Search

Background Despite advances in devices and techniques, coronary bifurcation lesion remains a challenging lesion subset in the field of percutaneous coronary intervention (PCI). We evaluate 10‐year trends in bifurcation PCI and their effects on patient outcomes. Methods and Results We analyzed 10‐year trends in patient/lesion characteristics, devices, PCI strategy, stent optimization techniques, and clinical outcomes using data from 5498 patients who underwent bifurcation PCI from 2004 to 2015. Clinical outcomes 2 years after the index procedure were evaluated in terms of target vessel failure (a composite of cardiac death, myocardial infarction, and target vessel revascularization) and a patient‐oriented composite outcome (a composite of all‐cause death, myocardial infarction, and any revascularization). During the 10‐year study period, patient and lesion complexity, such as multivessel disease, diabetes mellitus, chronic kidney disease, and left main bifurcation, increased continuously (all P P P P values were Conclusions During the past decade of bifurcation PCI, patient and lesion characteristics, devices, PCI techniques, and patient prognosis have all significantly changed. Despite increased patient and lesion complexity, clinical outcomes after bifurcation PCI have improved, mainly because of better devices and more widespread adoption of procedural optimization techniques and appropriate treatment strategies. Registration URL: https://www.clinicaltrials.gov ; Unique identifiers: NCT01642992 and NCT03068494.

PURPOSE The three-dimensional (3D) principal strain represents the major direction and magnitude of the deformation by its definition and can be measured using 3D echocardiography. We aimed to validate 3D echocardiographic left ventricular (LV) global principal strains as an assessment of LV contractility by comparison with gold standard invasive measurements. METHODS In 14 beagles, the LV pressure-volume loop was recorded to invasively measure the end-systolic pressure-volume relationship (ESPVR) and dP/dt as reference indicators representing LV contractility. The echocardiographic image was obtained simultaneously, and endocardial motions and volume changes were extracted in the form of speckle-tracking point grids to calculate strains. High or low inotropic states were induced pharmacologically by using an intravenous infusion of dobutamine and esmolol, respectively. RESULTS The direction of 3D endocardial global principal strain (GP1S) appeared to be circumferential. The dP/dt showed the highest Pearson's correlation coefficients with GP1S (r = -0.845, P < 0.001), whereas ESPVR showed the best correlation with global secondary strain (GP2S; r = -0.819, P < 0.001). In comparison with GP1S and GP2S, global circumferential (GCS) and longitudinal strains (GLS) tended to correlate less with invasive measurements, respectively. LV ejection fraction showed excellent correlations with GP1S or GCS, but the correlation with GLS was relatively weak. The correlations between invasive measurements and GP2S or GLS were strengthened when strains were corrected by the LV residual volume ratio, whereas those of GP1S or GCS were weakened after correction. CONCLUSIONS The principal direction of the LV endocardial contraction presents circumferential behavior reflecting LV volume change. The 3D principal strains derived from 3D echocardiography are reliable indicators for LV contractility and seem better than conventional strains.

Background This study compared the efficacy of catheter ablation of atrial fibrillation (AF) between impedance (IMP)‐guided and contact force (CF)‐guided annotation using the automated annotation system (VisiTag™). Methods Fifty patients undergoing pulmonary vein isolation (PVI) for AF were randomized to the IMP‐guided or CF‐guided groups. The annotation criteria for VisiTag™ were a 10 second minimum ablation time and 2 mm maximum catheter movement range. A minimum CF of 10 g was added to the criteria in the CF‐guided group. In the IMP‐guided group, a minimum IMP drop of over 5 Ω was added to the criteria. Results The rates of successful PVI after an initial ablation line were higher in the CF‐guided group (80% vs 48%, P = .018). Although average CF was similar between two groups, the average force‐time integral (FTI) was significantly higher in the CF‐guided group (298.3 ± 65. 2 g·s vs 255.1 ± 38.3 g·s, P = .007). The atrial arrhythmia‐free survival at 1 year demonstrated no difference between the two groups (84.0% in the IMP‐guided group vs 80.0% in the CF‐guided group, P = .737). If the use of any antiarrhythmic drug beyond the blanking period was considered as a failure, the clinical success rate at 1 year was 52.0% for the CF‐guided group vs 56.0% for the IMP‐guided group (P = .813). Conclusions Atrial fibrillation ablation using an automated annotation system guided by CF improved the success rate of PVI after the initial circumferential ablation. An IMP‐guided annotation combined with catheter stability criteria showed similar clinical outcomes as compared to the CF‐guided annotation.

AIMS Although clinical guidelines advocate the use of the highest tolerated dose of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers after acute myocardial infarction (MI), the optimal dosing or the risk-benefit profile of different doses have not been fully identified. METHODS AND RESULTS In this multicentre trial, 495 Korean patients with acute ST segment elevation MI and subnormal left ventricular (LV) ejection fraction (

BACKGROUND: Data on treatment results of lipid‐lowering therapy (LLT) in familial hypercholesterolemia (FH) are limited, particularly in Asian patients. HYPOTHESIS: We sought to evaluate the target achievement rate and associated variables in Korean patients with FH after maximal statin‐based LLT. METHODS: We enrolled 146 patients with heterozygous FH, and 90 patients were finally analyzed. Patients were initially prescribed rosuvastatin 10 mg or atorvastatin 20 mg, and the regimen was adjusted to achieve the low‐density lipoprotein cholesterol (LDL‐C) target of 100 mg/dL. The primary evaluation point was the achievement rate of the LDL‐C targets at 12 months: LDL‐C < 100 mg/dL and ≥50% LDL‐C reduction. The associations between clinical variables and target achievement were also analyzed. RESULTS: At 12 months, 58% of patients were receiving high‐intensity regimens, whereas 46% were receiving combination therapy. The mean pre‐ and post‐treatment LDL‐C levels were 229 and 118 mg/dL, respectively. Twenty‐eight percent of patients achieved LDL‐C < 100 mg/dL, and 47% achieved ≥50% LDL‐C reduction. Pretreatment LDL‐C and high‐intensity regimens indicated a negative tendency toward the attainment of LDL‐C < 100 mg/dL. Conversely, pretreatment LDL‐C and diabetes mellitus were positively associated with a higher rate of ≥50% LDL‐C reduction. CONCLUSIONS: The target achievement of LDL‐C < 100 mg/dL was low, and 50% LDL‐C reduction was moderately achieved in Korean patients with FH receiving maximal statin‐based LLT. Pretreatment LDL‐C levels and diabetes mellitus were associated with target achievement. Our results provide rare and informative data on FH treatment in Asian patients.

Objective To evaluate the long-term mortality according to obesity in patients with chronic total occlusion (CTO) lesions after successful percutaneous coronary intervention (PCI). Background Despite the potential impact of coronary revascularization and lesion severity on the obesity paradox, the long-term survival according to obesity in CTO patients after successful PCI has been unknown. Methods and results Between January 2003 and September 2014, we examined 1,172 consecutive Korean patients with 1,190 CTO lesions who underwent successful drug-eluting stent (DES) implantation in two tertiary academic medical centers. The primary and secondary endpoints were all-cause and cardiac death, respectively. Obesity was defined as a body mass index ≥25.0 kg/m2, based on the criteria for Asians. The median follow-up time was 4.4 years. The prevalence of obesity was 54.4%. During the follow-up periods, the occurrence of all-cause (6.1 vs. 10.7%) and cardiac death (3.8 vs. 6.7%) was lower in obese patients than in non-obese patients (P

Background Despite improved long-term safety of biodegradable polymer (BP) drug-eluting stents (DES) compared to first-generation durable polymer (DP) DES, data on the safety and efficacy of BP-DES compared with second-generation (2G) DP-DES in patients with acute myocardial infarction (AMI) are limited. Hypothesis To evaluate the safety and efficacy of BP-DES compared with 2G-DP-DES in the higher stent thrombosis (ST) risk setting of AMI. Methods A total of 3359 AMI patients who received either BP-DES (n = 261) or 2G-DP-DES (n = 3098) were included from the Korea Acute Myocardial Infarction Registry (KAMIR). Differences in baseline clinical and angiographic characteristics were adjusted using a 1:5 propensity score matching analysis (n = 261 for BP-DES and n = 1305 for 2G-DP-DES). The primary outcome was the incidence of major adverse cardiac events (MACE) including all-cause death, recurrent myocardial infarction (re-MI), and target vessel revascularization (TVR). The rate of definite or probable ST was also investigated. Results In adjusted analysis, there was no significant difference between the 2 groups in baseline clinical and angiographic characteristics; 2-year MACE (10.7% and 9.9% in the BP-DES group and 2G-DP-DES group, respectively, P = 0.679); ST incidence (0.8% vs 0.9%, respectively, P = 1.0), and rates of all-cause death, re-MI, and TVR. By multivariate analysis, old age, diabetes mellitus, renal dysfunction, and left ventricular dysfunction were the independent predictors of MACE after BP-DES or 2G-DP-DES implantation. Conclusions BP-DES and 2G-DP-DES appear to have comparable 2-year safety and efficacy for the treatment of AMI. However, longer-term follow-up is needed.

Background Temporal trends of evidence-based optimal medical therapy (OMT) at discharge after acute myocardial infarction (AMI) have not been investigated in recent years. Hypothesis OMT should have been increased in AMI and gap between guidelines and practices in its use should have been narrowed. Methods We examined discharge medications of 17,578 post-MI patients who had no documented contraindications to antiplatelet agents, β-blockers, angiotensin-converting enzyme inhibitors, or statins across a 6-year period (divided into subperiods of November 2005 to December 2006 [period 1], 2007 [period 2], 2008 [period 3], 2009 [period 4], 2010 [period 5], and January to June 2011 [period 6]) in the Korean AMI Registry. OMT was defined as use of all 4 indicated medications. Results Marked increases in OMT (48.6% to 63.2%) were seen irrespective of age and sex, mainly attributed to marked increases in the use of β-blockers (70.3% to 83.7%) and statins (76.9% to 82.6%) from period 1 to period 6. The gap in use of OMT between men and women narrowed over time between the first and second 3 periods, but not between the young and the elderly. Advanced age (odds ratio [OR]: 0.88, P = 0.04) was independently associated with underuse of OMT. Adjusted ORs for OMT from period 1 to period 6 were as follows: 1, 1.14 (P = 0.024), 1.21 (P = 0.001), 1.40 (P < 0.001), 1.47 (P < 0.001), and 1.69 (P < 0.001), respectively. Conclusions Despite gradual increase in OMT over time, the gap between guidelines and practices in use of OMT continues to exist.

Results: The two groups had well matched baseline characteristics. The clinical outcomes at 1 year showed that the incidences of cardiac death and total death were comparable between the 2 groups. However, EES group had significantly lower incidences of Re-MI (1.4% vs 2.7%, P=0.008), TLR (1.2% vs 3.1%, P

Few studies have explored the clinical potentials of combined Cystatin C (Cys) and uric acid (UA) in heart failure (HF). The authors evaluated Cys and UA as predictors of clinical outcomes compared with conventional renal biomarkers. This prospective cohort study included 587 HF patients presenting with dyspnea. At admission, Cys, UA, and other renal measures including serum urea nitrogen (BUN), creatinine (Cr), and glomerular filtration rate (GFR) were obtained. The primary endpoint was the composite of cardiac death and rehospitalization for worsening HF. During a 25-month median follow-up period, 68 patients experienced clinical outcomes: 9 cardiac deaths and 59 HFs. They showed higher BUN and Cr values and lower GFR. Within these parameters, Cys and UA had the most favorable area under the curves, and patients with Cys ≥0.8 mg/L and UA ≥6.6 mg/dL showed more frequent events. The net reclassification improvement analysis showed the combination of Cys and UA had a greater incremental effect for cardiac prognosis. On multivariate Cox hazard analysis, Cys and UA were independent predictive markers for clinical outcomes. In HF patients presenting with dyspnea, Cys and UA appear to be more useful predictors of clinical events than other renal measures.

OBJECTIVES: To compare long-term clinical outcomes between intravascular ultrasound (IVUS)-guided and angiography-guided percutaneous coronary intervention (PCI) in a large "real world" registry. BACKGROUND: The impact of IVUS-guided PCI on clinical outcomes remains unclear. METHODS: Between January 1998 and February 2006, 8,371 patients who underwent IVUS- (n = 4,627) or angiography- (n = 3,744) guided PCI were consecutively enrolled. Three-year clinical outcomes were compared after adjustment for inverse-probability-of-treatment weighting (IPTW) in the overall population and in separate populations according to stent type. RESULTS: A crude analysis of the overall population showed that the 3-year mortality rate was significantly lower in the IVUS-guided group than in the angiography-guided group (96.4% ± 0.3% vs. 93.6% ± 0.4%, log-rank P < 0.001). When adjusted by IPTW, patients undergoing IVUS-guided PCI remained at lower risk of mortality (hazard ratio [HR] 0.627; 95% CI 0.50-0.79, P < 0.001). Similarly, in the drug-eluting stent (DES) population, the 3-year risk of mortality was significantly lower in patients undergoing IVUS-guided PCI (HR 0.46; 95% CI 0.33-0.66, P < 0.001). In contrast, IVUS-guided PCI did not reduce the risk of mortality in the bare metal stent population (HR 0.82; 95% CI 0.60-1.10, P = 0.185). However, the risks of myocardial infarction (HR 0.95; 95% CI 0.63-1.44, P = 0.810), target vessel revascularization (HR 1.00; 95% CI 0.86-1.15, P = 0.944), and stent thrombosis (HR 0.82; 95% CI 0.53-1.07, P = 0.109) were not associated with IVUS guidance. CONCLUSIONS: IVUS-guided PCI may reduce long-term mortality when compared with conventional angiography-guided PCI. This may encourage the routine use of IVUS for PCI in patients undergoing DES implantation. © 2012 Wiley Periodicals, Inc.

Background: The absolute benefit of drug-eluting stents (DES) in low-risk patients and lesions is not well established. Hypothesis: The long term clinical outcomes after percutaneous coronary intervention in a single coronary artery disease may not be affected by the type of stent. Methods: This study assessed and compared 2-year clinical outcomes of 304 consecutive patients (147 BMS patients and 157 DES patients) treated with a single coronary stent (4.0 mm) for single de novo large coronary artery disease in 3 referral cardiac centers. The primary outcome was a composite of major adverse cardiac events at 2 years after the index procedure. Results: The reference vessel diameter was similar in both groups (3.92 ± 0.29 mm in BMS vs 3.95 ± 0.24 mm in DES, P = 0.50). Late loss was larger in the BMS group (1.04 ± 0.83 mm vs 0.73 ± 0.91 mm in DES, P = 0.03). The incidence of major adverse cardiac events at the 2-year clinical follow-up was very low, 24 of 304 patients (7.9%), regardless of stent type deployed (7.5% in BMS vs 8.3% in DES, P = 0.83). The rate of target vessel revascularization was also similar in both groups (4.8% in BMS vs 5.7% in DES, P = 0.80). Conclusions: Two-year clinical outcomes after PCI with a single large coronary stent (4.0 mm) were excellent. The clinical outcomes were not affected by the type of stent used. Copyright © 2010 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Background Studies have suggested that women are biologically different and that female gender itself is independently associated with poor clinical outcome after an acute myocardial infarction (AMI). Hypothesis We analyzed data from the Korean Acute Myocardial Infarction Registry (KAMIR) to assess gender differences in in-hospital outcomes post ST-segment elevation myocardial infarction (STEMI). Methods Between November 2005 and July 2007, 4037 patients who were admitted with STEMI to 41 facilities were registered into the KAMIR database; patients admitted within 72 hours of symptom onset were selected and included in this study. Results The proportion of patients who had reperfusion therapy within 12 hours from chest pain onset was lower in women. Women had higher rates of in-hospital mortality (8.6% vs 3.2%, P < .01), noncardiac death (1.5% vs 0.4%, P < .01), cardiac death (7.1% vs 2.8%, P < .01), and stroke (1.2% vs 0.5%, P < .05) than men. Multivariate logistic regression analysis identified age, previous angina, hypertension, a Killip class ≥ II, a left ventricular ejection fraction (LVEF) < 40%, and a thrombolysis in myocardial infarction flow (TIMI) grade ≤ 3 after angioplasty as independent risk factors for in-hospital death for all patients; however, female gender itself was not an independent risk factor. Conclusions The results of this study show that although women have a higher in-hospital mortality than men, female gender itself is not an independent risk factor for in-hospital mortality. Copyright © 2010 Wiley Periodicals, Inc.

Although uric acid (UA) level has been associated with an increased risk of cardiovascular events, it is unclear whether UA can provide greater prognostic information than N-terminal pro B-type natriuretic peptide (NT-proBNP) in advanced heart failure with nonischemic dilated cardiomyopathy (DCM). UA and NT-proBNP values were obtained from a total of 122 DCM patients. Development of clinical events during follow-up was defined as the composite of cardiac death and readmission for heart failure. During follow-up, there were 18 cardiac events. UA and NT-proBNP values were significantly higher in patients with events. The receiver operating characteristics curve showed the area under the curve for UA was greater than that for NT-proBNP. On multivariate analysis, UA remained the only independent predictor of prognosis. UA concentrations > or =8.7 mg/dL rather than NT-proBNP > or =3800 pg/mL were associated with significantly decreased event-free survival. The authors' findings demonstrated that UA value could be an informative predictor in nonischemic DCM.

Background The advent of drug-eluting stent (DES) use has raised concerns regarding later occurring stent thrombosis, especially very late stent thrombosis (VLST), and little is known about long-term clinical outcomes after VLST occurrence. Hypothesis Long-term clinical outcomes after detection of VLST may be poor. Method We evaluated 3572 consecutive patients who received DES implantation from May 2004 to July 2007 at 3 hospitals. The primary outcomes were a composite of major adverse cardiac events (MACE) including cardiac death, myocardial infarction (MI), target-lesion revascularization (TLR), and target-vessel revascularization (TVR) after VLST occurrence. Results We identified 19 patients (0.53%) with angiographically documented stent thrombosis developing over 1 year after DES implantation. The mean time to VLST occurrence was 899 days (899 ± 353). Discontinuation of antiplatelet drugs was noted in 4 (21%) patients and the average duration of discontinuation was 4 days. Clinical presentations of VLST were mainly MI (17 patients, 89%). Balloon angioplasty was only performed in 12 patients (63%) and stent implantation in 7 patients (37%). Mean follow-up duration from VLST occurrence was 620 days (620±256). During clinical follow-up after VLST occurrence, no cardiac deaths or MIs were detected. Target-vessel revascularization was done in 2 (11%) patients and TLR in 1 patient (6%). Major adverse cardiac events occurred in 3 (16%) patients during long-term clinical follow-up. Conclusions Clinical presentation of VLST after DES implantation is associated with serious adverse events, such as MI. Long-term follow-up outcomes after VLST occurrence appear unfavorable and more data from larger studies are warranted. Copyright © 2009 Wiley Periodicals, Inc.

BACKGROUND: The data of long‐term outcomes of sirolimus‐eluting stent (SES) according to lesion location of unprotected left main coronary artery (LMCA) is scarce. HYPOTHESIS: The purpose of this study was to evaluate the long‐term outcomes after implantation of the SES in LMCA. METHODS: A total of 84 patients (51 males) who had undergone SES implantation for the treatment of native LMCA stenosis were enrolled. The patients were divided into 2 groups based on angiographic lesion location: those with significant stenosis in the ostium and/or body (group 1; n = 39) and those involving bifurcation (group 2; n = 45). RESULTS: All of the group 1 patients were treated with simple lesion coverage while different stenting techniques were used in group 2 (cross‐over: 44.8%, T: 6.7%, kissing: 37.8%, and crush techniques: 11.1%). The 8‐month quantitative angiographic findings and in‐hospital and 2 year rates of major adverse cardiac events (MACE) were compared between the 2 groups. Although angiographic success and in‐hospital MACE rates were similar in both groups with 1 cardiac death due to acute stent thrombosis in group 2, at 2‐year follow‐up, the MACE rate was significantly higher in group 2 than in group 1 at 2 years (22.2% vs 2.6%, respectively, P = 0.008). Coronary angiography revealed a significantly higher binary restenosis rate in group 2 compared with group 1 (20% vs 0%, respectively, P = 0.003). CONCLUSIONS: Interventional treatment using SES in left main lesions showed favorable short‐term and long‐term outcomes in selected patients with lesion location being an important determinant of clinical and angiographic outcomes. Copyright © 2009 Wiley Periodicals, Inc.

BACKGROUND Patients with heart failure with a preserved ejection fraction (HFPEF) have high N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) level and a high ratio of early transmitral inflow to diastolic velocity of the mitral annulus (E/E') derived from tissue Doppler imaging (TDI). Because left atrial volume indexed to body surface area (LAVI) is believed to reflect chronic diastolic dysfunction, we assessed the ability of LAVI and E/E' ratio to predict NT-pro-BNP level in patients with HFPEF. METHODS One hundred forty-eight patients with HFPEF (ejection fraction >or= 50%, NT-pro-BNP >or= 100 pg/ml) underwent conventional echocardiography including LAVI and E/E' ratio, which were compared with NT-pro-BNP level. RESULTS In the overall patient population, modest correlations were found between NT-pro-BNP level and peak systolic TDI (S') (P = 0.009), LAVI (P = 0.009), and E/E' ratio (P = 0.017). However, in patients with E/E' ratio >or=13, LAVI was the most important predictor of NT-pro-BNP level (P < 0.001), whereas in those with E/E' ratio

Vascular smooth muscle cells (VSMCs) play an important role in the development and progression of atherosclerosis. Tumor necrosis factor alpha (TNFalpha), a cytokine secreted by VSMCs and macrophages in atherosclerotic lesions, regulates a variety of cellular functions of inflammatory cells and VSMCs by promoting cell growth and motility, which are critical for the initiation and progression of vascularlesions. Alpha lipoic acid (ALA), a well known antioxidant, acts as a pyruvate dehydrogenase cofactor in mitochondrial metabolism. Recently, we reported that ALA has many beneficial effects on vascular cells in atherosclerosis. The aim of the current study was to examine VSMCs, treated for 24 hours with TNFalpha (10 ng/mL) in the presence or absence of ALA (2 mM), for differential protein and genes expression using two-dimensional gel electrophoresis (2-DE) and DNA microarray analysis, respectively. Using 2-DE, we identified proteins whose expression changed by at least 2.5-fold after TNFalpha stimulation. Proteins up-regulated by TNFalpha that were subsequently down-regulated in the presence of ALA were identified by matrix-assisted laser desorption/ionization-time of flight mass spectrometry as plasminogen activator inhibitor-2, fetal liver LKB-interacting protein, osteoblast-specific factor 2, glucosidase II, cyclin-dependent kinase 3, endoplasmin precursor and glutathione synthetase. TNFalpha down-regulated proteins that were up-regulated in the presence of ALA were keratin 19, eukaryotic translation elongation factor and Rho GDP dissociation inhibitor alpha. Gene expression analysis using DNA microarray tools confirmed the up-regulation or down-regulation of some, but not all, of the proteins observed in ALA challenged, TNFalpha-treated cells. This data should provide valuable information about the underlying mechanisms of atherosclerosis.

A 79-year-old man was followed in our hospital for 4 years following primary percutaneous coronary intervention at another hospital to deploy two stents at the left anterior descending coronary artery for acute myocardial infarction (AMI). At the first visit in our hospital, echocardiography revealed a small ventricular septal defect (VSD, 0.8 to 1.0 cm) in the apicoseptal wall with an aneurysm that was probably the result of the AMI. There was no hemodynamic decompensation, and because the patient refused surgical correction we instead placed him under close follow-up observation in the outpatient clinic. A second follow-up echocardiography 6 months later still revealed a VSD. However, after 3 years the VSD murmur was no longer audible and follow-up echocardiography showed the defect to be nearly closed.