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Item does not contain fulltext BACKGROUND: Coronary blood flow in humans is known to be predominantly diastolic. Small studies in animals and humans suggest that this is less pronounced or even reversed in the right coronary artery (RCA). AIMS: This study aimed to characterise the phasic patterns of coronary flow in the left versus right coronary arteries of patients undergoing invasive physiological assessment. METHODS: We analysed data from the Iberian-Dutch-English Collaborators (IDEAL) study. A total of 482 simultaneous pressure and flow measurements from 301 patients were included in our analysis. RESULTS: On average, coronary flow was higher in diastole both at rest and during hyperaemia in both the RCA and LCA (mean diastolic-to-systolic velocity ratio [DSVR] was, respectively, 1.85±0.70, 1.76±0.58, 1.53±0.34 and 1.58±0.43 for LCA(rest), LCA(hyp), RCA(rest) and RCA(hyp), p

The physiological pattern of coronary artery disease as determined by pressure-wire (PW)-pullback is important for decision-making of revascularization and risk stratification of patients. However, it remains unclear whether inter-observer differences in interpreting PW-pullback data are subject to the expertise of physicians. This study sought to investigate the subjectivity of this assessment among non-experts. Expert interventional cardiologists classified 545 PW-pullback traces into physiologically focal or physiologically diffuse disease pattern. Defining expert-consensus as the reference standard, we evaluated ten non-expert doctors’ classification performance. Observers were stratified equally by two ways: (i) years of experience as interventional cardiologists (middle-level vs. junior-level) and (ii) volume of institutions where they belonged to (high-volume center vs. low-volume center). When judged against the expert-consensus, the agreement of non-expert observers in assessing physiological pattern of disease (focal or diffuse) ranged from 69.1 to 85.0% (p for heterogeneity

BACKGROUND The per-vessel level impact of physiological pattern of disease on the discordance between fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) has not been clarified.Methods and Results:Using the AJIP registry, vessels with FFR/iFR discordance (133/671 [19.8%]) were analyzed. In the left anterior descending artery (LAD), physiologically diffuse disease, as assessed by pressure-wire pullback, was associated with FFR-/iFR+ (83.3% [40/48]), while physiologically focal disease was associated with FFR+/iFR- (57.4% [31/54]), significantly (P

Objectives-\ud Adenosine hyperemia is an integral component of the physiological assessment of obstructive coronary artery disease in patients with chronic coronary syndrome (CCS). The aim of this study was to compare systemic, coronary and microcirculatory hemodynamics between intravenous (IV) adenosine hyperemia versus physical exercise stress in patients with CCS and coronary stenosis.\ud Methods-\ud Twenty-three patients (mean age, 60.6 ± 8.1 years) with CCS and single-vessel coronary stenosis underwent cardiac catheterization. Continuous trans-stenotic coronary pressure-flow measurements were performed during: i) IV adenosine hyperemia, and ii) physical exercise using a catheter-table-mounted supine ergometer. Systemic, coronary and microcirculatory hemodynamic responses were compared between IV adenosine and exercise stimuli.\ud Results-\ud Mean stenosis diameter was 74.6% ± 10.4. Median (interquartile range) FFR was 0.54 (0.44–0.72). At adenosine hyperemia versus exercise stress, mean aortic pressure (Pa, 91 ± 16 mmHg vs 99 ± 15 mmHg, p < 0.0001), distal coronary pressure (Pd, 58 ± 21 mmHg vs 69 ± 24 mmHg, p < 0.0001), trans-stenotic pressure ratio (Pd/Pa, 0.63 ± 0.18 vs 0.69 ± 0.19, p < 0.0001), microvascular resistance (MR, 2.9 ± 2.2 mmHg.cm−1.sec−1 vs 4.2 ± 1.7 mmHg.cm−1.sec−1, p = 0.001), heart rate (HR, 80 ± 15 bpm vs 85 ± 21 bpm, p = 0.02) and rate-pressure product (RPP, 7522 ± 2335 vs 9077 ± 3200, p = 0.0001) were all lower. Conversely, coronary flow velocity (APV, 23.7 ± 9.5 cm/s vs 18.5 ± 6.8 cm/s, p = 0.02) was higher. Additionally, temporal changes in Pa, Pd, Pd/Pa, MR, HR, RPP and APV during IV adenosine hyperemia versus exercise were all significantly different (p < 0.05 for all).\ud Conclusions-\ud In patients with CCS and coronary stenosis, invasive hemodynamic responses differed markedly between IV adenosine hyperemia versus physical exercise stress. These differences were observed across systemic, coronary and microcirculatory hemodynamics.

Supplemental Digital Content is available in the text., Background: Physiological assessment with pressure wire pullback can characterize coronary artery disease (CAD) with a focal or diffuse pattern. However, the clinical relevance of this distinction is unknown. We use data from the ORBITA trial (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) to test if the pattern of CAD predicts the placebo-controlled efficacy of percutaneous coronary intervention (PCI) on stress echocardiography ischemia and symptom end points. Methods: One hundred sixty-four patients in ORBITA underwent blinded instantaneous wave-free ratio (iFR) pullback assessment before randomization. Focal disease was defined as a ≥0.03 iFR unit drop within 15 mm, rather than over a longer distance. Analyses were performed using regression modeling. Results: In the PCI arm (n=85), 48 were focal and 37 were diffuse. In the placebo arm (n=79), 35 were focal and 44 were diffuse. Focal stenoses were associated with significantly lower fractional flow reserve (FFR) and iFR values than diffusely diseased vessels (mean FFR and iFR, focal 0.60±0.15 and 0.65±0.24, diffuse 0.78±0.10 and 0.88±0.08, respectively, P

Background: There is great degree of interobserver variability in the visual angiographic assessment of left main coronary disease (LMCD). Fractional flow reserve and intravascular ultrasound are often used in this setting. The use of instantaneous wave-free ratio (iFR) for evaluation of LMCD has not been well studied. The aim of this study is to evaluate the use of iFR in the assessment of angiographically intermediate LMCD. Methods: This is an international multicenter retrospective observational study of patients who underwent both iFR and intravascular ultrasound evaluation for angiographically intermediate LMCD. An independent core laboratory performed blinded off-line analysis of all intravascular ultrasound data. A minimum lumen area of 6 mm 2 was used as the cutoff for significant disease. Results: One hundred twenty-five patients (mean age, 68.4±9.5 years, 84.8% male) were included in this analysis. Receiver operating curve analysis showed that an iFR of ≤0.89 identified minimum lumen area 2 with an area under the curve of 0.77 (77% sensitivity, 66% specificity; P 2 with an area under the curve of 0.84 (70% sensitivity, 84% specificity; P Conclusions: In this study, in patients with intermediate LMCD, iFR of ≤0.89 correlates with intravascular ultrasound minimum lumen area 2 regardless of body surface area. The current study supports the use of iFR for the evaluation of intermediate LMCD.

Introduction: Atrial arrhythmia (AA) and left ventricular systolic dysfunction (LVSD) frequently co-exist, which loom as burgeoning public health problems. It is difficult to determine whether a tachycardia is the indicator or consequence of LVSD in patients with tachycardia and LVSD. Tachycardia mediated cardiomyopathy (TCM) raises a “chicken or egg” question. Regardless of the etiology, the patients with severe LVSD are considered as the candidate for the implantation of cardioverter defibrillator as primary prevention. It is well known that the LVSD improves after the successful treatment of AA in TCM population. However, enlarged left ventricular end-diastolic dimension (LVDd) is considered as a parameter of irreversible LVSD. Hypothesis: Enlarged LVDd could not be a predictor for irreversible LVSD in patients with AA. Methods: We assessed patients with persistent AA and heart failure (Ejection Fraction (EF) Results: Twenty-five patients with persistent AA and LVSD (23 men; mean age 63.8±9.3 years) were enrolled in this study. After restored and maintained SR, EF and left ventricular end-systolic volume (ESV) and BNP were improved in all patients respectively (EF 30.7±10.7 to 54.0±7.3%, ESV; 82.1±32.4 to 50.6±24.1ml, BNP; 379.2±237.9 to 48.0±29.7pg/ml P60mm were observed in 5 patients (25%) before the treatment. EF was normalized in patients with severe LVSD (EF Conclusions: The unnecessary device implantation could be avoided in patients with AA and severe LVSD with aggressive rhythm control therapy. Even in the patients with severe LVSD and enlarged LVDd, LVSD is reversible when AA exists.

Background Physiology-guided treatment strategy improves clinical outcomes of patients with coronary artery disease. However, it has not been fully evaluated whether such guideline-based strategy is useful for patients with diffuse coronary artery disease as well, which is known to be one of the major factors affecting morbidity and mortality. Purpose The aim of this study was to clarify clinical outcomes of patients with diffuse coronary artery disease whose treatment strategy was based on coronary physiology. Methods From an international multicentre registry of iFR-pullback, consecutive 1067 patients (1185 vessels) with stable angina were included in whom coronary lesions were deferred or revascularized according to the iFR cutoff: 0.89. The physiological pattern of disease was classified according to the iFR-pullback recording as predominantly physiologically diffuse (n=463) or predominantly physiologically focal (n=722). Major adverse cardiovascular events (MACEs), defined as a composite of cardiac death, non-fatal myocardial infarction, and ischemia-driven target lesion revascularization during follow-up period, were compared between diffuse and focal groups, in both deferred and revascularized groups, respectively. Results Mean age was 67.1±10.7 years and 75.8% of patients were men. Median iFR was 0.88 (interquartile range: 0.80 to 0.92). At a median follow-up period of 18 months, no significant differences in MACEs were found between diffuse and focal groups, in both iFR-based deferred and revascularized groups. In the deferred group (n=480), MACEs occurred in 6.9% patients (15/217) in the diffuse group and 8.0% patients (21/263) in the focal group (p=0.44). In the revascularized group (n=705), MACEs occurred in 8.9% patients (22/246) in the diffuse group and 7.2% patients (33/459) in the focal group (p=0.49). Conclusions Despite potentially higher risks in patients with diffuse coronary artery disease, clinical outcomes of those patients were comparable to those of patients without diffuse disease, as long as treatment strategy was based on the physiology guidance, which is globally recommended by international guidelines. Funding Acknowledgement Type of funding source: None

Objectives The aim of this study was to assess the long-term clinical outcomes of patients with left main coronary artery (LM) stenosis in whom treatment strategy was based on the instantaneous wave-free ratio (iFR). Background The overall safety of iFR to guide revascularization decision making in patients with stable coronary artery disease has been established. However, no study has examined the safety of deferral of revascularization of LM disease on the basis of iFR. Methods This multicenter observational study included 314 patients in whom LM stenosis was deferred (n = 163 [51.9%]) or revascularized (n = 151 [48.1%]) according to the iFR cutoff ≤0.89. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, and ischemia-driven target lesion revascularization. The secondary endpoints were each individual component of the primary endpoint and also cardiac death. Results At a median follow-up period of 30 months, the primary endpoint occurred in 15 patients (9.2%) in the deferred group and 22 patients (14.6%) in the revascularized group (hazard ratio: 1.45; 95% confidence interval: 0.75 to 2.81; p = 0.26), indicating no evidence of a significant difference between the 2 groups. For the secondary endpoints, findings in the iFR-based deferral and revascularization groups were as follows: all-cause death, 3.7% versus 4.6%; cardiac death, 1.2% versus 2.0%; nonfatal myocardial infarction, 2.5% versus 5.3%; and target lesion revascularization, 4.3% versus 5.3% (p > 0.05 for all). Conclusions Deferral of revascularization of LM stenosis on the basis of iFR appears to be safe, with similar long-term outcomes to those in patients in whom LM revascularization was performed according to iFR values.

Resumen Es bien sabido que ocasionalmente una lesion coronaria angiograficamente aparentemente significativa podria no causar isquemia y viceversa. Por eso las decisiones terapeuticas basadas en un conocimiento de la fisiologia coronaria son cada vez mas importantes. El uso de la reserva fraccional de flujo (RFF), una herramienta util para determinar en el laboratorio de hemodinamica las lesiones que se pueden beneficiar de revascularizacion, ha conseguido una indicacion de clase IA en las guias de la Sociedad Europea de Cardiologia. Recientemente, el indice diastolico instantaneo sin ondas, de mas facilidad de uso que la RFF, se considera equivalente a ella. En esta revision se repasan y se profundiza en los conceptos de RFF e indice diastolico instantaneo sin ondas y se revisan las evidencias que justifican su uso, asi como sus perspectivas futuras.

We report a case of successful coronary intervention with coronary lithotripsy facilitated by guide extension catheter for the treatment of severely calcified and bent vessel. Even though lithotripsy balloon currently available is relatively bulky, the contemporary rapid exchange guide extension catheter accommodated it with ease and helped smooth delivery of it. The present case showed the usefulness of this device combination for patients with complex coronary anatomies.

While several complications related to pressure-wire (PW) have been reported, mechanistic justification has not always been offered. Furthermore, interference between a PW and a protruding side-branch stent has not been previously reported. The purpose of this study was to evaluate interference between PW-pullback from a main-branch with a protruded ostial stent deployed in a side-branch.In a polyurethane bifurcation vessel model, PW-pullback was performed in a main-branch following protruded ostial stenting in a side-branch. Tested PWs included PressureWire X, Comet, OptoWire, and Verrata. For each PW, pullback was performed through the same proximal cell of the protruded stent 20 times. Interference during PW-pullback was objectively analyzed with a fiberscope placed at the distal main-branch and classified into 3 grades according to the interaction with stent strut.There were significant differences in the rate of interference between the PWs. No-interference, interference without strut traction, and interference with strut traction (i.e. stent deformation) were observed as follows: 17/20, 3/20, and 0/20 in PressureWire X; 19/20, 1/20, and 0/20 in Comet; 8/20, 10/20, and 2/20 in OptoWire; and 13/20, 2/20, and 5/20 in Verrata, respectively (p for any differences:0.001). Visually identifiable major stent deformation was observed once in OptoWire due to the deep concave sensor window and twice in Verrata due to the proximal gap between the sensor and coiled-wire.PW-pullback in the main-branch after side-branch ostial stenting should be carefully performed to avoid stent deformation. Consideration on the specific mechanical features of the PW is also essential.

Previous reports showed that GuideLiner (GL) and Guidezilla (GZ) can accommodate bulky and multiple devices beyond the official profiles. However, feasibility of kissing balloon technique (KBT) through these devices is unknown. The tested devices included 7Fr-GL/GZ and respective three types of 2.5 mm semi-compliant (SC) and non-compliant (NC) balloons: conventional model (CM), tapered-tip model (TM) and latest model (LM). First, three experienced operators attempted to advance all 21 combinations of the 2 balloons through GL/GZ on the guidewires and assessed the crossability in 3 grades: easy, difficult and impossible. Second, the only balloon combinations graded as easy by all operators were tested in the polyurethane-made bifurcation model which required KBT following cross-over stenting. Within the total of 42 device combinations, only one balloon combination of double LM–NC balloons was classified as easy in both GL/GZ by consensus opinion of the operators. While two combinations of LM–SC and LM–SC/NC balloons were classified as difficult in both GL/GZ, all four combinations of LM–SC/NC and CM/TM–NC balloons were classified as difficult only in GL. Other 32 combinations were all classified as impossible. In the bifurcation model, the combination of double LM–NC balloons using GL achieved KBT while the same balloon combination with GZ failed. The feasibility of KBT using child-catheter is highly dependent on the device characteristics. The combination of latest small-profile NC balloons through GL could be clinically applicable.

Background Identifying the individual hemodynamic significance of tandem coronary artery lesions can be complicated by the crosstalk phenomenon which occurs between serial stenoses under hyperemic conditions. Physiological assessments performed under resting conditions are considered to be, theoretically, less affected by the hemodynamic interaction between serial coronary stenoses. The purpose of this study was to assess whether pressure-wire (PW) pullback measurements at rest and during hyperemia provided different information as to which stenosis appeared to be most functionally significant. Methods In consecutive patients with angiographically discrete serial lesions, physiological lesion predominance (i.e. proximal or distal) was defined according to the pressure gradient along the vessels on PW-pullback trace. We used instantaneous wave-free ratio (iFR) based assessment as the reference standard and compared fractional flow reserve (FFR) based and hyperemic-iFR based lesion predominance. Results Eighty-eight vessels (70 patients, mean age 70.3 ± 9.4 years, 80% male) were included in this study. Median iFR, FFR and hyperemic-iFR were 0.85 (interquartile range [IQR]: 0.74 to 0.91), 0.73 (IQR: 0.65 to 0.80) and 0.60 (IQR: 0.49 to 0.71), respectively. When judged against iFR-pullback based physiological assessment, lesion predominance changed in 22.7% (20/88) in FFR and in 20.5% (18/88) in hyperemic-iFR, respectively. There was no statistical difference between FFR and hyperemic-iFR for the impact on these changes (p = 0.77). Conclusions In serial coronary lesions, hyperemic PW-pullback disagreed with resting PW-pullback on the lesion-specific identification of ischemia in approximately 20% of cases, either in whole cardiac cycle or in wave-free period.

Background: Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) disagree on the hemodynamic significance of a coronary lesion in ≈20% of cases. It is unknown whether the physiological pattern of disease is an influencing factor for this. This study assessed whether the physiological pattern of coronary artery disease influences discordance between FFR and iFR measurement. Methods and Results: Three-hundred and sixty intermediate coronary lesions (345 patients; mean age, 64.4±10.3 years; 76% men) with combined FFR, iFR, and iFR pressure-wire pullback were included for analysis from an international multicenter registry. Cut points for hemodynamic significance were FFR ≤0.80 and iFR ≤0.89, respectively. Lesions were classified into FFR+/iFR+ (n=154; 42.7%), FFR−/iFR+ (n=38; 10.6%), FFR+/iFR− (n=41; 11.4%), and FFR−/iFR− (n=127; 35.3%) groups. The physiological pattern of disease was classified according to the iFR pullback recordings as predominantly physiologically focal (n=171; 47.5%) or predominantly physiologically diffuse (n=189; 52.5%). Median FFR and iFR were 0.80 (interquartile range, 0.75–0.85) and 0.89 (interquartile range, 0.86–0.92), respectively. FFR disagreed with iFR in 22% (79 of 360). The physiological pattern of disease was the only influencing factor relating to FFR/iFR discordance: predominantly physiologically focal was significantly associated with FFR+/iFR− (58.5% [24 of 41]), and predominantly physiologically diffuse was significantly associated with FFR−/iFR+ (81.6% [31 of 38]; P Conclusions: The physiological pattern of coronary artery disease was an important influencing factor for FFR/iFR discordance.

Background: Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation. Methods: Group 1: 55 patients with severe AS and intermediate coronary stenoses treated with transcatheter aortic valve implantation (TAVI) were included. Group 2: 85 patients with intermediate coronary stenoses and no AS treated with percutaneous coronary intervention were included. Coronary pressure and flow were measured at rest and during hyperemia in both groups, before and after TAVI (group 1) and before and after percutaneous coronary intervention (group 2). Results: Microvascular resistance over the wave-free period of diastole increased significantly post-TAVI (pre-TAVI, 2.71±1.4 mm Hg·cm·s −1 versus post-TAVI 3.04±1.6 mm Hg·cm·s −1 [ P =0.03]). Microvascular reserve over the wave-free period of diastole significantly improved post-TAVI (pre-TAVI 1.88±1.0 versus post-TAVI 2.09±0.8 [ P =0.003]); this was independent of the severity of the underlying coronary stenosis. The change in microvascular resistance post-TAVI was equivalent to that produced by stenting a coronary lesion with an instantaneous wave-free ratio of ≤0.74. Conclusions: TAVI improves microcirculatory function regardless of the severity of underlying coronary disease. TAVI for severe AS produces a coronary hemodynamic improvement equivalent to the hemodynamic benefit of stenting coronary stenoses with instantaneous wave-free ratio values

Optical coherence tomography (OCT) has contributed to a better understanding of in-stent restenosis (ISR); however, studies evaluating ISR pattern after two-stent technique in unprotected left main (ULM) are lacking. We aim to evaluate the ISR pattern of proximal LAD and LCX after two-stent technique in ULM.We performed OCT in 26 patients with isolated or combined ISR (identified by angiography as50%) after two stent implantation in the proximal LCX and LAD. Finally, 13 LAD and 22 LCX ISR lesions underwent OCT assessments. OCT analyses were undertaken in the proximal segments of the LAD and LCX. In addition, we compared OCT findings in the flow divider (FD) and lateral wall (LW).In both the LAD and LCX, the distance from the ostium to the minimum lumen area (MLA; LAD, 2.00mm [1.00, 3.00]; LCX, 1.00mm [0.00, 1.80] distal to ostium) was short. Uncovered struts were more common on the FD side compared with the LW in the LAD (6.25% [0.00, 20.00] vs 0.00% [0.00, 0.00], respectively, p=0.016) and LCX (11.32% [0.00, 19.44] vs 0.00% [0.00, 4.55], respectively, p0.001). Conversely, neointimal hyperplasia (NIH) was significantly thicker on the FD side compared with the LW in the LCX (0.31mm [0.19, 0.47] vs 0.15mm [0.09, 0.31], p0.001).While uncovered struts were more commonly found on the FD side of both arteries, NIH was significantly thicker on the FD side compared with the LW in the LCX. These unique findings might indicate inferior outcomes after two-stent techniques in ULM bifurcation lesions.

A minimum lumen area (MLA) ≥ 6 mm2 measured by intravascular ultrasound (IVUS) has been proposed as a cut-off value to defer left main coronary artery disease (LMCA) revascularization. However, there is a lack of data evaluating correlation with the instant wave-free ratio (iFR). We conducted a

We report a case of successful percutaneous retrieval of an unexpectedly disrupted balloon catheter using GuideLiner and a low-profile balloon. The procedure and the mechanism of this novel technique were described in detail with ex-vivo testing. This case demonstrated the utility of the combination of GuideLiner and low-profile balloon as a bail-out for intravascular foreign body.

Background: This study assesses clinical outcomes after drug-eluting balloon treatment for recurrent in-stent restenosis lesions based on the number of metallic layers. Methods and Results: We enrolled 304 consecutive patients (333 lesions) treated with percutaneous coronary intervention using drug-eluting balloon for in-stent restenosis lesions between March 2014 and June 2015. Per the number of stent layers previously implanted to the lesion, the patients were categorized into 3 groups, 1 stent layer (1L), 166 patients; 2 stent layers (2L), 87 patients; and ≥3 stent layers (≥3L), 51 patients. The end points were major adverse cardiovascular events (MACE), including cardiac death, target lesion revascularization, myocardial infarction, and definite or probable stent thrombosis. No significant differences were observed in patients’ baseline characteristics among the groups. The 1-year MACE and target lesion revascularization rates were significantly higher in the ≥3L group than those in the 1L and 2L groups (MACE: 1L, 16.9%; 2L, 16.1%; and ≥3L, 43.1%, P P P P =0.02]) were independent predictors for MACE. No significant differences were observed in the occurrence of cardiac death among the groups ( P =0.34). Conclusions: Seemingly, drug-eluting balloon is less effective for ≥3L in-stent restenosis lesions. Hemodialysis and in-stent restenosis with the number of metallic layers are independent predictors for MACE.

It is well known that the apparent significant coronary stenosis on angiography sometimes does not cause significant ischemia, and vice versa. For this reason, decision-making based on coronary physiology is becoming more and more important. Fractional flow reserve (FFR), which has emerged as a useful tool to determine which lesions need revascularization in the catheterization laboratory, now has a class IA indication in the European Society of Cardiology guidelines. More recently, the instantaneous wave-free ratio, which is considered easier to use than FFR, has been graded as equivalent to FFR. This review discusses the concepts of FFR and instantaneous wave-free ratio, current evidence supporting their use, and future directions in coronary physiology.

Background:There is little data on percutaneous coronary intervention (PCI) using rotational atherectomy (Rota) for severely calcified unprotected left main (ULM) lesions.Methods and Results:Between January 2005 and August 2011, 64 consecutive patients who underwent drug-eluting stent implantation using Rota were retrospectively evaluated. Of these, 54.7% and 20.3% patients had diabetes and were undergoing hemodialysis (HD), respectively. The mean EuroSCORE and SYNTAX score was 5.6 and 35.4, respectively. Procedural success, defined as residual stenosis

Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) disagrees on the hemodynamic significance of a coronary lesion in approximately 20% of cases. It is unknown if the physiological pattern of disease is an influencing factor for this discordance. This study assessed whether the

Kissing-balloon technique (KBT) is commonly performed during percutaneous coronary intervention of distal unprotected left main coronary artery (ULM) aiming at obtaining optimal opening of the side branch (left circumflex artery; LCX) ostium. Nonetheless, detailed evaluation of vascular response to stents in LCX ostium is lacking. We therefore evaluated the vascular response to different drug-eluting stents (DES) in ostial LCX after ULM by means of optical coherence tomography (OCT).We prospectively enrolled 38 consecutive patients with ULM disease, who were treated with single-stent procedure using DES, crossover the ULM-left anterior descending artery (LAD) followed by KBT. Twelve patients were treated with sirolimus-eluting stents (SES) and 26 patients were treated with everolimus-eluting stents (EES). OCT was conducted at post-PCI and 9-month follow-up. We evaluated the DES-vessel interactions and number of stent struts at the side branch (LCX) ostium (SO) at post-PCI, and compared the narrowing of ostial area at LCX between SES and EES.Post-procedure, the number of stent struts at SO was significantly higher in SES compared to EES (median 14.47% vs 0.19%, p0.001). The narrowing of LCX ostial area at follow-up was more pronounced in SES compared with EES (29.16% vs 2.46%, respectively, p0.001). Linear regression analysis showed a high correlation between the number of stent struts in LCX ostium and ostial area narrowing (r=0.771, p0.001).OCT showed differences between EES- and SES-vessel interactions at ULM bifurcation PCI. Number of LCX ostium struts at post-PCI impacted the narrowing of ostial area at 9-month follow-up.

We report a case of percutaneous coronary intervention in a bifurcation lesion involving left circumflex (LCx) artery and 2 major posterolateral (PL) arteries. The target LCx had diffuse long and severely calcified lesion with the acute takeoff angle from the left main. Despite adequate lesion preparation with rotational atherectomy and balloon angioplasty, the stent was not deliverable, even with deep intubation of 7Fr-guiding catheter. Conventional use of guiding extension catheter (GEC) would have required removal of a wire from at least one PL because of the device interference in the GEC. However, successful stenting was achieved without removal of wires from both PL with 7Fr GuideLiner. We have also demonstrated this mechanism on ex vivo bench testing.

We report a case of percutaneous coronary intervention in a bifurcation lesion involving the left anterior descending artery and the first-diagonal branch. The lesion was calcified with vessel tortuosity. Despite adequate lesion preparation using scoring balloon, the stent was not deliverable, even with deep intubation of 7Fr-guiding catheter. The use of 6-in-7 guiding extension catheter would have required removal of wire from the diagonal branch. To avoid this situation, we down-sized the extension catheter to 5Fr, which was successful in delivering the stent without removal of the wire from diagonal branch. We have also demonstrated this novel technique on ex vivo bench testing.

Coronary physiology is recommended to guide percutaneous coronary intervention (PCI) in stable coronary disease. PCI in such settings aims to relieve angina and improve exercise capacity. The aim of this study was to determine the relationship between instantaneous wave-free ratio (iFR), fractional

Background: Takotsubo cardiomyopathy (TCM) is notable for reversible left ventricular (LV) systolic dysfunction in a short-term whereas it is well-known long-duration or persistent wall-motion abnormality is observed in some cases. However, its prevalence and predictor have yet to be fully-clarified

Rotational atherectomy (RA) is an effective strategy for the modification of heavily calcified coronary lesions, particularly those which balloon catheters or imaging devices cannot cross. Identification of extended superficial calcium by intravascular ultrasound (IVUS) has led to selected vessel