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Background: Left ventricular mechanical dyssynchrony (LVMD) induced by exercise stress was reported to be clinically useful in detecting multivessel coronary artery diseases. The aim of this study was to compare the prognostic value of LVMD induced by pharmacological stress with that induced by exercise stress. Methods: We retrospectively examined 918 consecutive patients who underwent exercise (N = 310) or pharmacological stress (N = 608) 99mTc-tetrofosmin single-photon emission computed tomography (SPECT) with normal myocardial perfusion. LVMD was evaluated by phase analysis as the indices of phase bandwidth and phase standard deviation (PSD). Results: During the follow-up period (2.2 ± 1.9 years), 74 major cardiac events (MCEs) occurred (7 cases of cardiac death, 17 cases of heart failure, and 50 cases of coronary intervention). In global patients, the indices of LVMD on rest images were significantly greater in patients with MCEs (bandwidth (°): 51 ± 31 vs 37 ± 21, P =.001, PSD: 14 ± 9 vs 10 ± 6, P =.001). The exercise stress bandwidth was significantly higher in patients with MCEs (62 ± 37° vs 42 ± 21°, P =.026), as was the pharmacological stress bandwidth (57 ± 35° vs 43 ± 24°, P =.006). Multivariate analysis demonstrated the exercise stress bandwidth to be an independent predictor of MCEs (HR 1.017, CI 1.003 to 1.032, P =.019), but the pharmacological stress bandwidth had no influence on MCEs. Conclusions: LVMD induced by exercise stress was an independent predictor of MCEs in patients with normal perfusion SPECT, whereas that induced by pharmacological stress had no association with further events. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the utility and feasibility of physiological maps coregistered with angiograms using the pullback of a pressure guidewire with continuous instantaneous wave-free ratio (iFR) measurements. iFR pullback was obtained for 70 lesions from 70 patients with stable angina pectoris using SyncVision (Philips Corp.). Physiological maps were created, whereby the post-intervention iFR (post-iFR) was predicted as iFRpred. The iFR gap was defined if the difference between the iFRpred and post-iFR was ≥ 0.3. The lesion morphology changed from that during the physiological assessment to that during the angiographic assessment in 26 lesions (37.1%). In particular, 22.6% of angiographic tandem lesions changed to physiological focal lesions. The mean pre-intervention iFR, post-iFR, and iFRpred were 0.73 ± 0.17, 0.90 ± 0.06, and 0.93 ± 0.05, respectively. The mean difference between the iFRpred and post-iFR was 0.029 ± 0.099, with 95% limits of agreement of -0.070–0.128. iFR gaps occurred in 28 patients (40%). Notably, a new iFR gradient causing a ≥ 0.03 iFR drop after stenting occurred in 11 (15.7%) cases. The study patients were divided into two groups according to biases between post-iFR and iFRpred < 0.03 (good concordance group) or ≥ 0.03 (poor concordance group). The pre-intervention heart rate was the only independent predictor of poor concordance (odds ratio, 0.936; 95% confidence interval 0.883–0.992; p = 0.027). Physiological maps under resting conditions may contribute to a reduction in unnecessary stent placements without missing lesions requiring treatment. However, the predictive accuracy of post-iFR performance in the present study was slightly lower than that in the previous reports. [ABSTRACT FROM AUTHOR]

Background: An assessment of cardiac events and survival using quantitative gated myocardial single-photon emission computed tomography (SPECT) (J-ACCESS) associated several risk factors with cardiac events in Japan. The clinical course after revascularization and/or optimal medical therapy (OMT) was followed in patients with coronary artery disease (CAD) at moderate-to-high risk estimated by software incorporating the J-ACCESS risk model. The present study aimed to determine the relevance of changes in estimated risk to outcomes of these therapies. Methods: This study included 494 patients with possible or definite CAD who underwent initial pharmacological stress 99mTc-tetrofosmin myocardial perfusion SPECT (MPS) before and eight months after therapy. Major cardiac event risk during 3 years of follow-up was calculated using an equation based on that in the J-ACCESS study. Patients with ≥ 10% cardiac event risk estimated at the first MPS (n = 31) were analyzed and followed up for at least 1 year. Results: Estimated risk was reduced by ≥ 5% in 14 patients (45%) after therapy. During a follow-up period of 22.1 ± 6.7 months, one patient without such reduction had a major cardiac event. Mean %summed stress scores significantly decreased from baseline to follow-up in patients with and without risk reduction. Left ventricular ejection fraction (LVEF [%]) at rest was significantly increased at the second, compared with the first MPS between patients with, than without risk reduction (57 ± 17 vs. 45 ± 16%, p = 0.001 and 50 ± 11 vs. 49 ± 9%, p = 0.953, respectively). Conclusions: A reduction in cardiac ischemia and an increase in LVEF by revascularization and/or OMT were necessary to avoid cardiac events among patients with moderate-to-high estimated risk, and changes in event risk were quantifiable. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluated the clinical characteristics of calcified nodule-like in-stent restenosis (ISR) lesions using optical coherence tomography (OCT) in vivo. A total of 124 ISR lesions that were treated with a repeat coronary intervention under OCT guidance were included in this analysis. ISR neointimal morphology was classified as "calcified nodule-like ISR", that appeared as a high-backscattering protruding mass with an irregular surface covered by signal-rich bands, or "non-calcified nodule-like ISR". The maximum arc and thickness of calcium behind the stent struts was also measured. Of the 124 ISR lesions, calcified nodule-like ISR was observed in 11 lesions (9%). OCT analysis data showed that the maximum arc of calcium and the maximum calcium thickness behind the stent were significantly larger in the calcified nodule-like ISR lesions than in the non-calcified nodule-like ISR lesions (269 ± 51 vs. 179 ± 92°, p < 0.01 and 989 ± 174 vs. 684 ± 241 μm, p < 0.01, respectively). The enlargement of the stent area was significantly larger in the calcified nodule-like ISR lesions than in the non-calcified nodule-like ISR lesions (1.6 ± 2.3 vs. 0.7 ± 1.3 mm2, p = 0.02). As a result, the enlargement of the lumen area tended to be larger in the calcified group (2.8 ± 1.7 vs. 2.4 ± 1.3 mm2, p = 0.3). Calcified nodule-like neointima within the stent could develop in approximately 10% of all ISR lesions, especially within stents deployed in severely calcified lesions. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the feasibility and utility of using motorized pullback of the pressure guidewire to provide a graphic assessment and prediction of the benefits of coronary intervention. Fractional flow reserve (FFR) measurements were performed with motorized pullback imaging in 20 patients who underwent successful percutaneous coronary intervention (PCI) of the left anterior descending artery. Physiological lesion length (PLL) was calculated using frame counts to determine stent length. FFR area was calculated by integrating the FFR values recorded during pullback tracing (FFRarea). The percentage increase in FFR area (%FFRarea) was defined as the ratio of the difference between the pre- and post-intervention FFRarea to the total frame count. The average FFR values were enhanced following PCI, from 0.64 to 0.82, and the median value of the difference between pre- and post-interventional FFR values (D-FFR) and %FFRarea were 0.13 and 10.6%, respectively. The %FFRarea demonstrated a significant positive correlation with D-FFR (R2, 0.61; p < 0.01). PLL tended to be longer and the %FFRarea was smaller in lesions with a gradual pressure-drop pattern than those with an abrupt pressure-drop pattern (35.37 vs. 20.40 mm, p = 0.07; 5.78 vs. 16.21%, p < 0.05, respectively). Motorized pullback tracing was able to identify the extent and location of stenosis and help in appropriate stent implantation, in addition to visualizing and quantifying the improvement in FFR following PCI. [ABSTRACT FROM AUTHOR]

Background: Myocardial perfusion single-photon emission-computed tomography (SPECT) can predict cardiac events in patients with coronary artery disease with high accuracy; however, pseudo-negative cases sometimes occur. Heart Risk View, which is based on the prospective cohort study (J-ACCESS), is a software for evaluating cardiac event probability. Objectives: We examined whether Heart Risk View was useful to evaluate the cardiac risk in patients with normal myocardial perfusion SPECT (MPS). Methods and Results: We studied 3461 consecutive patients who underwent MPS to detect myocardial ischemia and those who had normal MPS were enrolled in this study (n = 698). We calculated cardiac event probability by Heart Risk View and followed-up for 3.8 ± 2.4 years. The cardiac events were defined as cardiac death, non-fatal myocardial infarction, and heart failure requiring hospitalization. During the follow-up period, 21 patients (3.0 %) had cardiac events. The event probability calculated by Heart Risk View was higher in the event group (5.5 ± 2.6 vs. 2.9 ± 2.6 %, p < 0.001). According to the receiver-operating characteristics curve, the cut-off point of the event probability for predicting cardiac events was 3.4 % (sensitivity 0.76, specificity 0.72, and AUC 0.85). Kaplan-Meier curves revealed that a higher event rate was observed in the high-event probability group by the log-rank test (p < 0.001). Conclusion: Although myocardial perfusion SPECT is useful for the prediction of cardiac events, risk estimation by Heart Risk View adds more prognostic information, especially in patients with normal MPS. [ABSTRACT FROM AUTHOR]

This study investigated the effect of fractional flow reserve (FFR) after stent implantation on clinical outcomes. Pressurewire measurements and follow-up data were obtained after stent implantation. Regarding the end point, target lesion revascularization (TLR) occurred in 11 patients (15.9 %). Patients with TLR had higher frequencies of multiple stenting (54.5 vs. 19.0 %, p = 0.01), lower post-interventional FFRs (0.84 vs. 0.88, p = 0.01), and longer stent lengths (42.20 vs. 27.69 mm, p = 0.01) than patients without TLR. The post-interventional FFR cutoff for TLR was 0.79, although this value had a weak discriminatory ability. However, multivariate analysis did not show any significant independent predictors of TLR (odds ratio 6.33; confidence interval 0.75-53.4, p = 0.09). Post-interventional FFR values were not significantly associated with TLR when a sub-analysis was performed in patients who underwent only drug-eluting stent (DES) implantation. It was difficult to achieve post-interventional FFRs of 0.9 or greater. DES implantation eliminated the effect of post-interventional FFR on TLR. Post-interventional FFR was not able to predict TLR in the present study. [ABSTRACT FROM AUTHOR]

Angiography is not always an accurate indicator of physiologically significant stenosis. We examined the usefulness of functional evaluation of coronary stenosis severity by determining the fractional flow reserve (FFR) using a pressure wire in patients who received hemodialysis with angiographically intermediate lesions. We recruited 44 patients with intermediate lesions; of these, 22 were undergoing hemodialysis while 22 were not. Quantitative coronary angiography (QCA) was performed to measure the minimal lumen diameter (MLD) and calculate the percent diameter stenosis (%DS). The FFR was calculated as the ratio of the coronary pressure at the distal stenotic site to the mean aortic pressure during maximum hyperemia. In each group, we investigated the relationship between the FFR and %DS and FFR and MLD. The patients in the hemodialysis group were significantly younger and had more calcified and type B2/C lesions than those in the non-dialysis group. Although the FFR was correlated with both %DS ( r = 0.71, p < 0.01) and MLD ( r = 0.58, p < 0.01) in the non-dialysis group, the FFR was not correlated with either MLD or %DS in the hemodialysis group. In the hemodialysis group, there was a discordance between the QCA- and FFR-based assessments of the severity of coronary stenosis. In patients receiving hemodialysis, both anatomical and functional assessments should be conducted to determine the physiological significance of the stenosis accurately. [ABSTRACT FROM AUTHOR]