Background:The risks of ventricular fibrillation (Vfib) associated with frequency-domain optical coherence tomography (OCT)/optical frequency domain imaging (OFDI) remain undetermined.Methods and ...Results:We retrospectively studied the occurrence of Vfib during OCT/OFDI for unselected indications. The frequency of Vfib and patient and procedural characteristics were investigated. A total of 4,467 OCT/OFDI pullback examinations were performed in 1,754 patients (median of 2.0 2.0–3.0 pullbacks for 1.0 1.0–1.3 vessels). OCT/OFDI was performed during PCI in 899 patients (51.3%). The contrast injection volume per pullback was 14.4 (11.7–17.2) mL with a flow rate of 3.4 (3.2–3.5) mL/s. Vfib occurred in 31 pullbacks (0.69%) in 30 patients (1.7%). No cases of Vfib occurred when using low-molecular-weight dextran. On multivariate analysis, contrast volume was the only independent factor for predicting Vfib (odds ratio, 1.080; 95% confidence interval, 1.008–1.158, P=0.029). The best cutoff value of contrast volume for predicting Vfib was 19.2 mL (area under the curve, 0.713, P<0.001; diagnostic accuracy, 87.1%).Conclusions:The present large, single-center registry study indicated that Vfib during OCT/OFDI was rare for unselected indications. Contrast injection volume used to displace blood should be limited to avoid Vfib.
Background:The in vivo lesion morphologies and plaque components of coronary chronic total occlusion (CTO) lesions remain unclear.Methods and Results:We investigated 57 consecutive CTO lesions in 57 ...patients with stable angina pectoris undergoing elective percutaneous coronary intervention with intravascular ultrasound (IVUS) and coronary angioscopy (CAS) examination. All CTO lesions were classified according to the proximal angiographic lumen pattern; tapered-type (T-CTO) and abrupt-type (A-CTO). The differences in the intracoronary images of these lesion types were evaluated according to the location within the CTO segment. A total of 35 lesions (61.4%) were T-CTO. T-CTO lesions had higher frequencies of red thrombi (proximal 71.4%; middle 74.3%; distal 31.4%; P<0.001) and bright-yellow plaques (yellow-grade 2–3) (48.6%; 74.3%; 2.9%; P<0.001) at the proximal or middle than at the distal subsegment; A-CTO lesions showed no significant differences among the 3 sub-segments. At the middle subsegment, T-CTO lesions showed higher frequencies of positive remodeling (51.4% vs. 18.2%, P=0.01) and bright-yellow plaques (74.3% vs. 13.6%, P<0.001) compared with A-CTO lesions. Multivariate analysis identified bright-yellow plaque as an independent predictor (odds ratio, 7.25; 95% confidence interval, 1.25–42.04; P=0.03) of the occurrence of periprocedural myocardial necrosis.Conclusions:The combination of IVUS and CAS analysis may be useful for identifying lesion morphology and plaque components, which may help clarify the pathogenetic mechanism of CTO lesions.
The relationship of layered plaque detected by optical coherence tomography (OCT) with coronary inflammation and coronary flow reserve (CFR) remains elusive. We aimed to investigate the association ...of OCT-defined layered plaque with pericoronary adipose tissue (PCAT) inflammation assessed by coronary computed tomography angiography (CCTA) and global (G)-CFR assessed by cardiac magnetic resonance imaging (CMR) in patients with acute coronary syndrome (ACS).
We retrospectively investigated 88 patients with first ACS who underwent preprocedural CCTA, OCT imaging of the culprit lesion prior to primary/urgent percutaneous coronary intervention (PCI), and postprocedural CMR. All patients were divided into two groups according to the presence and absence of OCT-defined layered plaque at the culprit lesion. Coronary inflammation was assessed by the mean value of PCAT attenuation (-190 to -30 HU) of the three major coronary vessels. G-CFR was obtained by quantifying absolute coronary sinus flow at rest and during maximum hyperemia. CCTA and CMR findings were compared between the groups.
In a total of 88 patients, layered plaque was detected in 51 patients (58.0%). The patients with layered plaque had higher three-vessel-PCAT attenuation value (-68.58 ± 6.41 vs. -71.60 ± 5.21 HU, P = 0.021) and culprit vessel-PCAT attenuation value (-67.69 ± 7.76 vs. -72.07 ± 6.57 HU, P = 0.007) than those with non-layered plaque. The patients with layered plaque had lower G-CFR value (median, 2.26 interquartile range, 1.78, 2.89 vs. 3.06 2.41, 3.90, P = 0.003) than those with non-layered plaque.
The presence of OCT-defined layered plaque at the culprit lesion was associated with high PCAT attenuation and low G-CFR after primary/urgent PCI in patients with ACS. OCT assessment of culprit plaque morphology and detection of layered plaque may help identify increased pericoronary inflammation and impaired CFR, potentially providing the risk stratification in patients with ACS and residual microvascular dysfunction after PCI.
Background:Differences between resting full-cycle ratio (RFR) and diastolic pressure ratio (dPR) have not been sufficiently discussed. This study aimed to investigate if there is a difference in ...diagnostic performance between RFR and dPR for the functional lesion assessment and to assess if there are specific characteristics for discordant revascularization decision-makings between RFR and dPR.Methods and Results:A total of 936 intermediate lesions in 776 patients who underwent measurements of fractional flow reserve (FFR), coronary flow reserve (CFR), and the index of microcirculatory resistance (IMR) were retrospectively studied. Physiological indices were measured from anonymized pressure recordings at an independent core laboratory. Both RFR and dPR measures were highly correlated (r=0.997, P<0.001), with equivalent diagnostic performance relative to FFR-based decision-makings measured by using a dichotomous threshold of 0.80 (accuracy, 79.7% vs. 80.1%, respectively, P=0.960). The rate of diagnostic discordance was 4.7% (44/936), with no RFR−/dPR+ lesions observed. An overall significant difference in FFR and CFR values were detected among RFR/dPR-based classifications. The prevalence of positive studies was significantly higher for RFR than dPR (54.3% vs. 49.6%, respectively, P=0.047) when using the cut-off value of 0.89.Conclusions:Both RFR and dPR were highly correlated, but the prevalence of positive studies was significantly different. The revascularization rate may differ significantly according to the resting index used.
Background Plaque erosion is responsible for 25% to 40% of patients with acute coronary syndromes (ACS). Recent studies suggest that anti-thrombotic therapy without stenting may be an option for this ...subset of patients. Currently, however, an invasive procedure is required to make a diagnosis of plaque erosion. The aim of this study was to identify clinical or laboratory predictors of plaque erosion in patients with ACS to enable a diagnosis of erosion without additional invasive procedures. Methods and Results Patients with ACS who underwent optical coherence tomography imaging were selected from 11 institutions in 6 countries. The patients were classified into plaque rupture, plaque erosion, or calcified plaque, and predictors were identified using multivariable logistic modeling. Among 1241 patients with ACS, 477 (38.4%) patients were found to have plaque erosion. Plaque erosion was more frequent in non-ST-segment elevation-ACS than in ST-segment-elevation myocardial infarction (47.9% versus 29.8%,
=0.0002). Multivariable logistic regression models showed 5 independent parameters associated with plaque erosion: age <68 years, anterior ischemia, no diabetes mellitus, hemoglobin >15.0 g/dL, and normal renal function. When all 5 parameters are present in a patient with non-ST-segment elevation-ACS, the probability of plaque erosion increased to 73.1%. Conclusions Clinical and laboratory parameters associated with plaque erosion are explored in this retrospective registry study. These parameters may be useful to identify the subset of ACS patients with plaque erosion and guide them to conservative management without invasive procedures. The results of this exploratory analysis need to be confirmed in large scale prospective clinical studies. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03479723.
Diabetes mellitus (DM) is a major risk factor for cardiovascular events. We aimed to investigate the coronary plaque phenotype of diabetic patients who presented with acute coronary syndromes by ...optical coherence tomography.
A total of 322 patients with acute coronary syndromes who underwent preintervention optical coherence tomography imaging of the culprit lesion were included. Culprit plaque characteristics were compared between patients with DM (n=95) and those without DM (n=227). In the subgroup of 250 patients in whom sufficient length of nonculprit region in the culprit vessel was imaged by optical coherence tomography, the characteristics of nonculprit plaques were also evaluated. Patients with DM had a higher prevalence of lipid-rich plaque (58.9% versus 44.9%,
=0.030) and macrophage accumulation (60.0% versus 44.9%,
=0.019) in the culprit lesion compared with patients without DM. The prevalence of plaque rupture (33.7% versus 30.4%,
=0.896) and plaque erosion (21.1% versus 22.0%,
=0.458) was similar. In the nonculprit lesions, the DM group had greater maximal lipid arc (248.9°±83.9° versus 179.9°±58.3°,
=0.006), thinner fibrous cap thickness (103.3±56.2 μm versus 140.7±70.0 μm,
=0.013), and a higher prevalence of thin-cap fibroatheroma (17.2% versus 6.3%,
=0.031), compared with the non-DM group.
Compared with patients without DM, those with DM had more vulnerable features in both culprit and nonculprit lesions, thus indicating a higher level of panvascular instability.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01110538.
Unrecognized myocardial infarction (UMI) is associated with adverse outcomes. This prospective, single-center study elucidated the prevalence and prognostic significance of UMI before elective ...percutaneous coronary intervention (PCI) using delayed-enhancement cardiac magnetic resonance (DE-CMR). We enrolled 236 patients with stable coronary artery disease who underwent DE-CMR before elective PCI. The prevalence of UMI and the association of clinical and CMR-derived variables with major adverse cardiac events (MACE), defined as cardiovascular death, nonfatal MI, hospitalization for congestive heart failure, and unplanned late revascularization, were assessed. Final analysis revealed that 63/213 (29.6%) patients had UMI. Target territory UMI was observed in 38 patients (17.8% of the total cohort, 60.3% of patients with UMI). UMI was significantly associated with sex, diabetes mellitus, left ventricular ejection fraction, SYNTAX score, and fractional flow reserve in the target vessels. During follow-up (median, 23 months), MACE occurred in 17 (27.0%) patients with UMI and 17 (11.3%) without UMI (P = 0.001). Multivariable modeling revealed that UMI (hazard ratio: 2.18, 95%CI, 1.10-4.33, P = 0.001) was an independent predictor of MACE. Kaplan-Meier analysis indicated that the presence of UMI was significantly associated with a higher incidence of MACE. UMI was independently associated with a greater risk of MACE after successful PCI.
Previous studies reported the association between inflammation and atrial fibrillation (AF). Pericoronary adipose tissue (PCAT) attenuation, PCATA, on cardiac CT angiography (CTA) reflects ...pericoronary inflammation. We hypothesized that the PCATA predicts AF recurrence after cryoballoon ablation (CBA) for paroxysmal and persistent AF.
We studied 364 patients (median age, 65 years) with persistent (
= 41) and paroxysmal (
= 323) AF undergoing successful first-session second-generation CBA with pre-ablation cardiac CTA. Three-vessel (3V)-PCATA was defined as the mean CT attenuation value of PCAT of all three major coronary arteries. Predictors of AF recurrence during follow-up were evaluated.
AF recurrence after the 3-month blanking period was detected in 90 patients (24.7%) during the median follow-up of 26 (interquartile range, 19-42) months. AF recurrence was associated with prior stroke and statin use, NT-proBNP and high-sensitivity cardiac troponin-I levels, left ventricular dimension, left atrial volume index (LAVI), 3V-PCATA, and early AF recurrence during the blanking period. On multivariable Cox proportional hazard analysis, prior stroke (hazard ratio HR, 2.208, 95% confidence interval CI, 1.166-4.180,
= 0.015), LAVI (HR, 1.030, 95% CI, 1.010-1.051,
= 0.003), 3V-PCATA (HR, 1.034, 95% CI, 1.001-1.069,
= 0.046), and early AF recurrence (HR, 2.858, 95% CI, 1.855-4.405,
< 0.001) remained statistically significant.
Pre-ablation CTA-derived 3V-PCATA, representing pericoronary inflammation, was an independent predictor of recurrence after first-session AF ablation using a second-generation cryoballoon.
Assessment of 3V-PCATA may identify patients at high risk of AF recurrence after CBA for AF.
Pericoronary adipose tissue attenuation expressed by fat attenuation index (FAI) on coronary CT angiography (CCTA) reflects pericoronary inflammation and is associated with cardiac mortality.
The aim ...of this study was to define the sub-phenotypes of coronary CCTA-defined plaque and whole vessel quantification by unsupervised machine learning (ML) and its prognostic impact when combined with pericoronary inflammation.
A total of 220 left anterior descending arteries (LAD) with intermediate stenosis who underwent fractional flow reserve (FFR) measurement and CCTA were studied. After removal of outcome and FAI data, the phenotype heterogeneity of CCTA-defined plaque and whole vessel quantification was investigated by unsupervised hierarchical clustering analysis based on Ward's method. Detailed features of CCTA findings were assessed according to the clusters (CS1 and CS2). Major adverse cardiac events (MACE)-free survivals were assessed according to the stratifications by FAI and the clusters.
Compared with CS2 (n = 119), CS1 (n = 101) were characterized by greater vessel size, increased plaque volume, and high-risk plaque features. FAI was significantly higher in CS1. ROC analyses revealed that best cut-off value of FAI to predict MACE was −73.1. Kaplan-Meier analysis revealed that lesions with FAI ≥ -73.1 had a significantly higher risk of MACE. Multivariate Cox proportional hazards regression analysis revealed that age, FAI ≥ -73.1, and the clusters were independent predictors of MACE.
Unsupervised hierarchical clustering analysis revealed two distinct CCTA-defined subgroups and discriminated by high-risk plaque features and increased FAI. The risk of MACE differs significantly according to the increased FAI and ML-defined clusters.
•This study applied unsupervised machine learning (ML) to define subpopulations with coronary artery disease (CAD).•ML-defined two subgroups were discriminated by high-risk plaque features.•ML-defined two subgroups were discriminated by increased fat attenuation index (FAI).•The risk of major adverse cardiac events differs according to the increased FAI and clusters.
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