Background A previous coronary computed tomography (CT) angiographic study failed to discriminate optical coherence tomography-defined intact fibrous cap culprit lesions (IFC group) from those with ...ruptured fibrous caps (RFC group) in patients with coronary artery disease. This study aimed to evaluate the diagnostic efficacy of preprocedural coronary CT imaging in identifying subsequently performed optical coherence tomography-defined plaque rupture or erosion at culprit lesions in patients with non-ST-segment-elevation acute myocardial infarction. Methods and Results This study used data from 2 recently published studies that tested the hypothesis that coronary CT angiography (CCTA) before percutaneous coronary intervention may provide diagnostic information on the high-risk atherosclerotic burden in patients with non-ST-segment-elevation acute myocardial infarction. In the analysis of 186 patients, optical coherence tomography identified 106 RFC plaques and 80 IFC plaques as the culprit lesions. On CT, the prevalence of low-attenuation plaque, positive remodeling, napkin-ring sign, and spotty calcification were all significantly lower in the IFC group. The culprit vessel pericoronary adipose tissue inflammation and coronary artery calcium scores were significantly lower in the IFC group than in the RFC group. The absence of low-attenuation plaque, napkin-ring sign, zero coronary artery calcium, and low pericoronary adipose tissue inflammation were independent predictors of IFC. When stratified into 5 subgroups according to the number of these 4 CT factors, the prevalence of IFC was 8.3%, 20.8%, 44.6%, 75.6%, and 100% (
<0.001), respectively. Conclusions Preprocedural comprehensive coronary CT imaging, including coronary artery calcium and pericoronary adipose tissue inflammation assessment, can accurately and noninvasively identify optical coherence tomography-defined IFC or RFC culprit lesions.
Background
Electrical connections between ipsilateral pulmonary veins (PVs) have been reported histologically and electrophysiologically. This study investigated the impact of electrical connections ...between ipsilateral PVs on PV isolation using second‐generation cryoballoons (CB2‐PVI).
Methods
Five hundred eleven atrial fibrillation patients, without any PV anomalies, underwent CB2‐PVI using one 28‐mm balloon and a single 3‐minute freeze strategy without any bonus applications.
Results
Overall, 1966 of 2044 (96.2%) PVs were isolated exclusively by using 28‐mm cryoballoons. Among them, 13 left superior PV (LSPVs) and two right superior PV were not persistently isolated by the first application despite a complete vein occlusion, but were isolated by subsequent applications targeting other ipsilateral PVs. Among the 13 LSPVs, six were transiently isolated by 87 (62‐146) second time‐to‐isolation LSPV applications, but were immediately reconnected after the application. The nadir balloon temperature during the LSPV application was similar between the 13 LSPVs not isolated by the LSPV application but were not so by subsequent left inferior PV (LIPV) applications and the 488 LSPVs persistently isolated by LSPV applications (−49.4℃ ± 4.3℃ vs −50.8℃ ± 5.1℃; P = 0.328). In 59 patients in whom the initial LSPV application failed despite a complete occlusion, LIPVs were targeted for the second applications in 31 patients, and both the LSPV and LIPV were simultaneously isolated in 13 of 31 (41.9%).
Conclusions
Electrical connections between ipsilateral PVs could have an impact on the CB2‐PVI procedure. When the vein isolation failed despite a complete occlusion, especially for left ipsilateral PVs, it was reasonable to target the other ipsilateral PV instead of repeatedly targeting the same vein.
Background Impaired global coronary flow reserve (g-CFR) is related to worse outcomes. Inflammation has been postulated to play a role in atherosclerosis. This study aimed to evaluate the ...relationship between pre-procedural pericoronary adipose tissue inflammation and g-CFR after the urgent percutaneous coronary intervention in patients with first non-ST-segment-elevation acute coronary syndrome. Methods and Results Phase-contrast cine-magnetic resonance imaging was performed to obtain g-CFR by quantifying coronary sinus flow at 1 month after percutaneous coronary intervention in a total of 116 first non-ST-segment-elevation acute coronary syndrome patients who underwent pre-percutaneous coronary intervention computed tomography angiography. On proximal 40-mm segments of 3 major coronary vessels on computed tomography angiography, pericoronary adipose tissue attenuation was assessed by the crude analysis of mean computed tomography attenuation value. The patients were divided into 2 groups with and without impaired g-CFR divided by the g-CFR value of 1.8. There were significant differences in age, culprit lesion location, N-terminal pro-B-type natriuretic peptide levels, high-sensitivity C-reactive protein (hs-CRP) levels, mean pericoronary adipose tissue attenuation between patients with impaired g-CFR and those without (g-CFR, 1.47 1.16, 1.68 versus 2.66 2.22, 3.28;
<0.001). Multivariable logistic regression analysis revealed that age (odds ratio OR, 1.060; 95% CI, 1.012-1.111,
=0.015) and mean pericoronary adipose tissue attenuation (OR, 1.108; 95% CI, 1.026-1.197,
=0.009) were independent predictors of impaired g-CFR (g-CFR <1.8). Conclusions Mean pericoronary adipose tissue attenuation, a marker of perivascular inflammation, obtained by computed tomography angiography performed before urgent percutaneous coronary intervention, but not hs-CRP, a marker of systemic inflammation was significantly associated with g-CFR at 1-month after revascularization. Our results may suggest the pathophysiological mechanisms linking perivascular inflammation and g-CFR in patients with non-ST-segment-elevation acute coronary syndrome.
The prognostic implications of cardiovascular magnetic resonance imaging (CMR)-derived hyperemic myocardial blood flow (MBF) in patients with ST-elevation myocardial infarction (STEMI) are unknown. ...This study sought to investigate the incremental prognostic value of hyperemic MBF over conventional CMR markers to identify patients with high risk of future incidence of patient-oriented composite outcomes (POCO) and major adverse cardiac events (MACE) after STEMI. A total of 237 patients who presented with STEMI were prospectively enrolled. The CMR protocol included left-ventricular ejection fraction (LVEF), late gadolinium enhancement (LGE) and microvascular obstruction (MVO) measurement, and volumetric MBF assessment. During a median follow-up of 2.6 years, 47 patients experienced POCO (primary outcome) and 21 patients had MACE. In a multivariable model, multivessel disease, LGE, MVO, and hyperemic MBF were independently associated with POCO. Addition of hyperemic MBF to the model consisting of GRACE score, multivessel disease, LVEF, LGE, and MVO significantly improved the predictive efficacy (integrated discrimination improvement 0.020,
p
= 0.021). Patients with low hyperemic MBF had significantly higher incidence of MACE compared to those with high hyperemic MBF in propensity score matching analysis (
p
= 0.018). In conclusion, CMR-derived hyperemic MBF could provide independent and incremental prognostic value over LVEF, LGE, and MVO in patients with STEMI.
Few data are available regarding pulmonary vein (PV) stenosis after second-generation cryoballoon PV isolation (CB2-PVI). Currently, a single short freeze strategy is standard for CB2-PVI owing to ...enhanced cooling effects. This study aimed to evaluate the incidence of PV stenosis after CB2-PVI with the current standard strategy.
Two hundred seventy-six atrial fibrillation patients underwent CB2-PVI using one 28-mm balloon and single 3-minute freeze strategy. If balloon temperatures reached −60 °C or phrenic nerve injury was suspected, freezing was terminated. Enhanced cardiac computed tomography (CT) was obtained before and >3 months after the procedure.
Overall, 1067 of 1101 (96.9%) PVs were isolated with cryoballoons, while the remaining 34 PVs required touch-up ablation. The total application number/patient was 5.1 ± 1.4, and total application time 216 ± 104, 205 ± 77, 186 ± 68, and 246 ± 142 s for the left superior (LSPV), left inferior (LIPV), right superior (RSPV), and right inferior PVs, respectively. Follow-up CT obtained a median of 5.0 3.3–7.0 months post-procedure revealed no PVs with moderate or severe stenosis. Asymptomatic mild stenosis was documented in 16 total (1.4%) PVs (5 LSPVs, 5 LIPVs, and 6 RSPVs), but not in right inferior, left common, right middle, or PVs requiring touch-up ablation. Mild stenosis did not progress during the follow-up. Among the potential factors associated with PV stenosis, longer application times were the sole significant factor associated with mild RSPV stenosis.
In CB2-PVI with the current single short freeze strategy, the risk of PV stenosis is extremely low, and routine follow-up imaging for evaluation seems not to be necessary.
•In current second-generation CB ablation strategy, none of the PVs exhibited moderate or severe PV stenosis.•Asymptomatic mild PV stenosis was detected in 1.4% of the PVs, but not in the RIPV, LCPV, or right middle vein.•None of the mild PV stenosis progressed during the follow-up period.•A longer application time was the sole significant factor associated with the incidence of mild RSPV stenosis.
Sick sinus syndrome (SSS) frequently coexists with atrial fibrillation (AF). The results of AF ablation in patients with SSS have not been fully evaluated. We retrospectively investigated 65 patients ...with paroxysmal AF (PAF) and SSS who underwent AF ablation using either radiofrequency (
n
= 50) or cryoballoon ablation (
n
= 15) in our institute. Forty-nine (75.4%) patients had a median of 5.6 (4.8–6.0) s of documented sinus pauses prior to the procedure (42 patients on antiarrhythmic drugs), and were observed when AF terminated in 47 patients. Successful pulmonary vein isolation was achieved in all, and substrate modification was added in 3 patients. Freedom from recurrent atrial arrhythmias after single procedures was 58.7, 45.2, and 38.9% at 1, 2, and 3 years after the initial procedure. During a 23.4 (11.1–40.7) month median follow-up and after 1.4 ± 0.6 sessions, 80.6% of patients were free from arrhythmia recurrence; however, permanent pacemaker implantations were required in 9 (13.8%) patients at a median of 5.3 (2.9–21.0) months after initial procedures. The average heart rate did not significantly differ before or a median of 2.5 (1.2–5.3) months post-procedure (76.7 ± 17.4 vs. 73.5 ± 14.6 bpm,
p
= 0.90). Multivariate analyses revealed that larger left atrial diameters odds ratio (OR) 1.21, 95% confidential interval (CI) 1.01–1.45,
p
= 0.042 were independent predictor of AF recurrence, and SSS type 1 was the sole predictor of pacemaker implantations (OR 10.30, 95% CI 1.38–76.7,
p
= 0.023), respectively. AF ablation obviated permanent pacemaker implantations in the majority of the patients with SSS and PAF, and SSS type 1 was a sole factor predicting pacemaker implantations.
Baseline cardiac troponin is a strong predictor of major adverse cardiac events (MACE), and the high sensitive assay can provide risk stratification under the 99th percentile values. Currently, ...prognostic benefit of PCI has not been established in patients with stable coronary artery disease (CAD), and the influence on baseline troponin levels is unknown. This study aimed to investigate the impact of PCI on baseline high-sensitivity cardiac troponin-I (hs-cTnI) levels and the association with MACE incidence. For 401 patients with stable CAD who were indicated for PCI, baseline hs-cTnI levels were measured before PCI for two times (the average: pre-PCI hs-cTnI) and 10 months after PCI (post-PCI remote hs-cTnI). Hs-cTnI day-to-day variability was assessed based on the pre-PCI values and patients were divided into three groups (Increase/No change/Decrease group) according to the extent of hs-cTnI change (post-PCI remote hs-cTnI minus pre-PCI hs-cTnI) considering the day-to-day variability. A total of 77 patients were categorized into Decrease group. Although Decrease group had significantly higher pre-PCI hs-cTnI levels compared to the other groups, this group had lowest incidence of MACE (
p
< 0.001). Hs-cTnI changes were independently associated with MACE incidence after adjustment (HR 2.069, 95% CI 1.032–4.006,
p
= 0.041 for Increase group vs. No change group; HR 0.143, 95% CI 0.008–0.680,
p
= 0.009 for Decrease group vs. No change group). Hs-cTnI change following PCI was significantly predicted by pre-PCI hs-cTnI, hs-cTnI variability, the presence of dyslipidemia, multivessel disease, and lesions with chronic total occlusion or low quantitative flow ratio. In conclusion, PCI could lower hs-cTnI levels in a certain subset of patients, in whom prognostic benefit might be expected by the intervention.
Objective
This study aimed to investigate the prevalence and prognostic significance of atherosclerotic aortic plaques (AAPs) or specific AAP types detected by nonobstructive angioscopy (NOA) in ...patients who underwent percutaneous coronary intervention (PCI).
Background
Although recent studies have reported the presence of various patterns of AAPs, identified by NOA, the clinical significance of the presence of AAPs remains elusive.
Methods
In this retrospective, multicenter cohort study, a total of 167 patients who underwent PCI and intra‐aortic scans with NOA were studied. The association between AAPs and the incidence of major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, stroke, and clinically driven unplanned revascularizations, was assessed.
Results
AAPs were detected in 126 patients (75%) who underwent NOA. MACEs occurred in 28 (17%) patients during the follow‐up (median 2.9 years range 2.1–3.8). Among all types of AAPs, only puff‐chandelier rupture (PCR) showed a significant difference in frequency between patients with and those without MACEs: 21 (75%) and 49 (35%), respectively (p < .001). Multivariable Cox proportional hazard analysis revealed that PCR (hazard ratio HR 3.73, 95% confidence interval CI 1.57–8.87, p = .004) and chronic kidney disease (HR 2.97, 95% CI 1.37–6.44, p = .010) were independent predictors of MACEs. Kaplan–Meier analysis revealed that PCR was significantly associated with more frequent MACEs.
Conclusion
The detection of PCR in the aorta using NOA was significantly associated with an increased risk of subsequent adverse events after PCI.
•Outcome after CB and RF PVI was comparable in the patients with a LCPV.•The ovality index and configuration of LCPV might predict the procedural difficulty.•The total procedure time was ...significantly shorter with the CB than RF ablation.
Adaptability of cryoballoons to anatomic pulmonary vein (PV) variations is limited due to the fixed geometrical shape, and use for left common PVs (LCPVs) is controversial. We compared the procedural and clinical outcomes in patients with LCPVs after cryoballoon and radiofrequency ablation, and explored the morphological parameters associated with procedural difficulty in LCPV isolations using cryoballoons.
Eighty-nine consecutive atrial fibrillation patients with LCPVs undergoing PV isolation using either 28-mm second-generation cryoballoons (n=30) or irrigated-tip catheters (n=59) were included. The patient characteristics except for the left atrial diameter (p=0.05) or morphological parameters obtained from cardiac computed tomography were similar between the two groups. The number needed to disconnect the LCPVs (NND) in the cryoballoon-group was ≦3 applications in 22 patients, but ≧4 in the remaining 8, including 1 requiring touch-up ablation. The PV isolation procedure time was significantly shorter in the cryoballoon-group than radiofrequency-group (43.0±19.5min vs. 68.2±31.4min, p<0.001), whereas the single procedure 1-year atrial fibrillation freedom was similar between the groups (74% vs. 67%, p=0.73). A multivariate logistic regression analysis revealed that the ovality index in the cryoballoon-group (odds ratio=1.474; 95%confidence interval=1.020–2.128; p=0.039) and orientation difference between the LCPV and lower branch in the frontal plane (odds ratio=1.071; 95%confidence interval=1.008–1.137; p=0.026) were independent predictors of an NND≧4. The incidence of LCPV reconnections was similar between the cryoballoon- and radiofrequency-groups during the second procedure (50.0% vs. 58.3%, p=0.73).
Cryoballoon ablation was similarly as effective as radiofrequency ablation in patients with LCPVs, and morphological evaluations aided in predicting procedural difficulty in LCPV isolations.
Objective: The use of laparoscopic surgery for rectal disease is expected to provide good cosmetic benefits for patients postoperatively. However, this expectation is significantly reduced when a ...diverting ileostomy is created. We present a new technique that reduces the size of the skin wound by constructing a diverting ileostomy in the umbilicus. This procedure, diverting umbilical ileostomy (umbistoma) does not require special tools for its construction and closure. Methods: Twenty-nine patients underwent treatment with umbilical diverting stoma, including five women and 24 men, with a mean age of 70 years (range: 40-88 years). At the time of ostomy closure, a new umbilicus was formed by subcutaneously suturing the wound to the fascia. In addition, we did not close the new umbilical upper and lower spaces, so as to allow open drainage of the healing wound. Results: All procedures were completed successfully without any perioperative complications. Conclusions: Our findings suggest that the umbilical diverting stoma could provide improved safety and cosmetic advantages in laparoscopic rectal resection.
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