Search

Right-to-left shunt in atrial septal defect without pulmonary hypertension is a rare condition and can present with complications such as cyanosis. This is a rare case of cyanosis caused by right-to-left shunt atrial septal defect related to prominent crista terminalis

Objective Percutaneous patent foramen ovale (PFO) closure is a procedure widely used to prevent recurrence of cryptogenic stroke. Since December 2019, the Amplatzer PFO occluder device has been available in Japan through medical insurance. However, data on the clinical experience with this device are lacking, as it has been approved for use in only a limited number of institutions. This study assessed the clinical data of Japanese patients who underwent PFO closure using the Amplatzer PFO occluder. Methods Between February and October 2020, 14 patients at our institution underwent percutaneous PFO closure using the Amplatzer PFO occluder. The procedural characteristics, safety, and adverse events were retrospectively analyzed. Results The mean age of the patients was 52.4±13.3 years old, and 57.1% were women. Deep vein thrombosis was revealed in 2 patients, and the risk of paradoxical embolism score was 6.6±1.2 points. The PFO height and tunnel length were 2.3±1.4 mm and 11.5±4.1 mm. All patients had a PFO during the bubble study of grade >3 at the Valsalva maneuver on transthoracic echocardiography or transesophageal echocardiography. The average diameter of the PFO measured using a stiff guidewire and sizing balloon was 5.1±1.3 and 7.9±2.3 mm, respectively. Almost all cases (92.9%) were performed with a 25-mm device and without significant complications within approximately 1 hour. Conclusion Percutaneous closure using Amplatzer PFO occluder is a safe procedure for Japanese patients. However, further investigations with a larger sample and longer follow-up are needed to confirm this result.

Background Reverse takotsubo cardiomyopathy (rTTC) is recognized as an atypical type of TTC. It has been suggested that neurological events are typical trigger of rTTC, especially in young individuals. Case summary In this case report, we describe a 16-year-girl who presented with neurological deficits due to embolic stroke and acute heart failure. Transthoracic echocardiography on admission revealed a severely reduced left ventricular (LV) function with akinesis of basal to mid LV, but normal contraction in apex. Coronary computed tomography angiography confirmed unobstructed coronary arteries. Two weeks later, her LV wall motion and ejection fraction were completely normalized. Transthoracic echocardiography and transoesophageal echocardiography demonstrated no evidence of intracardiac thrombus but showed a patent foramen ovale (PFO) with large shunt. After thorough work-up and brain–heart team discussion, we concluded that the patient developed rTTC due to cryptogenic stroke related with her PFO. She underwent percutaneous PFO closure for secondary prevention with good clinical course. Discussion Reverse TTC is a rare condition. It should be considered in stroke patients with acute heart failure. Quick diagnosis and management with brain–heart team is crucial for better prognosis.

Accessory tricuspid valve is rare congenital abnormality. We describe a case of cryptogenic stroke in teenager boy caused by patent foramen ovale with thrombophilia and accessory tricuspid valve.

Background: Previous studies have shown favorable clinical outcomes of polymer-based paclitaxel-eluting stents (PB-PESs) in patients with femoropopliteal artery (FPA) disease. However, the effectiveness of PB-PES in hemodialysis (HD) patients has not been reported. The aim of this study was to compare the clinical performance of PB-PESs between HD and non-HD patients with symptomatic FPA disease.Materials and Methods: Between January 2019 and February 2020, 52 consecutive patients (mean age: 75.5 years; 42 men) underwent PB-PES implantation for symptomatic FPA diseases. Of these, 29 patients received HD and were classified into the HD cohort. The remaining 23 patients were classified into the non-HD cohort. Clinical outcomes were compared between the two cohorts. The primary efficacy endpoint was the primary patency at 12 months, and the primary safety endpoint was the 12-month incidence of major adverse cardiovascular and limb events (MACLEs), which were defined as the composite of the incidence of all-cause death, major amputation, stent thrombosis, and clinically driven target lesion revascularization (CD-TLR).Results: The overall primary patency rate was 93.3%. No significant difference existed in primary patency between the HD and non-HD cohorts (91.7% vs. 95.0%, P=0.577). The overall incidence rate of MACLEs was 16.6%, and the incidence rate was not significantly different between the HD and non-HD cohorts (20.2% vs. 13.3%, P=0.954). The incidence of stent thrombosis was not different between the HD and non-HD cohorts (8.3% vs. 5.0%, P=0.956).Conclusion: PB-PESs have exceptional 1-year primary patency and acceptable safety in HD patients and non-HD patients.Level of Evidence: Level 3, nonrandomized, follow-up study

Background Left main coronary artery (LMCA)–acute coronary syndrome (ACS) is a rare complication of a floating thrombus in the ascending aorta. However, diagnosing the aetiology of LMCA–ACS during an emergency situation is challenging. We present a rare case of LMCA–ACS caused by a large thrombus in the ascending aorta, confirmed by intravascular ultrasound (IVUS). Case summary A 90-year-old woman presented to the emergency department complaining of chest pain and syncope. On admission, her electrocardiogram showed normal sinus rhythm and a complete right bundle branch block with significant ST depression in the V3–V6 leads; hence, ACS was suspected. The first emergency angiogram of the left coronary artery showed filling defect in the proximal ascending aorta. IVUS revealed a large thrombus in the ascending aorta. The thrombus extended from the ascending aorta to the proximal left anterior descending coronary artery. IVUS confirmed that there was no dissection of the coronary artery or the proximal ascending aorta. Based on the IVUS findings, this case was diagnosed as ACS of the LMCA caused by a floating thrombus in the ascending aorta. Discussion This rare case of LMCA–ACS caused by a thrombus in the ascending aorta was confirmed by IVUS, which can be a useful imaging tool for diagnosing morphological abnormalities during emergencies.

The efficacy of percutaneous transcatheter closure for preventing recurrent cerebrovascular events in elderly patients with high-risk patent foramen ovale (PFO) remains unclear, whereas in young patients, it has been shown to effectively prevent the recurrence of embolic stroke. The aim of this study was to investigate the safety and efficacy of percutaneous PFO closure in elderly patients with high-risk PFO. Between September 2012 and October 2018, 14 patients ≥ 60 years old with high-risk PFO underwent percutaneous closure to prevent recurrence of cerebrovascular events. The primary end point was recurrence of cerebrovascular events after closure in elderly patients with high-risk PFO, and the secondary end points were occurrence of device-related complications, cerebral hemorrhage, and new-onset atrial fibrillation (AF). The mean patient age and number of cerebrovascular events before closure were 75.2 ± 6.5 years and 1.7 ± 0.7, respectively. All procedures were successfully performed under general anesthesia by transesophageal echocardiography and using a 25-mm Amplatzer Cribriform device. No procedure-related complications occurred. Patients were followed up for a mean 2.6 ± 1.8 years. No patients experienced device-related complications or recurrent cerebrovascular events. However, one patient had AF-related device closure complications at 1 month postoperatively. In addition, other patient had a cerebral hemorrhage with unknown relationship to PFO closure 3 years postoperatively. Percutaneous closure of high-risk PFO in elderly patients may be as effective and safe as in younger patients. It is crucial to evaluate PFO morphology regardless of age in cases of paradoxical embolism.

This study aimed to investigate the efficacy of percutaneous transcatheter aortic valvuloplasty (PTAV) performed prior to non-cardiac surgery and the safety of non-cardiac surgery after PTAV in elderly Japanese patients. Between March 2012 and August 2018, 14 patients who underwent PTAVs prior to non-cardiac surgery were enrolled. The mean age was 82.2 ± 7.0 years. A total of 9 patients (64.3%) were women. A retrograde approach was selected for 57.1% of the patients. More than 75% of the procedures were performed using echocardiographic imaging. Echocardiographic data including the aortic valve area (AVA), peak aortic valve blood velocity flow (AVF), peak aortic valve pressure gradient (AVPG), and mean AVPG significantly improved after PTAV (AVA; from 0.54 ± 0.11 to 0.80 ± 0.13 cm2, peak AVF; from 4.6 ± 0.8 to 3.8 ± 0.7 m/s, peak AVG; from 87.9 ± 28.0 to 62.2 ± 19.9 mmHg, mean AVG; from 49.8 ± 18.9 to 35.7 ± 11.6 mmHg; p

The efficacy of second-generation drug-eluting stent (DES) for the treatment of left main disease (LM) and/or three vessel disease (3VD) remains unclear. We compared 2-year outcomes of second- versus first -generation DES implantation among patients with LM and/or 3VD and to assess the differential of risk by complexity of coronary artery disease using synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) scores. Between April 2007 and December 2012, 341 patients with LM and/or 3VD were treated by percutaneous coronary intervention; 154 with first-generation DES and 137 with second-generation DES. After propensity matching, 101 patients remained in each group. The rate of target lesion revascularization (TLR) and major adverse cardiac event (MACE) were compared. TLR and MACE at 2 years were more common in the first- compared with second-generation DES group (TLR 19.8 vs. 8.9 %; p = 0.016, MACE 24.8 vs. 10.9 %; p = 0.008). In patients with low (0-22) and intermediate (23-32) SYNTAX scores, TLR and MACE tended to occur more often with first-generation DES group. In patients with high SYNTAX scores (≧33), TLR and MACE were significantly more common with first-generation DES group (TLR 29.0 vs. 11.1 %; p = 0.035, MACE 35.5 vs. 13.9 %; p = 0.034). Compared with first-generation DES, second-generation DES proved beneficial in reducing risk of TLR and MACE in patients with LM and/or 3VD, particularly among those with high SYNTAX scores (≧33).

The efficacy of percutaneous transcatheter closure for preventing recurrent cerebrovascular events in elderly patients with high-risk patent foramen ovale (PFO) remains unclear, whereas in young patients, it has been shown to effectively prevent the recurrence of embolic stroke. The aim of this study was to investigate the safety and efficacy of percutaneous PFO closure in elderly patients with high-risk PFO. Between September 2012 and October 2018, 14 patients ≥ 60 years old with high-risk PFO underwent percutaneous closure to prevent recurrence of cerebrovascular events. The primary end point was recurrence of cerebrovascular events after closure in elderly patients with high-risk PFO, and the secondary end points were occurrence of device-related complications, cerebral hemorrhage, and new-onset atrial fibrillation (AF). The mean patient age and number of cerebrovascular events before closure were 75.2 ± 6.5 years and 1.7 ± 0.7, respectively. All procedures were successfully performed under general anesthesia by transesophageal echocardiography and using a 25-mm Amplatzer Cribriform device. No procedure-related complications occurred. Patients were followed up for a mean 2.6 ± 1.8 years. No patients experienced device-related complications or recurrent cerebrovascular events. However, one patient had AF-related device closure complications at 1 month postoperatively. In addition, other patient had a cerebral hemorrhage with unknown relationship to PFO closure 3 years postoperatively. Percutaneous closure of high-risk PFO in elderly patients may be as effective and safe as in younger patients. It is crucial to evaluate PFO morphology regardless of age in cases of paradoxical embolism.

Objectives This study investigated the safety and prognosis of ultra-long second DES (UL-2nd DES) implantation in real-world practice. Background Long stenting is a widely known predictor of stent thrombosis (ST) or target lesion revascularization (TLR) in first-generation drug-eluting stents (DES). Methods Participants were 1,669 patients (2,763 lesions) who had undergone successful second DES implantation; they were assigned to one of three groups: ultra-long 2nd DES (UL-DES; >50 mm, 166 patients, 259 lesions), long second DES (L-DES; 20–50 mm, 758 patients, 1,212 lesions), or short second DES (S-DES

AIMS Nicorandil, an ATP sensitive potassium channel opener, may reduce the incidence of microvascular dysfunction after percutaneous coronary intervention (PCI) by dilating coronary resistance vessels. The aim of the study was evaluation of the impact of the administration of intravenous nicorandil on measuring the index of microcirculatory resistance (IMR) in PCI to patients with stable angina pectoris (SAP). METHODS AND RESULTS Intravascular ultrasound (IVUS), fractional flow reserve (FFR), IMR and blood examination (CK-MB), cardiac troponin I (cTnI) immediately post-PCI (and 24 hours later) were performed in 62 consecutive patients with SAP undergoing PCI. FFR and IMR were measured simultaneously with a single coronary pressure wire. IMR was defined as Pd/coronary flow (or Pd* mean transit time) at peak hyperaemia. Patients were randomised to the control (n=29), or nicorandil group (n=33). In the nicorandil group, nicorandil was intravenously administered as a 6 mg bolus injection just before PCI and as a constant infusion at 6 mg/hour for 24 hours thereafter. All volumetric IVUS parameters and FFR were similar between the two groups both pre- and post-PCI. However, IMR immediately post-PCI and cTnI 24 hours post-PCI were significantly higher in the control group compared to the nicorandil group (IMR: 25.4±12.1 vs. 17.9±9.1 units, and cTnI: 0.21±0.13 vs. 0.12±0.08 ng/mL, for control vs. nicorandil). The incidence for cTnI elevation more than fivefold the normal range (>0.20 ng/mL) was significantly larger in the control group than in the nicorandil group (41% vs. 12%, p

There are few clinical reports of elderly patients with paradoxical embolism in the current literature. Herein, we describe the case of a nonagenarian patient with paradoxical embolism of stroke-related patent foramen ovale (PFO). A 95-year-old woman was admitted to our hospital because of dysarthria. Her medical history included cerebral infarction, hypertension, and dyslipidemia. Magnetic resonance imaging performed in the emergency room revealed cerebral infarction of the left temporal lobe. After hospitalization in the neurosurgery department, we performed further clinical investigations to diagnose the type of stroke. There was no significant stenosis with plaque of the carotid and cerebral arteries, and there were no sources of cardiac embolism or an episode of atrial arrhythmia. Transesophageal echocardiography (TEE) showed PFO with separation and the Eustachian valve. In addition, spontaneous bidirectional shunt flow through the PFO was detected by TEE with the patient at rest. Ultrasonography of the leg vein revealed a thrombus in the deep vein. Therefore, she was diagnosed as having paradoxical embolism of stroke-related PFO and prescribed a direct oral anticoagulant (DOAC). This very rare case in which stroke-related PFO was diagnosed in a nonagenarian patient demonstrates that PFO is the cause of paradoxical embolism of stroke regardless of age.

Background The previous OLIVUS trial reported a positive role in achieving a lower rate of coronary atheroma progression through the administration of Olmesartan, an angiotension-II receptor blocking agent (ARB), for stable angina pectoris (SAP) patients requiring percutaneous coronary intervention (PCI). However, the benefits between ARB administration on long-term clinical outcomes and serial atheroma changes by IVUS remain unclear. Thus, we examined the 4-year clinical outcomes from OLIVUS according to treatment strategy with Olmesartan. Methods Serial volumetric IVUS examinations (baseline and 14 months) were performed in 247 patients with hypertension and SAP. When these patients underwent PCI for culprit lesions, IVUS was performed in their non-culprit vessels. Patients were randomly assigned to receive 20–40 mg of Olmesartan or control, and treated with a combination of β-blockers, calcium channel blockers, glycemic control agents and/or statins per physician's guidance. Four-year clinical outcomes and annual progression rate of atherosclerosis, assessed by serial IVUS, were compared with major adverse cardio- and cerebrovascular events (MACCE). Results Cumulative event-free survival was significantly higher in the Olmesartan group than in the control group ( p = 0.04; log-rank test). By adjusting for validated prognosticators, Olmesartan administration was identified as a good predictor of MACCE ( p = 0.041). On the other hand, patients with adverse events ( n = 31) had larger annual atheroma progression than the rest of the population (23.8% vs. 2.1%, p Conclusions Olmesartan therapy appears to confer improved long-term clinical outcomes. Atheroma volume changes, assessed by IVUS, seem to be a reliable surrogate for future major adverse cardio- and cerebrovascular events in this study cohort.

This study investigated the safety and prognosis of ultra-long second DES (UL-2nd DES) implantation in real-world practice.Long stenting is a widely known predictor of stent thrombosis (ST) or target lesion revascularization (TLR) in first-generation drug-eluting stents (DES).Participants were 1,669 patients (2,763 lesions) who had undergone successful second DES implantation; they were assigned to one of three groups: ultra-long 2nd DES (UL-DES;50 mm, 166 patients, 259 lesions), long second DES (L-DES; 20-50 mm, 758 patients, 1,212 lesions), or short second DES (S-DES;20 mm, 745 patients, 1,292 lesions). The primary endpoint was TLR, and secondary endpoints were ST, cardiac death, and major adverse cardiac events (MACE; composite of TLR, ST and cardiac death). A Cox proportional hazards model was used to identify independent predictors of TLR.Patient characteristics including dual antiplatelet therapy duration were similar across groups. Follow-up data were obtained from hospital charts, by contacting patients. Target lesion characteristics in the UL-DES group showed higher right coronary artery and chronic total occlusion lesion rates. TLR rates (23.1 ± 13.2 months) were significantly higher in the UL-DES group relative to other groups during follow up (P0.001). TLR rate was similar between S-DES and L-DES (P = 0.30). The incidence of ST was similar across groups (P = 0.40). MACE was significantly higher in the UL-DES group relative to other groups due to higher TLR rates (P = 0.01). In a Cox proportional hazard model, hemodialysis (RR: 2.53, 95% CI: 1.69-3.67, P0.001) and total stent length of50 mm (RR: 1.67, 95% CI: 1.07-2.55, P = 0.02) were independent predictors of TLR.Ultra-long DES implantation was associated with higher TLR rates but did not increase ST, while long DES implantation up to 50 mm was safe and acceptable.

The clinical outcomes of EVT for the restenosis of SFA stent with jailed DFA were poorly understood. The aim of this study was to reveal the SFA patency and the fate of DFA after EVT for the restenosis of SFA stent with jailed DFA. From April 2007 to January 2013, we performed de novo 490 ostial

Nicorandil, an ATP sensitive potassium-channel opener, may reduce the incidence of microvascular dysfunction after percutaneous coronary intervention (PCI) by dilating coronary resistance vessels. The aim of this study was to evaluate a coronary pressure wire-derived Index of Microcirculatory

The OLIVUS trial, using volumetric IVUS, reported a positive role in achieving a potentially lower rate of coronary atheroma progression through the administration of Olmesartan, an angiotension-II receptor blocker (ARB), for stable angina pectoris (SAP) patients requiring percutaneous coronary

Several studies showed peri-contrast staining (PSS) after silorimus-eluting stent was be associated with target-lesion revascularization (TLR) and very late stent thrombosis. However, the incidence and clinical sequela of PSS after second generation DES implantation are unclear, so we

Background: Presence of stent fracture (SF) after sirolimus-eluting stent (SES) implantation has reported to be associated with an increased risk of in-stent restenosis and target lesion revascular...