Search

Background Successful percutaneous coronary intervention (PCI) of the occluded infarct-related artery (IRA) in latecomers may improve long-term survival mainly by reducing left ventricular remodeling. It is not clear whether inhibition of renin–angiotensin system (RAS) brings additional better clinical outcomes in this specific population subset. Methods Between January 2008 and June 2013, 669 latecomer patients with acute ST-segment elevation myocardial infarction (STEMI) (66.2 ± 12.1 years, 71.0% males) in Korea Acute Myocardial Infarction Registry (KAMIR) who underwent a successful PCI were enrolled. The study population underwent a successful PCI for a totally occluded IRA. They were divided into two groups according to whether they were prescribed RAS inhibitors at the time of discharge: group I (RAS inhibition, n = 556), and group II (no RAS inhibition, n = 113). Results During the one-year follow-up, major adverse cardiac events (MACE), which consist of cardiac death and myocardial infarction, occurred in 71 patients (10.6%). There were significantly reduced incidences of MACE in the group I (hazard ratio = 0.34, 95% confidence interval 0.199–0.588, p = 0.001). In subgroup analyses, RAS inhibition was beneficial in patients with male gender, history of hypertension or diabetes mellitus, and even in patients with left ventricular ejection fraction (LVEF) ≥40%. In the baseline and follow-up echocardiographic data, benefit in changes of LVEF and left ventricular end-systolic volume was noted in group I. Conclusions In latecomers with STEMI, RAS inhibition improved long-term clinical outcomes after a successful PCI, even in patients with low risk who had relatively preserved LVEF. [ABSTRACT FROM AUTHOR]

Background Atrial remodeling associated with atrial fibrillation (AF) is known to be a risk factor for significant tricuspid regurgitation (TR), but the predictor of reversible TR in patients with severe functional TR and AF has been poorly studied. The aim of this study was to investigate the predictors of reversible TR in patients with severe functional TR and AF. Methods Among 232 patients with severe TR, a total of 71 patients with severe functional TR and AF were enrolled and divided into 2 groups: reversible TR group ( n = 16, 70.1 ± 15.5 years, 7 males) vs. non-reversible TR group ( n = 55, 72.3 ± 11.8 years, 20 males). Improvement of TR to moderate or lesser degree on follow-up (FU) echocardiography was considered as reversible TR in the present study. Results During 38.9 ± 26.7 months of FU period, reversible TR was observed in 16 patients (22.5%). The presence of left ventricular (LV) systolic dysfunction was significantly prevalent (43.8% vs. 20.0%, p = 0.03) and the improvement in LV ejection fraction (EF) more than 10% on FU echocardiography was more significantly frequent (62.5% vs. 23.3%, p = 0.003) in the reversible TR group than in the non-reversible TR group. However, the other echocardiographic parameters, including right ventricular function were not different between the groups. In multivariate analysis using Cox proportional hazard model, the improvement of LVEF more than 10% was the only independent predictor of reversible TR (HR = 7.39, 95%CI 1.80–30.28, p = 0.005). Nine patients died only in patients with non-reversible TR (12.7%), but the reversibility of TR was not associated with mortality. Conclusions The improvement of LV systolic function was the only independent predictor of reversible TR. Appropriate medical therapy including management for heart failure should be considered before performing surgery in patients with severe functional TR and AF, especially in patients with LV dysfunction. [ABSTRACT FROM AUTHOR]

Summary: Background: The aim of this study was to evaluate the gender differences in plaque components in acute coronary syndrome (ACS) patients. Methods: We used virtual histology-intravascular ultrasound to evaluate the plaque components in culprit lesions in 362 ACS patients (254 men, 108 women). Results: Women were more likely to be diabetic (34% vs 23%, p =0.030), had greater percentage necrotic core (%NC) volume (19.0±12.7% vs 16.8±11.9%, p =0.040), and had trends toward higher high-sensitivity C-reactive protein (hs-CRP) (0.85±1.28mg/dl vs 0.53±0.48mg/dl, p =0.063), and higher incidence of thin-cap fibroatheroma (TCFA) (62% vs 52%, p =0.078) compared with men. %NC volume was significantly greater in diabetic patients compared with nondiabetic patients (20.4±10.2% vs 16.0±8.9%, p <0.001) and was significantly greater in patients with elevated hs-CRP (≥0.2mg/dl) compared with those with normal hs-CRP (<0.2mg/dl) (18.8±8.9% vs 16.6±9.7%, p =0.021). However, there were no differences in plaque components between diabetic women and men, and between women and men with elevated hs-CRP levels. Diabetes [odds ratio (OR): 2.44, 95% confidence interval (CI): 1.35–3.82, p =0.003] and hs-CRP (OR: 1.54, 95% CI: 1.08–2.65, p =0.032), but not female gender, were the independent predictors of TCFA. Conclusions: Although it seems likely that female ACS patients have more vulnerable plaque components compared with male ACS patients, these findings may result not from true gender differences in plaque components but higher prevalence of diabetes and hs-CRP elevation in women. [Copyright &y& Elsevier]

Summary: Background: Previous studies have reported diffuse destabilization of atherosclerotic plaques in acute myocardial infarction (AMI). We used intravascular ultrasound (IVUS) to assess coronary culprit lesions in ST segment elevation MI (STEMI) vs. in non-ST segment elevation MI (NSTEMI). Methods: Patient population comprised 125 STEMI and 185 NSTEMI patients. IVUS findings included ruptured plaque (a cavity that communicated with the lumen with an overlying residual fibrous cap fragment), lipid-pool like image (a pooling of hypoechoic or echolucent material covered with a hyperechoic layer), thrombus (discrete intraluminal filling defects), and plaque prolapse (tissue extrusion through the stent strut at post-stenting). Results: Culprit lesions had larger external elastic membrane area (13.5±4.9mm2 vs. 11.9±4.3mm2, p =0.002), larger plaque plus media area (10.8±4.4mm2 vs. 9.1±4.1mm2, p =0.001), and greater plaque burden (78.7±10.1% vs. 74.8±12.0%, p =0.002), and smaller culprit lesion site calcium arc (96±90° vs. 153±114°, p =0.002) in patients with STEMI than in those with NSTEMI. Culprit lesion plaque ruptures, lipid-pool like images, and thrombus were observed more frequently in patients with STEMI than in those with NSTEMI (46% vs. 29%, p =0.002; 39% vs. 25%, p =0.010; and 34% vs. 21%, p =0.006, respectively). Culprit lesions were more predominantly hypoechoic in patients with STEMI than in those with NSTEMI (62% vs. 40%, p <0.001). There was a trend that post-stenting plaque prolapse was observed more frequently in patients with STEMI than in those with NSTEMI (33% vs. 24%, p =0.081). Conclusions: Culprit lesions in STEMI have more markers of plaque instability (more plaque rupture and thrombus, and larger plaque mass) compared with lesions in NSTEMI. [ABSTRACT FROM AUTHOR]

Summary: Background: We assessed the age-related differences in pre-intervention virtual histology-intravascular ultrasound (VH-IVUS) findings at target lesion sites in patients with coronary artery disease. Methods: A total of 553 patients who underwent pre-intervention VH-IVUS imaging were grouped according to age: non-elderly (≤70 years, n =429) and elderly (>70 years, n =124); 191 had stable angina and 362 acute coronary syndrome. VH-IVUS classified the tissue into: fibrotic, fibro-fatty, dense calcium (DC), and necrotic core (NC). Results: Overall, the absolute and percent volumes of DC (11.0±11.0mm3 vs. 9.7±11.9mm3, P =0.033; 11.7±8.1% vs. 9.8±7.2%, P =0.014, respectively) and NC (18.5±17.6mm3 vs. 16.6±18.9mm3, P =0.020; 18.8±8.8% vs. 16.5±9.3%, P =0.026, respectively) were significantly greater in the elderly than in the non-elderly. In stable angina patients, the absolute and percent volumes of DC (10.4±9.9mm3 vs. 7.2±7.6mm3, P =0.022; 13.4±10.0% vs. 9.2±6.5%, P =0.011, respectively) and NC (14.8±11.2mm3 vs. 12.0±11.9mm3, P =0.035; 19.6±8.8% vs. 15.5±8.4%, P =0.006, respectively) were significantly greater in the elderly. However, in acute coronary syndrome patients, there were no significant differences in absolute and percent volumes of DC (11.4±11.6mm3 vs. 10.9±13.4mm3, P =0.8; 10.7±6.5% vs. 10.1±7.5%, P =0.5, respectively) and NC (24.1±20.3mm3 vs. 23.9±21.2mm3, P =0.9; 22.0±8.8% vs. 21.3±9.6%, P =0.6, respectively) between the elderly and non-elderly groups. Myocardial infarction (OR: 2.56, 95% CI: 1.45–4.12, P =0.003), diabetes mellitus (OR: 2.23, 95% CI: 1.30–3.53, P =0.009), and high-sensitivity C-reactive protein (OR: 1.44, 95% CI: 1.06–2.45, P =0.042), but not age, were independent predictors of percent NC volume >20% in lesion site. Conclusions: Myocardial infarction, diabetes mellitus, and high-sensitivity C-reactive protein, but not age, were associated with NC-rich lesions. Clinical presentation, risk factors, and inflammatory status, but not age, are important factors for plaque components. [Copyright &y& Elsevier]

Summary: Background: We investigated the predictors of the no-reflow phenomenon after percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) patients with plaque rupture (PR). Methods: The study group comprised 112 AMI patients who underwent pre- and post-PCI intravascular ultrasound (IVUS) and stent implantation. Angiographic no-reflow was defined as TIMI flow grade 0, 1, and 2 after PCI. IVUS findings included multiple ruptured plaques (PRs separated by a >5-mm length of artery containing smooth lumen contours), thrombus (had a layered lobulated appearance, evidence of blood flow within the mass, and speckling or scintillation), and plaque prolapse (tissue extrusion through the stent struts). Results: Of 112 patients, no-reflow was observed in 17 patients (15.2%). High-sensitivity C-reactive protein (hs-CRP) was significantly higher (6.2±6.0mg/dl vs. 2.2±2.9mg/dl, p = 0.002) and baseline TIMI flow grade was significantly lower in no-reflow group (TIMI flow grade<3: 59% vs. 18%, p <0.001). Lesion site plaque plus media area was significantly greater (12.9±2.6mm2 vs. 10.8±4.2mm2, p = 0.009), remodeling index was significantly higher (1.14±0.17 vs. 1.03±0.20, p = 0.031), and the presence of IVUS-detected thrombus (88% vs. 56%, p =0.012), culprit lesion multiple PRs (71% vs. 37%, p =0.009), and plaque prolapse (65% vs. 34%, p =0.015) were significantly more common in no-reflow group. In the multivariate analysis, plaque prolapse (OR=33.02; 95% CI 3.38–322.75, p =0.003), hs-CRP (OR=1.03; 95% CI 1.01–1.05, p =0.013), and culprit lesion multiple PRs (OR=15.73; 95% CI 1.61–153.46, p =0.018) were independent predictors of post-PCI no-reflow in AMI patients with PR. Conclusions: Elevated hs-CRP and IVUS-detected multiple PRs and plaque prolapse are associated with no-reflow after PCI for PR-containing culprit lesion in infarct-related arteries in AMI patients. [Copyright &y& Elsevier]

Summary: Background: Many studies have suggested that in the era of drug-eluting stents (DES) one of the causes of in-stent restenosis is stent fracture (SF). Yet there have been few studies of the major adverse cardiac events and treatment of DES SF. Methods and results: From September 2003 to May 2008, 3365 patients received successful stent implantation with DES, of whom 1009 patients underwent a follow-up coronary angiography irrespective of symptoms. Seventeen SFs were detected in 15/1009 patients (1.5%). All SF patients were continued on medication with combination antiplatelet therapy, regardless of angina symptoms. If in-stent restenosis at the fractured site was significant, we performed coronary interventions even in patients without ischemic symptoms. Patients were treated with heterogenous DES for restenosis lesions (5/8 patients), and the rest were treated with either homogenous DES (2 patients), or plain old balloon angioplasty (1 patient) or medical treatment (7 patients). None of the SF patients suffered from cardiac death during a follow-up period of 20.4±12.3 months. Conclusion: If patients with SF were continued on combination antiplatelet therapy irrespective of ischemic symptoms, there would occur a low rate of major adverse cardiac events, especially cardiac death associated with SF. [Copyright &y& Elsevier]

Summary: Background: We assessed the impact of remodeling patterns on pre- and post-procedural intravascular ultrasound (IVUS) findings and cardiac enzyme elevation after stenting in 310 acute myocardial infarction (AMI) patients. Methods: The positive remodeling (PR) (PR group, n = 113) was defined as remodeling index (lesion/reference external elastic membrane cross-sectional area) >1.05, intermediate remodeling (IR) as between 0.95 and 1.05, and negative remodeling (NR) as<0.95 (IR/NR group, n = 197). IVUS findings included ruptured plaque (a cavity that communicated with the lumen with an overlying residual fibrous cap fragment), multiple ruptured plaques (different plaque ruptures separated by a >5-mm length of artery containing smooth lumen contours), thrombus (discrete intraluminal filling defects), and plaque prolapse (tissue extrusion through the stent strut at post-stenting). We compared pre- and post-procedural IVUS findings and cardiac-specific troponin I (cTnI) elevation after stenting according to the remodeling pattern. Results: The plaque rupture (60% vs. 42%, p =0.004), multiple plaque ruptures (22% vs. 14%, p =0.014), and IVUS-detected thrombus (42% vs. 28%, p =0.012) were more common in the PR group compared with the IR/NR group. Post-stenting plaque prolapse was observed more frequently (36% vs. 22%, p =0.008), and cTnI was elevated more significantly after stenting in the PR group compared with the IR/NR group (ΔcTnI; +7.8±51.1ng/ml vs. +0.9±41.1ng/ml, p =0.008). Multivariate analysis showed that PR [odds ratio (OR)=1.92; 95% CI 1.04–2.98, p =0.028], plaque rupture (OR 1.98; 95% CI 1.16–3.45, p =0.025), IVUS-detected thrombus (OR 2.30; 95% CI 1.22–3.98, p =0.008), and plaque prolapse (OR 8.40; 95% CI 4.19–16.84, p <0.001) were independently associated with post-stenting cTnI elevation. Conclusions: AMI patients with PR have more plaque vulnerability and higher frequency of plaque prolapse accompanied by post-procedural cardiac enzyme elevation compared with AMI patients with IR/NR. [Copyright &y& Elsevier]

Objectives: The aim of this study was to assess the plaque characteristics in culprit lesions in diabetic patients with acute coronary syndrome (ACS). Background: Data of the relationship between diabetes mellitus and plaque characteristics in patients with ACS are lacking. Methods: We performed grayscale intravascular ultrasound (IVUS) analysis in 422 ACS patients and virtual histology (VH)-IVUS in 310 ACS patients. By subgroup analysis, 112 patients with acute myocardial infarction (AMI) with plaque ruptures also were evaluated. Results: In the diabetic subgroup, high-sensitivity C-reactive protein (hs-CRP) was significantly increased (p = 0.008), multivessel disease was more common (65% vs. 29%, p < 0.001), and plaque burden was greater (79.7 ± 9.8 mm2 vs. 74.2 ± 8.9 mm2, p < 0.001). In the subgroup analysis of 112 AMI patients with plaque ruptures, the presence of multiple plaque ruptures (60% vs. 29%, p = 0.001) and thrombus (72% vs. 52%, p = 0.032) were more common in diabetic group. Diabetes mellitus was the independent predictor of hs-CRP elevation (odds ratio [OR]: 3.030, 95% confidence interval [CI]: 1.204 to 7.623, p = 0.019), and multiple plaque ruptures (OR: 2.984, 95% CI: 1.311 to 6.792, p = 0.009) by multivariable analysis. In 310 VH-IVUS subsets, the absolute and percent necrotic core volumes were significantly greater (16.9 ± 15.1 mm3 vs. 11.5 ± 11.4 mm3, p < 0.001, and 17.3 ± 9.4% vs. 13.7 ± 7.5%, p < 0.001, respectively), and the presence of at least one thin-cap fibroatheroma (TCFA) (60% vs. 42%, p = 0.003) and multiple TCFAs (28% vs. 11%, p < 0.001) were more common in the diabetic group. Diabetes mellitus was the only independent predictor of TCFA by multivariable analysis (OR: 2.139, 95% CI: 1.266 to 3.613, p = 0.004). Conclusions: Diabetic patients with ACS have more plaques with characteristics of plaque vulnerability, different composition of plaques, and have increased inflammatory status compared with nondiabetic patients with ACS. [Copyright &y& Elsevier]

Objectives: The aim of this study was to assess the incidence, predictors, and outcome of plaque prolapse (PP) after stent implantation in acute myocardial infarction. Background: The imaging characteristics of PP in patients with acute myocardial infarction are not well known. Methods: Intravascular ultrasound (IVUS) imaging was performed in 310 patients immediately following stenting for their first acute myocardial infarction. Multiple clinical, angiographic and IVUS derived variables were compared among patients with and without intrastent PP. Results: The PP was detected in 27% of the 310 lesions examined. Stent length was longer (31 ± 13 mm vs. 21 ± 8 mm, p < 0.001), and positive remodeling (48% vs. 32%, p = 0.008), plaque rupture (51% vs. 31%, p = 0.001), and thrombus (40% vs. 21%, p = 0.001) were significantly more common in PP lesions compared with non-PP lesions. The creatine kinase-myocardial band (CK-MB) was significantly greater after stenting in PP lesions compared with non-PP lesions (Δ = +12.3 ± 32.0 U/l vs. −4.9 ± 46.1 U/l, p = 0.002). During a 1-month follow-up, the incidence of stent thrombosis was not significantly different between PP and non-PP lesions [2/85 (2.4%) vs. 2/225 (0.9%), p = 0.308]. Multivariate analysis showed that PP (odds ratio [OR]: 7.34, p < 0.001), plaque rupture (OR: 1.95, p = 0.023), and thrombus (OR: 1.84, p = 0.026) were independently associated with post-stenting CK-MB elevation, and stent length (OR: 2.39, p = 0.003), plaque rupture (OR: 1.96, p = 0.015), and positive remodeling (OR: 1.72, p = 0.044) were independently associated with the development of PP. Conclusions: PP occurs in one-fourth of infarct-related arteries after stent implantation. Lesion characteristics such as plaque rupture and positive remodeling, together with longer stent predict PP. Although long-term follow-up is pending, PP is associated with more myonecrosis after stenting in patients with acute myocardial infarction. [Copyright &y& Elsevier]

Summary: Coronary aneurysm is a vascular anomaly which can cause hemodynamic problems due to coronary steal phenomenon. We report the case of an asymptomatic 68-year-old woman with a large coronary aneurysm with fistula arising from the left main coronary artery. As a consequence of the longstanding volume overload, the coronary arteries were extremely dilated and drained through the coronary sinus into the right atrium. [ABSTRACT FROM AUTHOR]

Summary: Few cases of a floating thrombus in an aorta have been reported without any systemic embolic complications. We report an unusual case of a huge floating thrombus (3cm×10cm in size) in the aortic arch. The patient had a history of old myocardial infarction and had undergone successful percutaneous coronary intervention 16 years previously. The aortic thrombus was detected incidentally after echocardiography and computed tomography without any evidence of aortic dissection or distal embolization. The huge thrombus was removed successfully from the aortic arch by urgent surgery. [Copyright &y& Elsevier]