninferior and superior to 12-month DAPT for the 1-year composite outcome of death, myocardial infarction, stent thrombosis, stroke, and major bleeding, primarily because of a significant reduction in major bleeding, among patients with acute coronary syndrome receiving drug-eluting stent implantation. Low event rates, which may suggest enrollment of relatively non-high-risk patients, should be considered in interpreting the trial.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03797651.

Hemo-metabolic impairment in patients with ST-segment elevation myocardial infarction: Data from the INTERSTELLAR registry

BACKGROUND

Not only hemo-dynamic (HD) factors but also hemo-metabolic (HM) risk factors reflecting multi-organ injuries are considered as important prognostic factors in ST-segment elevation myocardial infarction (STEMI). However, studies regarding HM risk factors in STEMI patients are currently limited.

METHOD

Under analysis were 1,524 patients with STEMI who underwent primary percutaneous coronary intervention in the INTERSTELLAR registry. Patients were divided into HM (≥ 2 risk factors) and non-HM impairment groups. The primary outcome was in-hospital all-cause mortality, and the secondary outcome was 1-year all-cause mortality.

RESULTS

Of 1,524 patients, 214 (14.0%) and 1,310 (86.0%) patients were in the HM and non-HM impairment groups, respectively. Patients with HM impairment had a higher incidence of in-hospital mortality than those without (24.3% vs. 2.7%, p < 0.001). After adjusting for confounders, HM impairment was independently associated with in-hospital mortality (inverse probability of treatment weighting [IPTW]-adjusted odds ratio: 1.81, 95% confidence interval: 1.08-3.14). In the third door-to-balloon (DTB) time tertile (≥ 82 min), HM impairment was strongly associated with in-hospital mortality. In the first DTB time tertile ( < 62 min), indicating relatively rapid revascularization, HM impairment was consistently associated with increased in-hospital mortality.

CONCLUSIONS

Hemo-metabolic impairment is significantly associated with increased risk of in-hospital and 1-year mortality in patients with STEMI. It remains a significant prognostic factor, regardless of DTB time.

A prospective double-blinded randomized study on drug-eluting stent implantation into nitrate-induced maximally dilated vessels in patients with coronary artery disease

BACKGROUND

Percutaneous coronary intervention (PCI) has been developed using drug-eluting stents (DES); however, stent implantation is associated with concerns of stent thrombosis and target vessel revascularization (TVR). The stent diameter is a critical factor in TVR and clinical events. The nitrate administration in coronary angiography can dilate the reference vessel diameter, enabling accurate vessel size measurement and optimal stent implantation support. This study was designed to evaluate the effect of stent implantation in the maximally dilated coronary artery in patients with coronary artery disease (CAD).

METHODS

This prospective double-blinded randomized (1:1) study is designed to compare the efficacy and safety between DES implantation into the nitrate-induced maximally dilated vessels and conventional DES implantation in patients with CAD. A total of 400 patients who underwent PCI with a sirolimus-eluting stent will be enrolled. The primary endpoint is the mean diameter of the deployed stents. Secondary endpoints include cardiac death, myocardial infarction, stent thrombosis, or ischemia-driven TVR 1 year after the procedure.

DISCUSSION

This study will be the first randomized controlled trial to evaluate the effect of DES implantation on nitrate-induced maximally dilated vessels in patients with CAD.

TRIAL REGISTRATION

The trial was registered on 18 June 2021 as Effect of Ultimaster Stents Treated to the Most Dilated Coronary Vessels (ClinicalTrials.gov Identifier: NCT04931784).

Association of height loss and cardiovascular disease: Data from a large Korean cohort

Background

Height declines with age, and its degree differs among individuals. Despite epidemiologic evidence for the inverse relationship between adult height and cardiovascular disease (CVD) incidence, the clinical significance of height loss in CVD remains to be elucidated. Therefore, this study investigated the association between height loss and CVD incidence.

Methods

In total, 127,573 Korean participants were enrolled; their heights were monitored from 2002 to 2011. The annual height loss (cm/year) was the difference between the first and last height measurements within the observation period divided by the number of years. The participants were classified as Group 1 (height loss: <0.3 cm/year; n = 102,554), Group 2 (height loss: 0.3– < 0.6 cm/year; n = 17,324), or Group 3 (height loss: ≥0.6 cm/year; n = 7,695).

Results

The cumulative major adverse cardiac and cerebral event (MACCE: cardiac death, non-fatal myocardial infarction, and unplanned hospitalization for heart failure or stroke) incidence rate was 3.6% for Group 1, 4.5% for Group 2, and 5.2% for Group 3. Group 2 (hazard ratio [HR] = 1.27, 95% confidence interval [CI] = 1.17–1.37) and Group 3 (HR = 1.46, 95% CI = 1.32–1.62) had a significantly higher incidence of MACCE than Group 1. In the model adjusted for age, sex, comorbidities, income level, body mass index, smoking, and drinking status, the MACCE risk was higher in Group 2 (HR = 1.11, 95% CI = 1.07–1.20) and Group 3 (HR = 1.25, 95% CI = 1.13–1.39) than in Group 1.

Conclusion

The degree of height loss was independently associated with CVD occurrences in the Korean population.

Impact of right atrial enlargement on clinical outcome in patients with atrial fibrillation

Background

Left atrial (LA) remodeling is associated with adverse cardiovascular events, including heart failure (HF) and stroke in patients with atrial fibrillation (AF). However, there are limited data on the value of right atrial (RA) remodeling in this population. We investigated the prognostic role of RA enlargement in patients with non-valvular AF.

Methods and results

We analyzed 254 consecutive patients (age = 69 ± 12years, male:female = 165:89, mean left ventricular ejection fraction = 58.0 ± 7.2%) with non-valvular AF who underwent two-dimensional echocardiography from a single center. RA and LA volumes were measured from apical views and indexed to the body surface areas (right atrial volume index [RAVI] and left atrial volume index [LAVI]) and RAVI &gt; 30mL/m2 and LAVI &gt; 34mL/m2 were considered as enlarged. The relationship between RA enlargement and composite clinical outcome of hospitalization for HF (HHF), stroke, systemic embolism, or death from any cause was assessed. Right atrial (RA) enlargement was associated with older age and more frequent prevalence of persistent or permanent AF. During a median follow-up of 47.1 months, 77 patients (30%) had experienced primary composite outcome. In a multivariable model, RA enlargement, but not LA enlargement, was independently associated with adverse clinical outcomes even after adjusting for clinical and echocardiographic factors {adjusted hazard ratio [HR], 1.90 [95% confidence interval (CI), 1.14–3.18], p = 0.014 for primary composite outcome; adjusted HR, 2.70 [95% CI, 1.27–5.67], p = 0.001 for HHF or all cause death}.

Conclusion

RA enlargement was independently associated with an increased risk of HF, stroke, systemic embolization or death in patients with non-valvular AF, suggesting that RA volume can be helpful in assessing future cardiovascular risk in this population.

Correlation of heart rate recovery and heart rate variability with atrial fibrillation progression

Objective

To examine the combination of heart rate recovery (HRR) and heart rate variability (HRV) in predicting atrial fibrillation (AF) progression.

Methods

Data from patients with a first detected episode of AF who underwent treadmill exercise testing and 24-h Holter electrocardiography were retrospectively analysed. Autonomic dysfunction was verified using HRR values. Sympathetic and parasympathetic modulation was analysed by HRV. AF progression was defined as transition from the first detected paroxysmal episode to persistent/permanent AF.

Results

Of 306 patients, mean LF/HF ratio and HRR did not differ significantly by AF progression regardless of age (< or ≥65 years). However, when the LF/HF ratio was divided into tertiles, in patients aged <65 years, the mid LF/HF (1.60–2.40) ratio was significantly associated with lower AF progression rates and longer maintenance of normal sinus rhythm. For patients aged <65 years, less metabolic equivalents were related to higher AF progression rates. For patients aged ≥65 years, a low HRR was associated with high AF progression rates.

Conclusion

In relatively younger age, high physical capacity and balanced autonomic nervous system regulation are important predictors of AF progression. Evaluation of autonomic function assessed by age could predict AF progression.

The Index of Microcirculatory Resistance after Primary Percutaneous Coronary Intervention Predicts Long-Term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction

The index of microcirculatory resistance (IMR) is a simple method that can measure microvascular function after primary percutaneous coronary intervention (PCI) in patients with ST-segment Elevation Myocardial Infarction (STEMI). This study is to find out whether IMR predicts clinical long-term outcomes in STEMI patients. A total of 316 patients with STEMI who underwent primary PCI from 2005 to 2015 were enrolled. The IMR was measured using pressure sensor/thermistor-tipped guidewire after primary PCI. The primary endpoint was the rate of death or hospitalization for heart failure (HF) over a mean follow-up period of 65 months. The mean corrected IMR was 29.4 ± 20.0. Patients with an IMR > 29 had a higher rate of the primary endpoint compared to patients with an IMR ≤ 29 (10.3% vs. 2.1%, p = 0.001). During the follow-up period, 13 patients (4.1%) died and 6 patients (1.9%) were hospitalized for HF. An IMR > 29 was associated with an increased risk of death or hospitalization for HF (OR 5.378, p = 0.004). On multivariable analysis, IMR > 29 (OR 3.962, p = 0.022) remained an independent predictor of death or hospitalization for HF with age (OR 1.048, p = 0.049) and symptom-to-balloon time (OR 1.002, p = 0.049). High IMR was an independent predictor for poor long-term clinical outcomes in STEMI patients after primary PCI.

Clinical Implication of Hypoxic Liver Injury for Predicting Hypoxic Hepatitis and In-Hospital Mortality in ST Elevation Myocardial Infarction Patients

PURPOSE

In this study, we aimed to determine the value of hypoxic liver injury (HLI) in the emergency room (ER) for predicting hypoxic hepatitis (HH) and in-hospital mortality in ST elevation myocardial infarction (STEMI) patients.

MATERIALS AND METHODS

1537 consecutive STEMI patients were enrolled. HLI in the ER was defined as a ≥2-fold increase in serum aspartate transaminase (AST). HH was defined as a ≥20-fold increase in peak serum transaminase. Patients were divided into four groups according to HLI and HH status (group 1, no HLI or HH; group 2, HLI, but no HH; group 3, no HLI, but HH; group 4, both HLI and HH).

RESULTS

The incidences of HLI and HH in the ER were 22% and 2%, respectively. In-hospital mortality rates were 3.1%, 11.8%, 28.6%, and 47.1% for groups 1, 2, 3, and 4, respectively. Patients with HLI and/or HH had worse Killip class, higher cardiac biomarker elevations, and lower left ventricular ejection fraction. Multivariate logistic regression analysis showed that HLI in the ER was an independent predictor of HH [odds ratio 2.572, 95% confidence interval (CI) 1.166-5.675, p=0.019]. The predictive value of HLI in the ER for the development of HH during hospitalization was favorable [area under the curve (AUC) 0.737, 95% CI 0.643-0.830, sensitivity 0.548, specificity 0.805, for cut-off value AST >80]. Furthermore, in terms of in-hospital mortality, predictive values of HLI in the ER and HH during hospitalization were comparable (AUC 0.701 for HLI at ER and AUC 0.674 for HH).

CONCLUSION

Among STEMI patients, HLI in the ER is a significant predictor for the development of HH and mortality during hospitalization (INTERSTELLAR ClinicalTrials.gov number, NCT02800421).

mHealth Interventions for Lifestyle and Risk Factor Modification in Coronary Heart Disease: Randomized Controlled Trial

Background

Self-management of lifestyle and cardiovascular disease risk factors is challenging in older patients with coronary heart disease (CHD). SMS text messaging could be a potential support tool for self-management and the most affordable and accessible method through a mobile phone. High-quality evidence had been lacking, and previous studies evaluated the effects of SMS text messaging on the subjective measures of short-term outcomes. Recently, a large-sized randomized controlled trial in Australia reported promising findings on the objective measures upon 6-month follow-up. However, an examination of the effectiveness of such interventions in an Asian population with unique demographic characteristics would be worthwhile.

Objective

This study examined the effectiveness of a 1-way SMS text messaging program to modify the lifestyle and cardiovascular disease risk factors of patients who underwent the first percutaneous coronary intervention (PCI).

Methods

A parallel, single-blinded, 1:1 random allocation clinical trial was conducted with 879 patients treated through PCI. They were recruited during hospital admission from April 2017 to May 2020 at 2 university hospitals in the Republic of Korea. In addition to standard care, the intervention group received access to a supporting website and 4 SMS text messages per week for 6 months regarding a healthy diet, physical activity, smoking cessation, and cardiovascular health. Random allocation upon study enrollment and SMS text messaging after hospital discharge were performed automatically using a computer program. The coprimary outcomes were low-density-lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), and BMI. The secondary outcomes were change in lifestyle and adherence to the recommended health behaviors.

Results

Of the eligible population, 440 and 439 patients who underwent PCI were assigned to the intervention and control groups, respectively. The 1-way SMS text messaging program significantly enhanced physical activity (P=.02), healthy diet (P<.01), and medication adherence (P<.04) among patients with CHD. Hence, more people were likely to control their cardiovascular disease risk factors per the recommendations. The intervention group was more likely to control all 5 risk factors by 62% (relative risk 1.62, 95% CI 1.05-2.50) per the recommendations. On the other hand, physiological measures of the primary outcomes, including LDL-C levels, SBP, and BMI, were not significant. Most participants found the SMS text messaging program useful and helpful in motivating lifestyle changes.

Conclusions

Lifestyle-focused SMS text messages were effective in the self-management of a healthy diet, exercise, and medication adherence, but their influence on the physiological measures was not significant. One-way SMS text messages can be used as an affordable adjuvant method for lifestyle modification to help prevent the recurrence of cardiovascular disease.

Trial Registration

Clinical Research Information Service (CRiS) KCT0005087; https://cris.nih.go.kr/cris/search/detailSearch.do/19282

Neutrophil-to-Lymphocyte Ratio at Emergency Room Predicts Mechanical Complications of ST-segment Elevation Myocardial Infarction

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) has been proven to be a reliable inflammatory marker. A recent study reported that elevated NLR is associated with adverse cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI). We investigated whether NLR at emergency room (ER) is associated with mechanical complications of STEMI undergoing primary percutaneous coronary intervention (PCI).

METHODS

A total of 744 patients with STEMI who underwent successful primary PCI from 2009 to 2018 were enrolled in this study. Total and differential leukocyte counts were measured at ER. The NLR was calculated as the ratio of neutrophil count to lymphocyte count. Patients were divided into tertiles according to NLR. Mechanical complications of STEMI were defined by STEMI combined with sudden cardiac arrest, stent thrombosis, pericardial effusion, post myocardial infarction (MI) pericarditis, and post MI ventricular septal rupture, free-wall rupture, left ventricular thrombus, and acute mitral regurgitation during hospitalization.

RESULTS

Patients in the high NLR group (> 4.90) had higher risk of mechanical complications of STEMI (P = 0.001) compared with those in the low and intermediate groups (13% vs. 13% vs. 23%). On multivariable analysis, NLR remained an independent predictor for mechanical complications of STEMI (RR = 1.947, 95% CI = 1.136-3.339, P = 0.015) along with symptom-to balloon time (P = 0.002) and left ventricular dysfunction (P < 0.001).

CONCLUSION

NLR at ER is an independent predictor of mechanical complications of STEMI undergoing primary PCI. STEMI patients with high NLR are at increased risk for complications during hospitalization, therefore, needs more intensive treatment after PCI.

Addition of routine blood biomarkers to TIMI risk score improves predictive performance of 1-year mortality in patients with ST-segment elevation myocardial infarction

Background

Several biomarkers have been proposed as independent predictors of poor outcomes in ST-segment elevation myocardial infarction (STEMI). We investigated whether adding information obtained from routine blood tests including hypoxic liver injury (HLI), dysglycemia, anemia, and high neutrophil to lymphocyte ratio (NLR) could improve the prognostic performance of the TIMI risk score for the prediction of 1-year mortality.

Methods

A total of 1057 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) between 2007 and 2014 were retrospectively enrolled from 4-regional hospitals. HLI and dysglycemia were defined as serum transaminase > twice the normal upper limit and glucose < 90 or > 250 mg/dL, respectively. The effect of adding biomarkers to the TIMI risk score on its discriminative ability was assessed using c-statistic, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

Results

The 1-year mortality rate was 7.1%. The best cutoff value of NLR for the prediction of 1-year mortality was 4.3 (sensitivity, 67%; specificity, 65%). HLI (HR 2.019; 95% CI 1.104–3.695), dysglycemia (HR 2.535; 95% CI 1.324–3.923), anemia (HR 2.071; 95% CI 1.093–3.923), and high NLR (HR 3.651; 95% CI 1.927–6.918) were independent predictors of 1-year mortality. When these 4 parameters were added to the TIMI risk score, the c-statistic significantly improved from 0.841 to 0.876 (p < 0.001), and the NRI and IDI were estimated at 0.203 (95% CI 0.130–0.275; p < 0.001) and 0.089 (95% CI 0.060–0.119; p < 0.001), respectively.

Conclusions

The addition of HLI, dysglycemia, anemia, and high NLR to the TIMI risk score may be useful for very early risk stratification in patients with STEMI receiving primary PCI.

Ivabradine-Induced Torsade de Pointes in Patients with Heart Failure Reduced Ejection Fraction

Ivabradine is a selective inhibitor of the sinoatrial node "funny" current, prolonging the slow diastolic depolarization. As it has the ability to block the heart rate selectively, it is more effective at a faster heart rate. It is recommended for the treatment of heart failure reduced ejection fraction in the presence of beta-blocker therapy for the further reduction of the heart rate. However, previous reports have shown the association of Torsade de pointes (TdP) with concurrent use of ivabradine and drugs resulting in QT prolongation or blockage of the metabolic breakdown of ivabradine. In this article, we report two cases of patients with heart failure reduced ejection fraction who developed TdP after ivabradine use. Our report highlights the need to exercise caution with the administration of ivabradine in the presence of a reduced repolarization reserve, such as QT prolongation or metabolic insufficiency.

The relationship between J wave and ventricular tachycardia during Takotsubo cardiomyopathy

Background and objectives

Takotsubo cardiomyopathy (TTC) occasionally causes life-threatening ventricular arrhythmia. J wave on surface electrocardiography (sECG) has also been associated with idiopathic ventricular fibrillation and cardiac events; therefore, we investigated whether the presence of J wave on sECG is a potential risk factor for ventricular arrhythmia in patients with TTC.

Subjects and methods

We performed a retrospective study in 79 patients who were diagnosed with TTC from 2010 to 2014. Among them, 20 (25.3%) were diagnosed with ventricular tachycardia (VT). The J wave on the sECG was defined as J point elevation manifested through QRS notching or slurring at least 1 mm above the baseline in at least two leads.

Results

A higher prevalence of ventricular tachycardia was observed in patients with J wave. The corrected QT interval (QTc) was significantly longer in the VT group than in the non-VT group. In a multivariate analysis, the presence of J wave appeared to be the only independent predictors of VT [Hazard Ratio (HR) 3.5, p = 0.019].

Conclusion

Our results suggest that the presence of J wave on the sECG is significantly associated with VT, and appear to indicate that the presence of J wave is a strong and independent predictor of VT in patients with TTC.

Prognostic impact of the combination of serum transaminase and alkaline phosphatase determined in the emergency room in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background

Elevated serum transaminase or alkaline phosphatase (ALP) has been proposed as a novel prognosticator for ST-segment elevation myocardial infarction (STEMI). We evaluated the combined prognostic impact of elevated serum transaminases and ALP on admission in STEMI patients who underwent primary percutaneous coronary intervention (PCI).

Methods

A total of 1176 patients with STEMI undergoing primary PCI were retrospectively enrolled from the INTERSTELLAR registry. Hypoxic liver injury (HLI) was defined as serum transaminase > twice the upper limit of normal. The cut-off value of high ALP was set at the median level (73 IU/L). Patients were divided into four groups according to their serum transaminase and ALP levels. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), defined as the composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, and ischemia-driven revascularization.

Results

Median follow-up duration was 25 months (interquartile range, 10–39 months). The rate of MACCE was highest in patients with HLI (+) and high ALP (25.9%), compared to those in the other groups (8.2% in HLI [-] and low ALP, 11.8% in HLI [-] and high ALP, and 15.0% in HLI [+] and low ALP). Each of HLI or high ALP was an independent predictor for MACCE (HR 1.807, 95% CI 1.191–2.741; HR 1.721, 95% CI 1.179–2.512, respectively). Combined HLI and high ALP was associated with the worst prognosis (HR 3.145, 95% CI 1.794–5.514).

Conclusions

Combined HLI and high ALP on admission is associated with poor clinical outcomes in patients with STEMI who have undergone primary PCI.

The selection of β-blocker after successful reperfusion in patients with ST-elevation myocardial infarction

Background:

The selection of β-blocker for survivors after primary intervention due to acute ST-elevation myocardial infarction seems crucial to improve the outcomes. However, rare comparison data existed for these patients. We aimed to compare the effectiveness of selective β-blockers to that of carvedilol in patients treated with primary intervention.

Methods and results:

Among the 1,485 patients in the “INTERSTELLAR” registry between 2007 and 2015, 238 patients with selective β-blockers (bisoprolol, nebivolol, atenolol, bevantolol, and betaxolol) and 988 with carvedilol were included and their clinical outcomes were compared for a 2-year observation period. In the clinical baseline characteristics, the unfavorable trends in the carvedilol group were high Killip presentation, lower ejection fractions, smaller diameters, and longer lengths of deployed stents. Although mortality (2.5% vs. 1.7%; p = 0.414) and the rate of stroke (0.8% vs. 0.6%; p = 0.693) were not different between groups, the rate of recurrent myocardial infarction (4.6% vs. 1.2%; p = 0.001) and of target vessel revascularization (4.2% vs. 0.9%; p < 0.001) were lower in the carvedilol group. After eliminating the difference by propensity matching, the similar outcome result was shown (all-cause death, 0.6% vs. 1.0%, p = 0.678; stroke, 0.6% vs. 1.2%, p = 0.479; myocardial infarction, 5.0% vs. 1.2%, p = 0.003; target vessel revascularization, 4.5% vs. 0.7%, p < 0.006) for 595 matched populations. The use of carvedilol was also determined to be an independent predictor for recurrent myocardial infarctions (hazard ratio = 0.305; p = 0.005; 95% confidence interval = 0.13-0.69).

Conclusion:

Use of a carvedilol in ST-segment myocardial infarction survivor is associated with lower recurrent myocardial infarction events. Thus, it might be the better choice of β-blocker for secondary prevention in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention.

Impact of gender on heart failure presentation in non-obstructive hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a genetic cardiac disease that represents a broad spectrum of morphologic features and clinical presentations. However, little is known about the impact of gender differences in heart failure (HF) development in non-obstructive HCM. We assessed clinical and echocardiographic parameters according to gender in patients with non-obstructive HCM and evaluated the impact of gender on HF presentation and cardiovascular (CV) outcomes in this population. We investigated 202 consecutive patients with non-obstructive HCM. Clinical parameters and conventional echocardiographic measurements including tissue Doppler measurements were evaluated and compared according to gender. Additionally, left ventricular (LV) deformation was assessed with global longitudinal strain (GLS) utilizing 2D speckle tracking software. Of the 202 patients (age = 63 ± 14 years, male: female = 141: 61), 51 patients (24.8%) presented with HF and female patients had HF more frequently (52.5% vs. 12.8%, P < 0.001). Females were older, had a higher prevalence of atrial fibrillation, had increased left atrial volume (LAV), and a higher ratio of early diastolic mitral inflow to early annular velocity (E/e') than males (70 ± 12 years vs. 59 ± 14 years, P < 0.001 for age; 51.4 ± 19.3 mL/m² vs. 40.0 [Formula: see text] 13.4 mL/m², P < 0.001 for indexed LAV; 17.2 [Formula: see text] 6.0 vs. 13.0 [Formula: see text] 4.3, P < 0.001 for E/e'). While LV maximal thickness and LV ejection fraction were comparable between men and women, GLS was decreased significantly in female patients (- 13.5 [Formula: see text] 3.4% vs. - 15.6 [Formula: see text] 4.0%, P = 0.001 for GLS). Even after adjusting for clinical factors, female was independently associated with HF presentation (Odd ratio 5.19, 95% CI 2.24-12.03, P < 0.001). During a median follow-up duration 34.0 months, 20 patients (9.9%) had HF hospitalization or CV death. In a multivariable analysis, female gender was associated with higher risk of the composite of HF hospitalization or CV death and HF hospitalization alone than male (Adjusted hazard ratio [HR] = 3.31, 95% CI 1.17-9.35, P = 0.024 for primary composite outcome of HF hospitalization or CV death; adjusted HR = 4.78, 95% CI 1.53-14.96, P = 0.007 for HF hospitalization). In patients with non-obstructive HCM, female patients presented with HF more frequently and showed a higher risk of CV events than male patients. LA volume, E/e' and LV mechanics were different between the genders, suggesting that these might contribute to greater susceptibility to HF in women with HCM.

Complete Versus Culprit-Only Revascularization for ST-Segment Elevation Myocardial Infarction and Multivessel Disease in the 2nd Generation Drug-Eluting Stent Era: Data from the INTERSTELLAR Registry

Background and Objectives

We aimed to compare outcomes of complete revascularization (CR) versus culprit-only revascularization for ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) in the 2^nd generation drug-eluting stent (DES) era.

Methods

From 2009 to 2014, patients with STEMI and MVD, who underwent primary percutaneous coronary intervention (PCI) using a 2^nd generation DES for culprit lesions were enrolled. CR was defined as PCI for a non-infarct-related artery during the index admission. Major adverse cardiovascular event (MACE) was defined as cardiovascular (CV) death, non-fatal myocardial infarction, target lesion revascularization, or heart failure during the follow-up year.

Results

In total, 705 MVD patients were suitable for the analysis, of whom 286 (41%) underwent culprit-only PCI and 419 (59%) underwent CR during the index admission. The incidence of MACE was 11.5% in the CR group versus 18.5% in the culprit-only group (hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.37–0.86; p<0.01; adjusted HR, 0.64; 95% CI, 0.40–0.99; p=0.04). The CR group revealed a significantly lower incidence of CV death (7.2% vs. 12.9%; HR, 0.51; 95% CI, 0.31–0.86; p=0.01 and adjusted HR, 0.57; 95% CI; 0.32–0.97; p=0.03, respectively).

Conclusions

CR was associated with better outcomes including reductions in MACE and CV death at 1 year of follow-up compared with culprit-only PCI in the 2^nd generation DES era.

Kilt Technique as an Angle Modification Method for Endovascular Repair of Abdominal Aortic Aneurysm with Severe Neck Angle

PURPOSE

Kilt technique can be useful for overcoming the severe angle in endovascular abdominal aortic repair. Thus, we investigate the utility of the Kilt technique as an angle modification method.

METHODS

This study included 16 patients with abdominal aortic aneurysm having severe neck angle (over 60°). Of these, eight were treated using Kilt technique, whereas the remaining eight were by the conventional endovascular method. We investigated the pre- and post-procedural differences in neck angle between the two groups using aortic computed tomography (CT) angiography.

RESULTS

Mean pre-procedural neck angles in the conventional group and the Kilt group were 70° ± 13° and 93° ± 14° (p = 0.007) and supra-renal neck angles were 54° ± 16° and 89° ± 26°, respectively (p = 0.016). However, the angle differences disappeared between the two groups after the procedure. Consequently, the Kilt group showed greater angle change than the conventional group (p value for ∆ supra-renal angle and ∆ neck angle were 0.015 and 0.021, respectively). There was no type 1 endoleak during 16 ± 16 months of CT follow-up.

CONCLUSION

Kilt technique may be an effective tool for modifying the neck angle without leaving increased risk of type 1 endoleak in this subset of patients.

Prognostic Impact of Combined Dysglycemia and Hypoxic Liver Injury on Admission in Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention (from the INTERSTELLAR Cohort)

Dysglycemia on admission is known to predict the prognosis of ST-segment elevation myocardial infarction (STEMI). Recently, hypoxic liver injury (HLI) has been proposed as a novel prognosticator for STEMI. We evaluated the prognostic impact of combined dysglycemia and HLI at the time of presentation in patients with STEMI who underwent primary percutaneous coronary intervention. From 2007 to 2014, 1,525 consecutive patients (79% men, mean age 61 years) who underwent primary percutaneous coronary intervention for STEMI in the INTERSTELLAR (Incheon-Bucheon Cohort of Patients Undergoing Primary PCI for Acute ST-Elevation Myocardial Infarction) cohort were analyzed retrospectively. Dysglycemia was defined as either hypoglycemia (serum glucose <90 mg/dl) or hyperglycemia (serum glucose >250 mg/dl). HLI was defined as more than twofold increase of any serum aminotransferases above the upper normal limit. Patients were divided into 4 groups according to their dysglycemia and HLI status on admission: group 1, normoglycemia without HLI; group 2, dysglycemia without HLI; group 3, normoglycemia with HLI; and group 4, dysglycemia with HLI. Primary end point was inhospital death and secondary end point was all-cause mortality at 12 months after the index procedure. Of the 1,525 patients, there were 87 inhospital deaths (5.7%) and 113 all-cause deaths (7.4%) at 12 months after the index procedure. Both dysglycemia and HLI on admission were independent predictors of inhospital death. Inhospital mortality rate was the highest in group 4 (32.1%), followed by groups 2 and 3. Kaplan-Meier survival analysis at 12 months showed similar trends among the 4 groups. In conclusion, combined dysglycemia and HLI on admission predicts early prognosis for STEMI.

Prognostic Implications of Newly Developed T-Wave Inversion After Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction

We investigated the prognostic value of newly developed T-wave inversion after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction. New T-wave inversion was defined as new onset of T-wave inversion after the primary PCI, without negative T waves on the presenting electrocardiogram. The primary end point was the occurrence of major adverse cardiac events (MACE), which consisted of cardiovascular mortality, nonfatal myocardial infarction, and rehospitalization for heart failure. A total of 271 patients were analyzed and followed up for 24 months in this study. New T-wave inversion was observed in 194 patients (72%), whereas the remaining 77 patients (28%) did not show T-wave inversion after the index PCI. Post-PCI Thrombolysis In Myocardial Infarction flow grade 2 or 3 was observed more frequently in patients with new T-wave inversion (97% vs 90%; p = 0.011). The cumulative MACE rate was significantly lower in patients with new T-wave inversion than in those without new T-wave inversion (8% vs 30%; odds ratio 0.197, 95% confidential interval 0.096 to 0.403; p <0.001). In multivariate Cox regression analysis, new T-wave inversion was an independent prognostic factor for MACE (hazard ratio 0.297, 95% confidential interval 0.144 to 0.611; p = 0.001). In conclusion, newly developed T-wave inversion after primary PCI was associated with favorable long-term outcome.

Prognostic impact of alkaline phosphatase measured at time of presentation in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

Background

Serum alkaline phosphatase (ALP) has been shown to be a prognostic factor in several subgroups of patients due to its promotion of vascular calcification. However, the prognostic impact of serum ALP level in ST-segment elevation myocardial infarction (STEMI) patients with a relatively low calcification burden has not been determined. We aimed to investigate the association of ALP level measured at time of presentation on clinical outcomes in patients with STEMI requiring primary percutaneous coronary intervention (PCI).

Methods

A total of 1178 patients with STEMI undergoing primary PCI between 2007 and 2014 were retrospectively enrolled from the INTERSTELLAR registry and classified into tertiles by ALP level (<64, 65–82, or >83 IU/L). The primary study outcome was a major adverse cardiac or cerebrovascular event (MACCE), defined as the composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, and ischemia-driven revascularization.

Results

Median follow-up duration was 25 months (interquartile range, 10–39 months). The incidence of MACCE significantly increased as ALP level increased, that is, for the <64, 65–82, and >83 IU/L tertiles incidences were 8.7%, 11.7%, and 15.7%, respectively; p for trend = 0.003). After adjustment for potential confounders, the adjusted hazard ratios for MACCE in the middle and highest tertiles were 1.69 (95% CI 1.01–2.81) and 2.46 (95% CI 1.48–4.09), respectively, as compared with the lowest ALP tertile.

Conclusions

Elevated ALP level at presentation, but within the higher limit of normal, was found to be independently associated with higher risk of MACCE after primary PCI in patients with STEMI.

Relation Between Neutrophil-to-Lymphocyte Ratio and Index of Microcirculatory Resistance in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

The neutrophil-to-lymphocyte ratio (NLR) has been proved as a reliable inflammatory marker for the atherosclerotic process and as a predictor for clinical outcomes in patients with various cardiovascular diseases. A recent study reported that elevated NLR is associated with impaired myocardial perfusion in patients with ST-segment elevation myocardial infarction (STEMI). We investigated whether NLR is associated with coronary microcirculation as assessed by the index of microcirculatory resistance (IMR) in patients with STEMI who had undergone primary percutaneous coronary intervention (PCI). A total of 123 patients with STEMI who underwent successful primary PCI were enrolled in this study. NLR was obtained on admission, and patients were divided into 3 groups by NLR tertile. IMR was measured using an intracoronary thermodilution-derived method immediately after index PCI. Symptom onset-to-balloon time was significantly longer (p = 0.005), and IMR was significantly higher in the high NLR group than that in the low and intermediate groups (21.94 ± 12.87 vs 23.22 ± 12.73 vs 32.95 ± 20.60, p = 0.003). Furthermore, in multiple linear regression analysis, NLR showed an independent positive correlation with IMR (r = 0.205, p = 0.009). In conclusion, NLR has shown positive correlation with IMR, whereas negative association with infarct-related artery patency in patients with STEMI who underwent primary PCI. Therefore, NLR at admission could reflect myocardial damage and the status of coronary microcirculation in patients with STEMI (ClinicalTrials.gov number, NCT02828137).

Relation of Stature to Outcomes in Korean Patients Undergoing Primary Percutaneous Coronary Intervention for Acute ST-Elevation Myocardial Infarction (from the INTERSTELLAR Registry)

Although epidemiologic studies have shown the impact of height on occurrence and/or prognosis of cardiovascular diseases, the underlying mechanism is unclear. In addition, the relation in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) remains unknown. We sought to assess the influence of height on outcomes of patients with acute STEMI undergoing primary PCI and to provide a pathophysiological explanation. All 1,490 patients with STEMI undergoing primary PCI were analyzed. Major adverse cardiac and cerebrovascular events (MACCE) were defined as all-cause mortality, nonfatal myocardial infarction, nonfatal stroke, and unplanned hospitalization for heart failure (HF). Patients were divided into (1) MACCE (+) versus MACCE (-) and (2) first- to third-tertile groups according to height. MACCE (+) group was shorter than MACCE (-) group (164 ± 8 vs 166 ± 8 cm, p = 0.012). Prognostic impact of short stature was significant in older (≥70 years) male patients even after adjusting for co-morbidities (hazard ratio 0.951, 95% confidence interval 0.912 to 0.991, p = 0.017). The first-tertile group showed the worst MACCE-free survival (p = 0.035), and most cases of MACCE were HF (n, 17 [3%] vs 6 [1%] vs 2 [0%], p = 0.004). On post-PCI echocardiography, left atrial volume and early diastolic mitral velocity to early diastolic mitral annulus velocity ratio showed an inverse relation with height (p <0.001 for all) despite similar left ventricular ejection fraction. In conclusion, short stature is associated with occurrence of HF after primary PCI for STEMI, and its influence is prominent in aged male patients presumably for its correlation with diastolic dysfunction.

A Case of Endovascular Treatment of Severe Graft Limb Kinking after Endovascular Abdominal Aortic Aneurysm Repair

Endovascular aneurysm repair (EVAR) has been recommended as an alternative to open aneurysm repair. The risk of severe perioperative complications is lower than that in open surgical repair; however, late complications are more likely. After EVAR, regular yearly surveillance by duplex ultrasonography or computed tomography is recommended. We report the case of a 67-year-old man with a severely kinked left iliac branch of the stent graft 10 years after EVAR. He had not undergone regular follow-up during the last 4 years. We realigned the endograft kink by percutaneous transluminal angioplasty.

Prognostic Value of Elevated Homocysteine Levels in Korean Patients with Coronary Artery Disease: A Propensity Score Matched Analysis

BACKGROUND AND OBJECTIVES

We sought to determine whether an elevated homocysteine (Hcy) level is associated with a worse prognosis in Korean patients with coronary artery disease (CAD).

SUBJECTS AND METHODS

A total of 5839 patients (60.4% male, mean age 61.3±11.2 years) with CAD were enrolled from 2000 to 2010 at Gangnam Severance Hospital. CAD was diagnosed by invasive coronary angiography. Laboratory values including Hcy level were obtained on the day of coronary angiography and analyses were performed shortly after sampling. Patients were divided into two groups according to their Hcy levels. Baseline risk factors, coronary angiographic findings, length of follow-up, and composite endpoints including cardiac death (CD) and non-fatal myocardial infarction (NFMI) were recorded. 1:1 propensity score matched analysis was also performed.

RESULTS

Over a mean follow-up period of 4.4±2.5 years, there were 132 composite endpoints (75 CD and 57 NFMI) with an event rate of 2.3%. Mean Hcy level was 9.9±4.3 µmol/L (normal Hcy 7.9±1.5 µmol/L and elevated Hcy 13.9±5.1 µmol/L). Kaplan-Meier survival analysis showed an association of elevated Hcy level with worse prognosis (p<0.0001). In addition, a multivariate Cox regression analysis showed an association of elevated Hcy level with worse prognosis for both the entire cohort (hazard ratio [HR] 2.077, 95% confidence interval [CI] 1.467-2.941, p<0.0001) and the propensity score matched cohort (HR 1.982, 95% CI 1.305-3.009, p=0.001).

CONCLUSION

Elevated Hcy level is associated with worse outcomes in Korean patients with CAD.

Numbness after Transradial Cardiac Catheterization: the Results from a Nerve Conduction Study of the Superficial Radial Nerve

Background and Objectives

Numbness on the hand occurs infrequently after a transradial cardiac catheterization (TRC). The symptom resembles that of neuropathy. We, therefore, investigated the prevalence, the predicting factors and the presence of neurological abnormalities of numbness, using a nerve conduction study (NCS).

Subjects and Methods

From April to December 2013, all patients who underwent a TRC were prospectively enrolled. From among these, the patients who experienced numbness on the ipsilateral hand were instructed to describe their symptoms using a visual analogue scale; subsequently, NCSs were performed on these patients.

Results

Of the total 479 patients in the study sample, numbness occurred in nine (1.8%) following the procedure. The NCS was performed for eight out of the nine patients, four (50%) of which had an abnormal NCS result at the superficial radial nerve. A larger sheath and history of myocardial infarction (p=0.14 and 0.08 respectively) tended towards the occurrence of numbness; however, only the use of size 7 French sheaths was an independent predictor for the occurrence of numbness (odds ratio: 5.50, 95% confidence interval: 1.06-28.58, p=0.042). The symptoms disappeared for all patients but one, within four months.

Conclusion

A transient injury of the superficial radial nerve could be one reason for numbness after a TRC. A large sheath size was an independent predictor of numbness; therefore, large sized sheaths should be used with caution when performing a TRC.

Left ventricular end diastolic pressure for detection of intracoronary ergonovine-induced myocardial ischemia

BACKGROUND

Recent consensus on variant angina defines significant spasm as total or subtotal occlusion of a coronary artery. However, the clinical significance of "less-than-subtotal" spasm needs to be reappraised, especially if the coronary spasm is combined with chest pain. Therefore, we evaluated the feasibility of left ventricular end diastolic pressure (LVEDP) as a tool to detect myocardial ischemia during ergonovine provocation testing.

METHODS

After achieving two access sites, 29 patients underwent successful LVEDP monitoring using 5-Fr pigtail catheters during ergonovine provocation tests. Patients were divided into two groups based on the occurrence of anginal symptoms.

RESULTS

Of the 29 patients, 16 (55 %) patients had anginal symptoms. LVEDP was significantly increased in the symptomatic group compared with the nonsymptomatic group (∆LVEDP 5.6 ± 4.2 vs. 1.2 ± 2.0 mmHg, p = 0.002). However, of the 16 patients with anginal symptoms, positive provocation test results were confirmed in only six patients (38 %) as per the traditional standard (> 90 % inducible spasm of the epicardial coronary artery).

CONCLUSION

Compared with the traditional standard, LVEDP may have advantages in terms of elucidating anginal symptoms in patients suspected of having coronary vasospasm when performing ergonovine provocation tests.

Impact of final kissing balloon inflation after simple stent implantation for the treatment of non-left main true coronary bifurcation lesions in patients with acute coronary syndrome

OBJECTIVES

We sought to evaluate the impact of final kissing balloon inflation (FKBI) after simple stent implantation for the treatment of non-left main true coronary bifurcation lesions in patients with acute coronary syndrome (ACS).

BACKGROUND

Whether FKBI should be mandatory after simple stent implantation for the treatment of coronary bifurcation lesion is controversial. Besides, ACS patients who have undergone bifurcation percutaneous coronary intervention with simple stent implantation may experience worse prognosis compared to stable angina pectoris patients.

METHODS

Two hundred and fifty one eligible patients (67.7% male, mean age 61.7 ± 10.4 years) were enrolled. The study population was divided into two groups according to the performance of FKBI. The primary end points were major adverse cardiac event (MACE); target lesion revascularization (TLR), non-fatal myocardial infarction (MI) and cardiac death during the follow-up period.

RESULTS

Over a mean follow-up period of 3.0 ± 1.9 years, there were 29 MACEs (10 TLR, 6 non-fatal MI, and 13 cardiac deaths), representing an event rate of 11.6%. Kaplan-Meier survival analysis revealed that FBKI group had favorable outcome compared to non-FKBI group with regard to hard events (p = 0.010) as well as composite MACEs (p = 0.008). In multivariable analysis, FKBI was a significant predictor of composite MACEs [hazard ratio 0.398 (95% confidence interval 0.190-0.836, p = 0.015)] and hard events [hazard ratio 0.325 (95% confidence interval 0.130-0.811, p = 0.016)].

CONCLUSIONS

In terms of prognosis, performing FKBI after simple stent implantation for the treatment of non-left main true coronary bifurcation lesions may be mandatory in ACS patients.

Multidetector computed tomography for the evaluation of coronary artery disease; the diagnostic accuracy in calcified coronary arteries, comparing with IVUS imaging

PURPOSE

Contrast enhanced multidetector computed tomography (MDCT) has been used as an alternative to coronary angiography for the assessment of coronary artery disease in the patient of the intermediate risk group. However, coronary calcium is a known limiting factor for MDCT evaluation. We investigated the diagnostic accuracy of 64-channel MDCT with each coronary artery calcium score (CACS) by compared with intravascular ultrasound (IVUS) imaging.

MATERIALS AND METHODS

A total of 54 symptomatic patients with intermediate-risk (10 females, mean age 59.9±6.9 years, Framingham point scores 9-20) with 162 sites who had a culprit lesion on 64-channel MDCT before performing coronary angiography with IVUS were enrolled. Patients were divided into 4 subgroups depending on CACS: 0, 1-99, 100-399, and >400. Lesion length, external elastic membrane (EEM) cross sectional area (CSA), minimal luminal area, and plaque area were measured and compared between IVUS and MDCT.

RESULTS

The correlation coefficients for the measurements of the EEM CSA, lumen CSA, and plaque area were r=0.514, r=0.837, and r=0.578, respectively. Furthermore, there were close correlation of plaque area between four subgroups of CACS (r=0.671, r=0.623, r=0.562, r=0.571, respectively).

CONCLUSION

Despite the increase in CACS, the geometric analysis of coronary arteries using with 64-channel MDCT was comparable with IVUS in symptomatic patient of the intermediate risk group.

Successful rescue of early graft failure in pediatric patients using T-cell-depleted haploidentical hematopoietic SCT

Graft failure (GF) is a significant complication after allogeneic hematopoietic stem cell transplantation (HCT) and is associated with a high mortality rate. We performed re-transplantation using haploidentical-related donors to rescue children with early GF. Between 2008 and 2013, 10 patients received re-transplantation from haploidentical family donors. The median age at HCT was 13.5 years and the median time between transplantations was 52.5 days. Conditioning regimen with fludarabine and CY was used in seven patients, and TBI was added in three patients. All 10 patients received T-cell-depleted grafts using CD3 or CD3/CD19 MoAb. The median numbers of CD34(+) and CD3(+) cells were 5.52 × 10(6)/kg and 1.08 × 10(6)/kg, respectively. For GVHD prophylaxis, mycophenolate mofetil (MMF) and tacrolimus or MMF and CYA were used. All 10 patients achieved a sustained neutrophil engraftment and maintained a complete donor chimerism at the time of analysis (median 23 months, range 6-62 months). Nine of 10 patients were alive, and one patient with moyamoya disease with AML died of encephalopathy 7 months post transplant. This study suggests that fludarabine- and CY-based conditioning with T-cell-depleted haploidentical HCT is a feasible option to rescue pediatric patients with primary GF.