Objectives This study sought to establish a model for grading lesion difficulty in interventional chronic total occlusion (CTO) treatment. Background Owing to uncertainty of success of the procedure ...and difficulties in selecting suitable cases for treatment, performance of interventional CTO remains infrequent. Methods Data from 494 native CTO lesions were analyzed. To eliminate operator bias, the objective parameter of successful guidewire crossing within 30 min was set as an end point, instead of actual procedural success. All observations were randomly assigned to a derivation set and a validation set at a 2:1 ratio. The J-CTO (Multicenter CTO Registry of Japan) score was determined by assigning 1 point for each independent predictor of this end point and summing all points accrued. This value was then used to develop a model stratifying all lesions into 4 difficulty groups: easy (J-CTO score of 0), intermediate (score of 1), difficult (score of 2), and very difficult (score of ≥3). Results The set end point was achieved in 48.2% of lesions. Independent predictors included calcification, bending, blunt stump, occlusion length >20 mm, and previously failed lesion. Easy, intermediate, difficult, and very difficult groups, stratified by J-CTO score, demonstrated stepwise, proportioned, and highly reproducible differences in probability of successful guidewire crossing within 30 min (87.7%, 67.1%, 42.4%, and 10.0% in the derivation set and 92.3%, 58.3%, 34.8%, and 22.2% in the validation set, respectively). Areas under receiver-operator characteristic curves were comparable (derivation: 0.82 vs. validation: 0.76). Conclusions This model predicted the probability of successful guidewire crossing within 30 min very well and can be applied for difficulty grading.
Abstract Background We sought to clarify the impact of final kissing inflation (FKI) after single stenting of bifurcation lesions on vessel healing. Methods From the J-REVERSE registry enrolling 303 ...bifurcation lesions treated with provisional single stenting using sirolimus- (SES) or everolimus-eluting stent (EES), 65 lesions treated with ( n = 30) and without ( n = 35) FKI underwent 9-month follow-up optical coherence tomography. Average stent eccentricity index (SEI: minimum/maximum stent diameter) and neointimal unevenness score (NUS: maximum/average neointimal thickness of the same cross-section) for the proximal, bifurcation, and distal segments were compared between FKI and non-FKI groups. Results At the proximal segment, the FKI group demonstrated significantly larger average stent area with greater asymmetric stent expansion, and average lumen area remained significantly larger at 9-month follow-up despite a tendency toward greater neointimal proliferation. Jailed strut and thrombus incidence were also significantly lower at the side branch orifice, and NUS was significantly smaller at the bifurcation and proximal segments in the FKI group. Conclusions Nine months after SES and EES treatment of bifurcation lesions, FKI reduced proximal-segment luminal narrowing. Considering its homogeneous neointimal distribution and fewer jailed struts, FKI may be beneficial for treating bifurcation lesions.
To investigate the reproducibility of imaging the foveal microstructures of healthy eyes with 3 spectral domain optical coherence tomography (SD-OCT) machines: Cirrus (Carl Zeiss Meditec Inc.), ...Spectralis (Heidelberg Engineering), and Topcon (Topcon 3D OCT-1000 Mark II).
Cross-sectional, prospective, noninterventional study.
Images were obtained for 50 eyes of 50 healthy undilated volunteers without ocular pathology in a clinical setting.
The fovea of all subjects was imaged using Cirrus, Spectralis, and Topcon.
Among the 4 hyperreflective bands in the outer subfovea on SD-OCT imaging, the innermost band (external limiting membrane ELM band), the second innermost band (second band), and the third innermost band (third band) were classified as "continuous," "disrupted," or "none" by 2 independent raters. Weighted κ-coefficient analysis and/or Fisher exact test were used to compare interrater, intermachine, and intramachine agreement measurements. The sensitivity of each machine was also evaluated.
The group of 50 subjects consisted of 22 men and 28 women, with an average age of 31.4 years (range, 21-52 years). Interrater agreement for 3 bands was high (κ = 0.876, 0.738, and 0.774) with Cirrus, Spectralis, and Topcon, respectively. The sensitivity of each machine was high for the ELM band (0.92, 0.98, and 0.96), the second band (all 1.00), and the third band (0.96, 0.94, and 0.88) with Cirrus, Spectralis, and Topcon, respectively. The sensitivity of the third band was significantly lower than the second band with Topcon (Fisher exact test, P = 0.027), but the difference was not significant with the other machines. Intermachine agreement was fair to moderate for the third band (κ = 0.65, 0.512, and 0.464) and for all bands (κ = 0.531, 0.369, and 0.362) between Cirrus-Spectralis, Spectralis-Topcon, and Topcon-Cirrus, respectively; however, it was not significant for ELM band (κ = -0.027) between Spectralis-Topcon.
In healthy adults with normal vision, there was almost perfect reproducibility between raters for foveal microstructural images acquired with the Cirrus, Spectralis, and Topcon devices. The machines have good sensitivity to image foveal microstructures, and the sensitivity does not differ significantly among machines; however, they are not necessarily identical or interchangeable for imaging certain structures.
Abstract Background We aimed to clarify the differences in vessel healing after stenting of bifurcation lesions using sirolimus-eluting stents (SESs) or everolimus-eluting stents (EESs). Methods J ...apanese R egistry Study in Comparison Between Ever olimus-Eluting Stent and S irolimus- E luting Stent for the Bifurcation Lesion (J-REVERSE) is a prospective multicentre registry of 303 bifurcation lesions that were treated with provisional SES or EES with or without final kissing inflation. The first 115 lesions at selected study sites were predefined for inclusion in the optical coherence tomography (OCT) substudy, and 9-month follow-up OCT was conducted in 64 lesions (SES, n = 18; EES, n = 46). In addition to standard OCT parameters, stent eccentricity index (SEI; minimum divided by the maximum stent diameter), neointimal unevenness score (NUS; maximum neointimal thickness in the cross-section CS divided by the average neointimal thickness NIT of the same CS; uniformity of the neointima suppression) were averaged for each segment (proximal, bifurcation, and distal segments). Results Overall, the average stent and luminal area, NIT, and frequency of uncovered struts were similar. The frequency of malapposed struts and SEI were significantly lower in the EES group than in the SES group. The EES group had a significantly smaller NUS in the proximal and distal segments. Conclusions EESs offer homogeneous vessel healing with less malapposition in the treatment of bifurcation lesions.
Iron deficiency anemia (IDA) can cause left ventricular (LV) dysfunction, causing heart failure. A 48-year-old woman with severe IDA developed congestive heart failure that was properly diagnosed, ...managed, and followed with multiple imaging modalities to explore potential mechanisms, highlighting the reversibility of LV function in unique cardiomyopathy. (Level of Difficulty: Intermediate.)
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Iron deficiency anemia (IDA) can cause left ventricular (LV) dysfunction, causing heart failure. A 48-year-old woman with severe IDA developed congestive…
We report a case of sudden-onset pulmonary edema due to failure of a bioprosthetic mitral valve. Gross inspection revealed a leaflet tear at a stent post without calcification or pannus formation and ...no evidence of sutures. This case highlights the mechanical failure of a bioprosthetic mitral valve associated with missing sutures. (Level of Difficulty: Intermediate.)
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We report a case of sudden-onset pulmonary edema due to failure of a bioprosthetic mitral valve. Gross inspection revealed a leaflet tear at a stent…
Objectives Our aim was to investigate in-hospital outcomes of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) using contemporary techniques. Background Despite its ...increasing popularity and technical complexity, clinical outcomes of PCI for CTO using contemporary techniques have not been adequately evaluated. Methods The J-CTO registry (multicenter CTO registry in Japan) is a large scale, multicenter registry enrolling consecutive patients undergoing PCI for CTO from 12 Japanese centers. In-hospital clinical outcomes were evaluated in 498 patients with 528 CTO lesions. Results Multiple wiring strategies were frequently attempted (parallel wiring 31% and retrograde approach 25%) with relatively long guidewire manipulation time (median 30 min). Utilizing these complex strategies, high procedural success rates (88.6% in the first attempt cases and 68.5% in the retry cases) were accomplished. In-hospital adverse event rates were strikingly low (cardiac death 0.2%, Q-wave myocardial infarction 0.2%, and stroke 0%). Potential disadvantages of these procedures, including a large amount of contrast volume (median 293 ml) and long fluoroscopic time (median 45 min), were not associated with serious clinical sequelae (contrast induced nephropathy 1.2% and radiation dermatitis 0%). Although coronary perforations were documented frequently by angiography (antegrade 7.2% and retrograde 13.6%), clinically significant perforation resulting in cardiac tamponade was rare (0.4%). Conclusions Most CTO lesions can be safely and successfully treated with PCI utilizing contemporary advanced techniques. Invasiveness and potential risks of these strategies, which have been the greatest concerns of CTO treatment, may be acceptable in the majority of cases considering the actual incidences of related adverse events and the procedural success rates.
Upfront Thrombus Aspiration in Primary Coronary Intervention for Patients With ST-Segment Elevation Acute Myocardial Infarction: Report of the VAMPIRE (VAcuuM asPIration thrombus REmoval) Trial Yuji ...Ikari, Masami Sakurada, Ken Kozuma, Shigeo Kawano, Takaaki Katsuki, Kazuo Kimura, Takahiko Suzuki, Takehiro Yamashita, Akinori Takizawa, Kazuo Misumi, Hideki Hashimoto, Takaaki Isshiki, for the VAMPIRE Investigators A prospective multicenter randomized trial was designed to evaluate safety and efficacy of upfront thrombus aspiration during primary percutaneous coronary intervention (PCI). Patients with ST-segment elevation acute myocardial infarction (n = 355) were randomized to primary PCI with or without thrombectomy using Nipro's (Osaka, Japan) TransVascular Aspiration Catheter. There was a trend toward lower incidence of slow flow (primary end point) in patients with thrombectomy. Patients presenting >6 h after symptoms onset experienced significant benefits. This study suggests the safety of primary PCI with upfront thrombectomy and indicates a potential benefit of such strategy, particularly in patients who are late for reperfusion therapy.
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