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BACKGROUNDS The relative apical sparing pattern (RASP) of left ventricular (LV) longitudinal strain (LS) is frequently associated with cardiac amyloidosis (CA). However, the visual assessment of RASP is inconsistent, and the quantitative assessment of RASP is time-consuming. This study aimed to compare assessments of RASP for the identification of CA with conventional assessments and investigate their reproducibility and relevance on the assessments. METHODS Forty patients with biopsy-proven CA were compared with 80 hypertrophied patients matched for mean LV wall thickness. We compared the discriminative abilities of three assessments of RASP to identify CA (visual, quantitative, and semiquantitative). Nine patterns of semiquantitative RASP were investigated; finally, it was defined as "reduction of LS" (≥ -10%) in ≥5 (of 6) basal segments, relative to "preserved LS" (

Introduction Atrial fibrillation (AF) promotes left atrial (LA) remodeling and vice versa. LA volume index (LAVI) ≥34 mL/m2 is an established cut-off value for identifying an enlarged left atrium. Catheter ablation has become an established therapy for AF and provides a reduction of LA volume by maintaining sinus rhythm (reverse remodeling). However, the definition of LA reverse remodeling after AF ablation is undetermined. Purpose We hypothesized that patients with LA dilatation who obtain normal LA volume (LAVI Methods We enrolled 140 AF patients with baseline LAVI ≥34 mL/m2, without AF recurrence for 1 year after the initial AF ablation. We acquired conventional and speckle-tracking echocardiographic parameters within 24 h and at 1 year after the procedure. Late recurrence was defined as AF recurrence >1 year after the initial ablation. To define the normal range of LA function, age-and sex-matched 140 controls without a history of AF were also enrolled. Results After restoration of sinus rhythm, overall LA structural and functional parameters were significantly improved, and 75 patients (54%) had normal LA volume at the time of follow-up (Table). During a median follow-up of 44 (31–61) months, 32 patients (23%) experienced a late recurrence of AF. Patients who obtained normal LA volume after AF ablation had fewer late recurrences than those who did not (P Conclusion Patients who obtain normal LA volume have better long-term outcomes of AF ablation than those who do not. Although AF ablation promotes beneficial effects on LA structure and function, LA function cannot be normalized even in patients who obtain normal LA volume after successful ablation. Thus, physicians should carefully consider long-term follow-up and residual AF risks, regardless of sinus rhythm restoration by catheter ablation. Funding Acknowledgement Type of funding sources: None.

Background Cardiac amyloidosis (CA) mimics left ventricular hypertrophy (LVH). It is treatable, but its prognosis is poor. A simple screening tool for CA would be valuable. CA is more precisely diagnosed with echocardiographic deformation parameters (e.g., relative apical sparing pattern [RASP]) than with conventional parameters. We aimed to 1) investigate incremental benefits of echocardiographic deformation parameters over established parameters for CA screening; 2) determine the resultant risk score for CA screening; and 3) externally validate the score in LVH patients. Methods We retrospectively studied 295 consecutive non-ischemic LVH patients who underwent detailed diagnostic tests. CA was diagnosed with biopsy or 99mTc-PYP scintigraphy. The base model comprised age (≥65 years [men], ≥70 years [women]), low voltage on the electrocardiogram, and posterior wall thickness ≥ 14 mm in reference to the literature. The incremental benefit of each binarized echocardiographic parameter over the base model was assessed using receiver operating characteristic curve analysis and comparisons of the area under the curve (AUC). Results Fifty-four (18%) patients had CA. RASP showed the most incremental benefit for CA screening over the base model. After conducting multiple logistic regression analysis for CA screening using four variables (RASP and base model components), a score was determined (range, 0–4 points). The score demonstrated adequate discrimination ability for CA (AUC = 0.86). This result was confirmed in another validation cohort (178 patients, AUC = 0.88). Conclusions We developed a score incorporating RASP for CA screening. This score is potentially useful in the risk stratification and management of LVH patients.

BackgroundCoronary angioscopy (CAS) is a useful modality to assess atherosclerotic changes, but interpretation of the images requires expert knowledge. Deep convolutional neural networks (DCNN) can be used for diagnostic prediction and image synthesis.Methods107 images from 47 patients, who underwent coronary angioscopy in our hospital between 2014 and 2017, and 864 images, selected from 142 MEDLINE-indexed articles published between 2000 and 2019, were analyzed. First, we developed a prediction model for the angioscopic findings. Next, we made a generative adversarial networks (GAN) model to simulate the CAS images. Finally, we tried to control the output images according to the angioscopic findings with conditional GAN architecture.ResultsFor both yellow color (YC) grade and neointimal coverage (NC) grade, we could observe strong correlations between the true grades and the predicted values (YC grade, average r value = 0.80 ± 0.02, p-value ConclusionDCNN is useful in both predictive and generative modeling that can help develop the diagnostic support system for CAS.

The cardiac phenotype of laminopathies is characterized by cardiac conduction disorders (CCDs) and dilated cardiomyopathy (DCM). Although laminopathies have been considered monogenic, they exhibit a remarkable degree of clinical variability. This case series aimed to detect the causal mutation and to investigate the causes of clinical variability in a Japanese family with inherited CCD and DCM.Of the five family members investigated, four had either CCD/DCM or CCD alone, while one subject had no cardiovascular disease and acted as a normal control. We performed targeted resequencing of 174 inherited cardiovascular disease-associated genes in this family and pathological mutations were confirmed using Sanger sequencing. The degree of clinical severity and variability were also evaluated using long-term medical records. We discovered a novel heterozygous truncating lamin A/C (LMNA) mutation (c.774delG) in all four subjects with CCD. Because this mutation was predicted to cause a frameshift mutation and premature termination (p.Gln258HisfsTer222) in LMNA, we believe that this LMNA mutation was the causal mutation in this family with CCD and laminopathies. In addition, gender-specific intra-familiar clinical variability was observed in this Japanese family where affected males exhibited an earlier onset of CCD and more severe DCM compared to affected females. Using targeted resequencing, we discovered a novel truncating LMNA mutation associated with CCD and DCM in this family characterized by gender differences in clinical severity in LMNA carriers. Our results suggest that in patients with laminopathy, clinical severity may be the result of multiple factors.

Coronary high-intensity plaques (HIPs) visualized by non-contrast T1-weighted imaging (T1WI) in cardiac magnetic resonance (CMR) are associated with slow-flow phenomena during percutaneous coronary intervention (PCI). We report a case of a 52-year-old man who had undergone left anterior descending artery stent implantation for unstable angina 5 years previously. He underwent CMR imaging for screening of vulnerable plaques. A lesion in the proximal right coronary artery showed HIP on non-contrast T1WI. Invasive coronary angiography showed progressive stenosis and PCI was performed. Non-contrast T1WI indicated a high risk for a slow-flow phenomenon. A distal protection device (Parachute™ (Tri-Med, Osaka, Japan)) was deployed at the distal site of the lesion. Following balloon dilation, a filter no-reflow phenomenon developed. Coronary flow was improved with removal of the Parachute™ after debris aspiration. Histological examination revealed aspirated debris composed of white thrombi, foamy macrophages, and cholesterol crystals.

Background A recent study showed that coronary high-intensity plaques (HIPs) visualized by noncontrast T1-weighted imaging (T1WI) in cardiac magnetic resonance were associated with coronary events. We used coronary angioscopy to analyze HIP plaque morphology. Methods and results A total 17 lesions from 17 patients with stable or unstable angina pectoris were evaluated at the culprit lesion by noncontrast T1WI using 1.5-T magnetic resonance; of them, nine (53%) were HIPs and eight (47%) were non-HIPs, and all were analyzed by coronary angioscopy. We assessed the existence of thrombus and plaque yellow color grade (YG). YG was assessed visually according to a four-grade scale: 0, white; 1, light yellow; 2, yellow; 3, intense yellow. The frequency of thrombus was significantly higher in HIPs than in non-HIPs (89% vs. 25%, respectively; p = 0.007). YG was significantly more frequent in HIPs than in non-HIPs (2.2 ± 0.4 vs. 0.7 ± 0.7, respectively; p = 0.01). Conclusions These data indicated that HIPs on noncontrast T1WI were associated with the presence of high-grade yellow plaque with thrombus.

Background Arterial stiffness is an important predictor of cardiovascular events; however, indexes for measuring arterial stiffness have not been widely incorporated into routine clinical practice. This study aimed to determine whether the cardio‐ankle vascular index (CAVI), based on the blood pressure–independent stiffness parameter β and reflecting arterial stiffness from the origin of the ascending aorta, is a good predictor of cardiovascular events in patients with cardiovascular disease risk factors in a large prospective cohort. Methods and Results This multicenter prospective cohort study, commencing in May 2013, with a 5‐year follow‐up period, included patients (aged 40‒74 years) with cardiovascular disease risks. The primary outcome was the composite of cardiovascular death, nonfatal stroke, or nonfatal myocardial infarction. Among 2932 included patients, 2001 (68.3%) were men; the mean (SD) age at diagnosis was 63 (8) years. During the median follow‐up of 4.9 years, 82 participants experienced primary outcomes. The CAVI predicted the primary outcome (hazard ratio, 1.38; 95% CI, 1.16‒1.65; P 2 value increased from 33.8 to 45.2 ( P P =0.024). Conclusions This large cohort study demonstrated that the CAVI predicted cardiovascular events. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01859897.

Background Non-obstructive general angioscopy (NOGA) has revealed the intimal damages or atheromatous plaques as well as its spontaneous rupture of the aorta. Recent study revealed that plaque debris or different size of cholesterol crystals were detected in the blood above the spontaneous ruptured aortic plaque observed by NOGA and these plaque materials might cause the peripheral organ damages as the embolic source. These various morphological changes may cause the acute aortic events or atheroembolic events on the peripheral organs, such as brain, kidney, peripheral artery and so on. Purpose EAST-NOGA (Evaluation of AtheroSclerotic and rupture events by Non-Obstructive General Angioscopy) is a multi-center prospective observational study to assess the relationship between the findings of NOGA and future cardiovascular events. Methods Five hundred and seventy-seven patients with atherosclerotic cardiovascular disease who underwent NOGA study. The major cerebrocardiovascular events including cardiovascular death, non-fatal myocardial infarction, non-fatal cerebral infarction, and acute aortic syndrome were accumulated during the 2-year follow-up after NOGA study. Results The median number of aortic atheromatous plaques was 6 [IQR: 3–12]. A total of 514 patients were followed up (89.1%). The mean follow-up duration was 757±120 days. Major adverse cardiovascular events developed in 23 (4.5%) during 2 years follow-up. Patients with MACE and cerebral infarction, had significantly greater number of aortic atheromatous plaques (11 [5–19] vs. 6 [3–11], p Conclusion The number of atheromatous plaques identified by NOGA has a significant relation to the onset of cerebral infarction, which suggest the atheromatous plaque were vulnerable and ruptured spontaneously, then cause the aortogenic cerebral infarction. The NOGA study would be useful for predicting the futured atheroembolic events. Acknowledgement/Funding None

A 39-year-old woman developed a pulmonary embolism at 28 weeks of gestation, after a 4-week period of bedrest, and required emergencycesarean section due to a decrease in fetal heart rate. Pulseless electrical activity (PEA) developed after intravenous anesthesia. The fetus was delivered 5 min after PEA onset, during cardiopulmonary resuscitation of the mother. Intravenous recombinant tissue-plasminogen activator injection, percutaneous cardiopulmonary support, and 24-h hypothermia therapy were administered to the mother, followed by inferior vena cava filter insertion, combined with catheter thrombus fragmentation and percutaneous thrombectomy. Both the patient and her baby survived.

A 72-year-old male was admitted to our hospital because of chest pain in a pre-shock condition. He underwent coronary artery bypass grafting (CABG) 25 years prior. The most recent coronary angiography revealed total occlusion of both native coronaries and the saphenous vein graft (SVG) that was anastomosed to the right coronary artery. Emergency coronary angiography revealed that his SVG anastomosed to the left circumflex artery (LCX) and the distal left anterior descending artery (LAD) were also occluded. Emergency revascularization of the SVG anastomosed to the LCX and distal LAD restored blood flow and hemodynamic function. Subsequently, he received reoperative CABG to the LCX and LAD, and his angina and chronic heart failure improved. Careful follow-up is needed in patients having an old and deteriorated SVG.

Coronary high-intensity plaques (HIPs) visualized by non-contrast T1-weighted imaging (T1WI) in cardiac magnetic resonance (CMR) were associated with coronary events. We report a case of a 68-year-old man with an old myocardial infarction. He had undergone CMR to exclude new coronary artery disease, because he sometimes had an atypical chest symptom. The moderate stenosis in the right coronary artery (RCA) showed non HIP on non-contrast T1WI. We observed HIP in the proximal left anterior descending artery (LAD) without significant stenosis. Non HIP lesion in the RCA showed fibrous and calcified plaque without thrombus by optical coherence tomography (OCT) and angioscopy. On the other hand, the HIP lesion in the LAD showed lipid plaque with thrombus by OCT, and yellow plaque with mobile mixed thrombus by angioscopy. Learning objective: These intracoronary modalities suggested that the HIP lesion is correlated with vulnerable plaques. Invasive coronary angiography (CAG) is considered the gold standard for the diagnosis of coronary disease, but CAG is thought not to be able to predict future events. Non-contrast T1WI on CMR may be able to use for screening of vulnerable plaques.>

Background The vascular response, in terms of quality and quantity, of the second- and third-generation drug-eluting stents (2G- and 3G-DES, respectively) was assessed prospectively on coronary angioscopy (CAS).Methods and Results:The Multicenter study on Intra-Coronary AngioScopy After Stent (MICASA) is a multicenter CAS registry. A total of 107 DES (71 2G- and 36 3G-DES) were prospectively observed on CAS 8.7±2.7 months after percutaneous coronary intervention. Neointimal coverage (NC) grade was evaluated using a 4-point grading scale, from 0 (no coverage) to 3 (complete coverage). Plaque yellow color (YC) was also assessed using a 4-point grading system, from 0 (white) to 3 (bright yellow). Max-NC (2G-DES vs. 3G-DES: 2.14±0.68 vs. 2.44±0.73, P=0.023); min-NC (1.07±0.48 vs. 1.39±0.60, P=0.002), and dominant-NC (1.57±0.69 vs. 2.08±0.84, P=0.002) were significantly higher and the YC grade (1.23±0.82 vs. 0.86±0.76, P=0.031) significantly lower in the 3G-DES group than in the 2G-DES group. There was no significant difference in the presence of thrombus (28.2% vs. 22.2%, P=0.51) between the 2G- and 3G-DES groups. Conclusions The higher NC grade and lower YC grade in 3G-DES than in 2G-DES might be associated with better long-term clinical outcome, which remains to be determined in future studies.

BACKGROUND: Coronary artery disease is a major cause of morbidity and mortality worldwide, and is a consequence of acute thrombotic events involving activation of platelets and coagulation proteins. Factor Xa inhibitors and aspirin each reduce thrombotic events but have not yet been tested in combination or against each other in patients with stable coronary artery disease.METHODS: In this multicentre, double-blind, randomised, placebo-controlled, outpatient trial, patients with stable coronary artery disease or peripheral artery disease were recruited at 602 hospitals, clinics, or community centres in 33 countries. This paper reports on patients with coronary artery disease. Eligible patients with coronary artery disease had to have had a myocardial infarction in the past 20 years, multi-vessel coronary artery disease, history of stable or unstable angina, previous multi-vessel percutaneous coronary intervention, or previous multi-vessel coronary artery bypass graft surgery. After a 30-day run in period, patients were randomly assigned (1:1:1) to receive rivaroxaban (2·5 mg orally twice a day) plus aspirin (100 mg once a day), rivaroxaban alone (5 mg orally twice a day), or aspirin alone (100 mg orally once a day). Randomisation was computer generated. Each treatment group was double dummy, and the patients, investigators, and central study staff were masked to treatment allocation. The primary outcome of the COMPASS trial was the occurrence of myocardial infarction, stroke, or cardiovascular death. This trial is registered with ClinicalTrials.gov, number NCT01776424, and is closed to new participants.FINDINGS: Between March 12, 2013, and May 10, 2016, 27 395 patients were enrolled to the COMPASS trial, of whom 24 824 patients had stable coronary artery disease from 558 centres. The combination of rivaroxaban plus aspirin reduced the primary outcome more than aspirin alone (347 [4%] of 8313 vs 460 [6%] of 8261; hazard ratio [HR] 0·74, 95% CI 0·65-0·86, pINTERPRETATION: In patients with stable coronary artery disease, addition of rivaroxaban to aspirin lowered major vascular events, but increased major bleeding. There was no significant increase in intracranial bleeding or other critical organ bleeding. There was also a significant net benefit in favour of rivaroxaban plus aspirin and deaths were reduced by 23%. Thus, addition of rivaroxaban to aspirin has the potential to substantially reduce morbidity and mortality from coronary artery disease worldwide.FUNDING: Bayer AG.

Fractional flow reserve (FFR) is widely used for the assessment of myocardial ischemia. Optical coherence tomography (OCT) provides accurate visualization of coronary artery morphology. The aim of this study was to investigate the relation between FFR and OCT-derived FFR. We retrospectively analyzed 31 lesions (25 left anterior descending arteries, 2 left circumflex arteries, and 4 right coronary arteries) in 31 patients with moderate-to-severe coronary stenosis, who underwent OCT and FFR measurements simultaneously. OCT-derived FFR was calculated by the original algorithm, which was calculated using the following equation based on fluid dynamics: ΔP = FV + SV 2 , where V is the flow velocity, F is the coefficient of pressure loss because of viscous friction (Poiseuille resistance), and S is the coefficient of local pressure loss because of abrupt enhancement (flow separation). Mean values of % diameter stenosis by quantitative coronary angiography and FFR were 55.2 ± 14.0% and 0.70 ± 0.14, respectively. OCT-derived FFR showed a stronger linear correlation with FFR measurements (r = 0.89, p

A 67-year-old man was admitted to our hospital due to chest pain at rest. Seven years previously, the patient underwent percutaneous coronary intervention (PCI) of the left ascending artery and implanted sirolimus-eluting stent (SES). Coronary angioscopy (CAS) performed at that time showed a white plaque at the SES site. Two years after the first PCI, repeat CAS demonstrated light yellow plaques at the SES site. At the time of his presentation to our hospital, coronary angiography showed in-stent restenosis at the SES site, and CAS demonstrated the plaque rupture with presence of dense yellow plaque and various thrombi. After distal protection, drug-eluting balloon treatment was performed. Collected specimens from culprit sites included foamy macrophages, cholesterin crystals, neutrophils, and fibrin, suggesting that progressive neoatherosclerosis at the SES site triggered the acute coronary syndrome. This study highlights the importance of ensuring careful patient follow-up after SES implantation. .

Although saphenous vein grafts (SVGs) are widely used as conduits for coronary artery bypass grafting (CABG), SVG atheroma following CABG remains one of the major concerns. However, the morphological characteristics of old SVGs are not fully understood, especially in patients with stable angina pectoris. We imaged 9 consecutive SVGs in patients with stable angina pectoris using optical coherence tomography and coronary angioscopy. The clinical, optical coherence tomography, and coronary angioscopy characteristics of the SVGs are summarized in the Table. Multimodality imaging observations were performed in 4 SVGs without stenosis (nonculprit) and in 5 SVGs with significant stenosis before percutaneous coronary intervention (culprit). The graft age of the 7 SVGs (old SVGs) was >10 years, and the remaining 2 SVGs (young SVGs) were aged

To develop technology based on the need for a Roboticbed® by the elderly and those with disabilities, this study extracts user needs and problems based on feasibility testing. This study makes it clear that those with severe disabilities want the Roboticbed® to support their independence in moving between bed and wheelchair and back. We propose a lifestyle for users and caregivers using the present version of the Roboticbed® based on experiments and extracted problems based on user needs. These results indicate that evaluation based on user needs is useful for specifying a design guide for user needs., 首都大学東京学位論文甲第476号 副論文 (要約)

To improve the practicality and safety of the transfer assist robot system “Roboticbed ®,”1which combines an electric bed and an electric wheelchair, trial use evaluation and risk assessment were conducted and Roboticbed was improved based on these results. In trial use evaluation, behavior was observed and subjects were interviewed to identify requirements for improving the prototype. In risk assessment, safety measures based on a three-step method were examined in hazardous situations for which risk reduction was necessary. This paper reports details of these studies. 1. Roboticbed is a domestic trademark of Panasonic.

Background: Clinical evaluation of novel assistive technologies is of utmost importance, as this would help in making such technologies practical and ensuring that they suit the user's requirements. Objective: The purpose of this study is to develop a new methodology for the addition of user and user's life centered clinical evaluation of assistive technologies (ULCEAT) to conventional evaluation methods. The proposed ULCEAT methodology consists of two steps: evaluation by rehabilitation professionals and evaluation by potential users. These evaluations were performed to identify target users and to ensure the effective use of new assistive technologies (ATs); the evaluations were based primarily on qualitative research involving the rehabilitation professionals and the potential users. Methods: The methodology was demonstrated by using it for the clinical evaluation of Roboticbed , which was developed by the Panasonic Corporation. Results: The effective use of Roboticbed was confirmed on the basis of the results, and three target user types were identified. The validity of this methodology was further confirmed by a user evaluation of Roboticbed in an experimental environment. Conclusions :T hefindings of this study will be used to help conduct conventional clinical evaluations for novel and prototype ATs.

Background Tissue protrusion detected with optical coherence tomography after percutaneous coronary intervention using stents is one of the risk factors for early stent thrombosis. However, tissue protrusion features have not been described. The aim of this study was to compare tissue morphology at stented sites with or without tissue protrusion by using coronary angioscopy. Methods Using optical coherence tomography and coronary angioscopy, we assessed 42 patients [31 men, 11 women; age, 70.7 ± 7.4 years; acute coronary syndrome (ACS), n = 19; effort angina pectoris (EAP), n = 23] after stenting. Results Twenty patients had tissue protrusion. ACS patients had a higher incidence of tissue protrusion than EAP patients (70.0% vs 29.4%; p = 0.002). The plaque at the protrusion site had higher-grade yellow plaque with thrombus than those without protrusion (2.35 ± 0.67 vs 1.40 ± 0.67; p

Background No previous study has reported a comprehensive comparison of the chronic angioscopic findings after bare metal stent (BMS), and 1st- and 2nd-generation drug-eluting stents (DES). Methods and results The Multicenter Study on Intra-Coronary Angioscopy after Stent (MICASA) is a multicenter registry of coronary angioscopy. A total of 264 stents were observed by coronary angioscopy 1 year after PCI. There were 15 BMS, 90 1st-generation DES, and 159 2nd-generation DES. Neointimal coverage (NC) of the stent was classified into 4 grades from 0 (no coverage) to 3 (complete coverage). Yellow color (YC) of plaque at the stented segment was graded from 0 (white) to 3 (bright yellow). Minimum (Min-) and Maximum (Max-) NC grade were significantly lower with 1st- and 2nd-generation DES than with BMS. Although the Max-NC grade was similar, the Min-NC grade was significantly higher for 2nd-generation DES than for 1st-generation DES. Both the YC grade and the incidence of thrombus with 2nd-generation DES were lower than with the 1st-generation DES and were comparable to BMS. Multivariate analysis showed that low-density lipoprotein, 1st-generation DES, and acute coronary syndrome were independent factors for yellow plaque (YG2 or 3), and that hypertension and 1st-generation DES were independent factors for the incidence of thrombus. Conclusions Coronary angioscopy revealed more homogeneous coverage with white neointima and less thrombus after 2nd-generation DES as compared with 1st-generation DES. These findings may explain the favorable clinical outcomes observed for patients treated with 2nd-generation DES. (Circ J 2016; 80: 1916-1921).

SummaryFollowing the positioning of a bare metal stent (BMS) implant, a yellow plaque is healed with a reduction of the color grade and thrombogenicity, i.e. vulnerability by angioscopy in the chronic phase (“plaque sealing” of BMS; the “whitening effect” of BMS). However, we have reported that thrombus and yellow plaque increases at the drug-eluting stent (DES) site.A 71-year-old man underwent percutaneous coronary intervention using two DESs for a severe stenotic lesion in his right coronary artery. Follow-up coronary angiography (CAG) showed in-stent restenosis (ISR) at the stent-overlap site. We performed traditional balloon angioplasty, but follow-up CAG showed ISR again at the same position as the first restenosis. In angioscopic findings, the normal vessel wall was white, but the site of DES implantation was yellow and a yellow, soft, swelling neointimal proliferation-like vulnerable plaque was observed at the restenotic site. In expectation of the “whitening effect” of BMS, we implanted a new BMS. As anticipated, follow-up CAG showed no restenosis. Moreover, the angioscopic findings indicated a clean, white, neointimal proliferation-like stable plaque at the BMS implant site in the yellow vulnerable area of DES. The “BMS in DES” therapy should be considered one of the strategies for ISR of DES.

We investigated the performance of 64-MDCT myocardial imaging in assessing myocardial ischemia in acute coronary syndrome (ACS).Cardiac CT was performed in 35 patients with ACS: 24 patients with acute myocardial infarction (AMI) and 11 patients with unstable angina pectoris (UAP). We reconstructed 2D myocardial images at diastolic and systolic phases using the same raw data as those used for coronary CT angiography. The CT number in the myocardium was used as an estimate of ischemia. The myocardium was shown using a color scale that depicts faint low-density areas more clearly than gray scale. We evaluated the variations in myocardial enhancement during the cardiac cycle in the territory of the culprit lesion. In addition, we classified patients on the basis of the transmurality of myocardial enhancement and examined whether this feature correlates with myocardial damage.Myocardial imaging at systole showed myocardial hypoenhancement in territories of the culprit lesion in 91% of patients with ACS, 96% of patients with AMI, and 75% of patients with UAP. The hypoenhancement areas at systole tended to be more extensive than those at diastole. The transmural extent of hypoenhancement at systole correlated with myocardial damage, which was shown by myocardial biomarkers.CT myocardial imaging can be used to assess myocardial ischemia in the appropriate region of ACS with high sensitivity.

Coronary angioscopy is a useful tool for understanding plaque characteristics through the plaque color and surface thrombus formation. We experienced an interesting case of a newly developed yellow neointima 400 days after a sirolimus-eluting stent implantation. A 72-year-old woman suffering from angina pectoris was admitted to our hospital. Coronary angiography revealed severe stenosis at the proximal left descending artery and she was implanted with a sirolimus-eluting stent. Coronary angioscopic observation immediately after stent implantation revealed the presence of yellow plaque only at the most severe stenosis lesion in the stent placement site. We performed a coronary angiography 400 days after the sirolimus-eluting stent implantation and did not find an in-stent restenosis. An intravascular ultrasound indicated minimum neointimal formation. By coronary angioscopy, we could clearly observe that the neointima had covered the surface of the stent struts; the stent struts were barely visible under the neointima. Surprisingly, neointima formed in response to the sirolimus-eluting stent was entirely yellow. Precise mechanisms of producing yellow neointima was unknown, we may observe a pathologic neointima induced by sirolimus-eluting stent.

Background: The purpose is to investigate the ability of 64-slice multidetector computed tomography (MDCT) at rest in detecting myocardial ischemia, conventionally depicted by myocardial perfusion scintigraphy (MPS). Methods and Results: In 75 patients with suspected coronary artery disease, cardiac CE-MDCT at rest and stress/rest MPS were performed. The 2D myocardial images were reconstructed in diastolic and systolic phases using raw data from coronary computed tomography (CT) angiography. CT numbers in the myocardium were used as an estimate of myocardial enhancement. The myocardium was shown using a color scale that depicts faint low-density areas more clearly than gray scale. The variation in myocardial enhancement was evaluated at systole and diastole for those segments depicted as ischemia on MPS. A pattern of transient endocardial hypo-enhancement at systole and normal enhancement at diastole as the ischemic pattern on CT myocardial image was defined. MPS diagnosed myocardial ischemia in 40 of 75 patients. Use of the ischemic pattern on CT images distinguished patients with and without ischemia with a sensitivity of 90%, specificity of 83%, positive predictive value of 86% and negative predictive value of 88%. Conclusions: CT myocardial imaging at rest demonstrates a characteristic enhancement pattern for ischemia. This has potential as a non-invasive method for detecting ischemia. (Circ J 2009; 73: 905 - 911)

Assessment of hemodynamic changes in ischemic cardiac segments at rest using CT has yet to be performed. We hypothesized that variations in subendocardial perfusion during the cardiac cycle might be related to the appearances of ischemia. The purpose of this study was to investigate myocardial perfusion in ischemic segments using contrast-enhanced 64-MDCT.We performed cardiac MDCT at rest and stress/rest (201)Tl myocardial perfusion scintigraphy (MPS) in 34 patients with suspected coronary artery disease. We reconstructed 2D long- and short-axis cardiac images in diastolic and systolic phases using raw data from coronary CT angiography. The attenuation value (in Hounsfield units) in the myocardium was used as an estimate of myocardial perfusion. We measured the subendocardial intensity of 17 segments according to the American Heart Association classification. Systolic perfusion or diastolic perfusion was calculated by dividing the subendocardial intensity at systole or diastole, respectively, for each segment by the mean value across all segments for each patient. We used stress/rest MPS to evaluate the variation in myocardial perfusion at systole and diastole for the segments diagnosed as ischemic or nonischemic.Systolic perfusion for ischemic segments was significantly lower than that for nonischemic segments in 15 of 17 segments. The difference between systolic perfusion and diastolic perfusion in ischemic segments was significantly lower than that in nonischemic segments (14 of 17 segments). There was no significant difference in diastolic perfusion between ischemic and nonischemic segments (15 of 17 segments).Our results suggest that a pattern of subendocardial hypoperfusion at systole and normal perfusion at diastole characterizes ischemic myocardium.

Background The aim of the present study was to investigate the clinical importance of microvascular obstruction (MO) on contrast-enhanced magnetic resonance imaging (MRI), comparing it with the myocardial perfusion index (MPI) assessed using first-pass MRI. Methods and Results Cardiac MRI was performed in 33 patients within 7 days after reperfusion of a myocardial infarction (MI). Using a bolus injection of Gd-DPTA, first-pass images were obtained with the Turbo-FLASH sequence. Time-intensity curves in the left ventricular cavity and in myocardial sections were generated and then the MPI was assessed by the maximum slope method. Late enhancement (LE) was assessed using the true-FISP sequence. According to the transmurality of LE, the patients were classified into 3 groups: Group 1 included patients with localized endocardial enhancement; Group 2, patients with transmural enhancement; Group 3, patients having LE with MO. In cases of anterior infarction, the MPI for the anterior wall and parts of the inferior wall in Group 3 was significantly lower than that for Group 1 and 2. For inferior infarction, the MPI for parts of the inferior wall in Group 3 was significantly lower than that for Group 1 and 2. Conclusion MO is related to lower MPI, indicating severe microvascular damage. LE with or without MO is an important marker of perfusion status after reperfused MI. (Circ J 2008; 72: 200 - 204)

The purpose of this study was (1) to demonstrate a computer-assisted gait analysis system that can visualize the locus of the dynamic loading axis on the proximal tibia joint surface, and (2) to assess the accuracy of this system in a patient with bilateral knee osteoarthritis (OA). This system uses force plate data, CT skeletal structure data and motion capture data obtained from an infrared position sensor. The relative positions between bones and markers were used to calculate skeletal model movement based on movement of the markers. The locus of the dynamic loading axis on the knee joint was defined as the point on the proximal tibia joint surface that intersected with the loading axis of the lower limb, which passed through the centre of the femoral head and the centroid of multiple points surrounded by the distal tibia joint surface contour. To assess the accuracy of this system, open MRI was used to evaluate positions of skin markers against bones in six healthy volunteers. The locus in a patient was affected by differences between the varus knee with medial compartment OA on the non-operative side and the knee treated with high tibial osteotomy (HTO) on the opposite side. At knee flexion angles of 0 degrees, 15 degrees and 30 degrees, the mean value of measurement error for point locations on the locus was within 5.6% of joint width in the lateral direction (JWLD) on the proximal tibia joint. This system can provide clinically useful information for evaluation of the dynamic loading axis on the knee joint surface.

Purpose: To biomechanically evaluate a new fixation device, DSP (Double Spike Plate; Meira Corp, Nagoya, Aichi, Japan), for pullout graft fixation. Type of Study: Biomechanical study. Methods: A porcine tibia in which 8-mm diameter drill holes had been made from the medial tibial metaphysis to the anterior cruciate ligament attachment was rigidly fixed to a tension analyzer. A quadrupled graft consisting of 2 double-looped bovine tendons was prepared with No. 3 polyester sutures placed distally. The graft was passed through the drill hole, and its proximal loop ends were rigidly fixed to a load cell for monitoring graft tension. The graft's distal ends were connected to the DSP by tying the sutures to the top hole in the DSP. The graft tension was predetermined at 49 N (n = 5) or 98 N (n = 5). This tension was maintained for 5 minutes with a suture passed through the bottom hole of the DSP. The plate was fixed to the tibia by hammering its spikes into the bone under the index tension. Finally, the fixation was completed by inserting a screw. Results: Although the graft tension immediately increased to 69 ± 11 N or 133 ± 14 N during hammering, it gradually reduced to 49 ± 10 N or 100 ± 7 N 5 minutes later. Conclusions: This study shows that graft fixation under a predetermined tension can be achieved with the DSP. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 8 (October), 2002: pp 908–911

This study was designed to assess heart performance in young (10-week-old) spontaneously hypertensive rats (SHR) and Wistar-Kyoto (WKY) rats, in terms of whole heart function in vivo and mechanics of isolated ventricular myocytes in vitro. The data suggest that left ventricular pressure (LVP) generation is greater, and the maximal velocities of LVP generation and decline are faster in SHR than in WKY. Two-dimensional morphologic measurements show that SHR myocytes are hypertrophied and that augmented contractile function is also present in isolated cells as determined by the extent of shortening and velocity of shortening. Relaxation is also faster at the myocyte level as determined by velocity of relengthening. However, the slope of the relationship between myocyte peak shortening and velocity of relaxation was similar in both groups. These results suggest that hyperdynamic myocyte relengthening may reflect changes in elastic recoil from increased shortening rather than intrinsic changes in cellular mechanisms, which are independent of shortening.

1. The aim of this study was to elucidate the pathophysiological role of adrenomedullin and the relation between adrenomedullin and other hormones in patients with hypertrophic cardiomyopathy. 2. Fourteen patients with hypertrophic obstructive cardiomyopathy (HOCM), 26 patients with hypertrophic non-obstructive cardiomyopathy (HNCM) and 14 normal control subjects participated in this study. Radioimmunoassay for plasma adrenomedullin concentration was performed with adrenomedullin-M antibody. Plasma levels of endothelin-1, atrial and brain natriuretic peptides and noradrenaline were also measured. 3. Plasma levels of adrenomedullin were higher in patients with hypertrophic cardiomyopathy (8.43 ± 3.73 pmol/l) than in normal controls (5.24 ± 0.44 pmol/l, P < 0.005). There was no significant difference between HOCM and HNCM patients. There was a weak correlation between plasma levels of adrenomedullin and total 12-lead QRS voltage in patients with hypertrophic cardiomyopathy (r = 0323, P < 0.05) 4. Plasma levels of endothelin-1, atrial and brain natriuretic peptides were higher in hypertrophic cardiomyopathy than in normal controls. Endothelin-1 showed no significant difference between HOCM and HNCM patients, but atrial and brain natriuretic peptides were higher in HOCM than in HNCM patients. There was a positive correlation between plasma levels of adrenomedullin and endothelin-1 (r = 0.575, P < 0.0001), but no correlation between plasma levels of adrenomedullin and atrial natriuretic peptide, brain natriuretic peptide and noradrenaline. 5. Our results indicate that adrenomedullin may play an important role to maintain haemodynamics in patients with hypertrophic cardiomyopathy, and its action may be related to endothelin-1 but independent of atrial natriuretic peptide, brain natriuretic peptide and noradrenaline.

Objectives To clarify whether the functional changes during the transition from compensatory myocardial hypertrophy to failure are associated with changes in sarcoplasmic reticulum gene expression. Methods We examined the gene expression of sarcoplasmic reticulum proteins [sarcoplasmic reticulum Ca 2+ -ATPase (SERCA), phospholamban, calsequestrin and ryanodine receptor] in Dahl salt-sensitive (Dahl-S) rats fed a high-salt (8%) diet from the age of 6 weeks. In-vivo contractile functioning was evaluated using echocardiography, and gene expression of sarcoplasmic reticulum proteins in the left ventricle was analyzed by Northern blotting for each stage of left ventricular hypertrophy. Results SERCA messenger RNA (mRNA) levels in Dahl-S rats with compensatory hypertrophy did not change significantly, whereas phospholamban mRNA levels were increased by 61% (P