Search

Background: With respect to total mortality and cardiovascular mortality, the feature and impact of guideline-directed medication (GDM) prescriptions for heart failure with reduced ejection fraction (HFrEF) with chronic kidney disease (CKD) are unknown. Therefore, we aimed to determine these aspects. Methods: GDM prescriptions and their impact on discharged patients with and without CKD were analyzed. To analyze differences in one-year clinical outcomes, propensity score matching was conducted on a cohort of patients with concomitant HFrEF and CKD who received more and fewer GDM prescriptions. Results: A total of 1509 patients were enrolled in Taiwan's HFrEF registry from May 2013 to October 2014, and 1275 discharged patients with complete one-year follow-up were further analyzed. Of these patients, 468 (36.7%) had moderate CKD, whereas 249 (19.5%) had advanced CKD. Patients with advanced CKD received fewer prescribed GDMs than other patients. Multivariate analysis revealed that peripheral arterial occlusive disease, thyroid disorder, advanced HF at discharge, diastolic blood pressure, digoxin use, and fewer prescribed GDMs were independent predictors of one-year total mortality. After propensity score matching, patients with fewer prescribed GDMs had higher one-year total mortality rate than those with more prescribed GDMs (P=0.036). Conclusions: CKD at discharge from HF hospitalization was associated with fewer GDM prescriptions, particularly in patients with more advanced CKD. The propensity-matched analysis indicated that more GDM prescriptions led to better clinical outcomes in HFrEF patients with CKD. Careful interpretation of changes in renal function during HF hospitalization may improve GDM prescriptions.

Pulmonary arterial hypertension (PAH) is characterized as a progressive and sustained increase in pulmonary vascular resistance, which may induce right ventricular failure. In 2014, the Working Group on Pulmonary Hypertension of the Taiwan Society of Cardiology (TSOC) conducted a review of data and developed a guideline for the management of PAH.4 In recent years, several advancements in diagnosis and treatment of PAH has occurred. Therefore, the Working Group on Pulmonary Hypertension of TSOC decided to come up with a focused update that addresses clinically important advances in PAH diagnosis and treatment. This 2018 focused update deals with: (1) the role of echocardiography in PAH; (2) new diagnostic algorithm for the evaluation of PAH; (3) comprehensive prognostic evaluation and risk assessment; (4) treatment goals and follow-up strategy; (5) updated PAH targeted therapy; (6) combination therapy and goal-orientated therapy; (7) updated treatment for PAH associated with congenital heart disease; (8) updated treatment for PAH associated with connective tissue disease; and (9) updated treatment for chronic thromboembolic pulmonary hypertension. Keywords: Guideline, Pulmonary arterial hypertension, Pulmonary hypertension

Background: There are few reports about non-vitamin K antagonist oral anticoagulant (NOAC) treatment for resolution of left atrium (LA) or left atrial appendage (LAA) thrombus. LAA thrombus is an important cause of cardiogenic cerebral thromboembolism, and the detection rate increases due to more and more patients receiving catheter ablation. However, the results from NOAC use for LA or LAA thrombus are still unknown in real-world practice. The aim of this study was to discover the resolution of LA or LAA thrombus after anticoagulant treatment in real-world practice. Method: From January 2013 to December 2016, a total 864 patients underwent transesophageal echocardiography (TEE), and 41 cases of LA or LAA thrombus were detected in our hospital. Among them, a total of 22 patients underwent follow-up TEE to detect the resolution of LA or LAA thrombus. Result: The average age of the study patients was 72.0 ± 11 years old, and 61% were male. The average CHA2DS2-VASc scores were 3.76 ± 2.01 points. A total of 22 patients underwent follow-up TEE, and 19 (86.4%) patients presented LA or LAA thrombus resolution. The average resolution duration was 258.47 ± 218.17 days. One-year all-cause mortality was 4.9%, and the incidence of ischemic stroke was 4.9%. Most physicians favored titration of the dosage of NOAC or warfarin in real-world practice. Conclusion: In real-world practice, most physicians favored titration of the dosage of NOAC or warfarin for LA or LAA thrombus. LA or LAA thrombus could exist if the patient received a reduced dose of NOAC. High frequency of LAA or LA thrombi could resolve, and a low incidence of ischemic stroke occurred after adjustment of oral anticoagulant treatment.

This study tested the hypothesis that intra-coronary transfusion of circulation-derived autologous CD34+ cells can improve ischemia-related left ventricular dysfunction in patients with severe diffuse coronary artery disease refractory to medication and unsuitable for coronary intervention.A prospective, randomized, double-blinded phase I clinical trial.Tertiary care center.Thirty-eight patients with severe diffuse coronary artery disease were randomized into group 1 and group 2 receiving CD34+ cell infusion with dosages of 1.0 x 107 and 3.0 x 107 cells/vessel, respectively, after subcutaneous G-CSF injection (5 μg/kg twice a day for 4 d).Cardiac catheterization and intra-coronary administration of CD34+ cells.This clinical trial was to test effectiveness and safety of these two different dosages of CD34+ cells in the setting of severe diffuse coronary artery disease. Blood samples were collected for endothelial progenitor cell culture before and after granulocyte colony-stimulating factor injection for matrigel-assay and comparison of levels of soluble angiogenesis factors (vascular endothelial growth factor, epithelial growth factor, hepatocyte growth factor, angiopoietin-1, and transforming growth factor-β). Procedural safety was 100% with all patients uneventfully discharged. The numbers of endothelial progenitor cells in blood samples from coronary sinus after transfusion were higher than those in circulation, and the circulatory level was higher after granulocyte colony-stimulating factor treatment (all p0.001). Cardiac MRI and three-dimensional echocardiography at 6 month and angiographic follow-up at 9 month showed improvement in left ventricular ejection fraction (p0.001) and consistent increase in neovascularization (p0.001), respectively, in both groups. Despite good correlation in angiogenesis between 9-month angiography and matrigel-assay (p0.001), no significant correlation was noted in of soluble angiogenesis factor levels. Angina and heart failure were improved in both groups at 12-month follow-up (all p0.001). The survival rate at 18.5-month follow-up was 94.7% (n = 36).CD34+ cell therapy was safe and efficacious in improving heart function for patients with severe diffuse coronary artery disease unsuitable for coronary intervention and with poor response to pharmacotherapy.

Background Hypertension is common among patients who have undergone liver transplantation and is a major contributor to cardiovascular events. Few studies have studied the risk factors associated with post–liver transplantation (LT) hypertension. This prospective study assessed the prevalence of post-LT hypertension and associated preoperative risk factors. Methods From May 2008 to December 2009, 79 normotensive adult patients (≥18 years old) who underwent living-donor LT with a median follow up of 4.79 ± 0.88 years were enrolled. Patients' pre-LT demographics, clinical data, pre-LT diabetes, and immunosuppressive agents used after LT were studied for their association with post-LT hypertension. Results The prevalence of post-LT hypertension was 49.4%. The independent risk factors for post–living-donor LT hypertension were pre-LT systolic blood pressure (SBP; odds ratio [OR], 1.04; 95% confidence interval [CI], 1.00–1.09; P = .039) and post-LT administration of mammalian target of rapamycin (mTOR) inhibitors (OR, 4.08; 95% CI, 1.40–11.94; P = .010). Pre-LT diabetes had a negative predictive value (OR, 0.15; 95% CI, 0.03–0.74; P = .019). Neither age, male sex, smoking, pre-LT serum cholesterol and triglyceride levels, tacrolimus, nor glucocorticoid was associated with post-LT hypertension. Conclusions The prevalence of hypertension is high after LT. Higher pre-LT SBP and post-LT mTOR inhibitor administration predispose patients to post-LT hypertension.

Background This study aimed to evaluate the longitudinal changes in cardiac structure and function in incident-automated peritoneal dialysis (APD) patients. Methods We conducted a 2-year prospective, randomized, open-label, parallel-group study to compare the efficacy of icodextrin solution versus glucose-based solution. Echocardiography was performed at baseline, 1 and 2 years. Echocardiographic parameters over 2 years were evaluated for each group, using the Friedman test. Generalized linear regression analysis was used to test the associations between baseline clinical variables and echocardiographic changes, and a multivariate model was used to analyze cardiac function between the two groups. Results A total of 43 APD patients were enrolled in the beginning of this study. Twenty patients in the icodextrin group (ICO) and 18 patients in the glucose group (GLU) completed the study. In left ventricular (LV) systolic function measurements, ejection fraction (EF) increased significantly in the GLU group. Measurements of LV diastolic function and septal early mitral annulus velocity (EMV) increased significantly from baseline to 24-months in the ICO group (5.43–5.51 ms). The GLU group showed a significant decrease in peak early diastolic velocity (EDV) (70.67–68.25 cm/s), but a significant increase in septal EMV (5.94–7.57 ms) from baseline to 24-months. No significant association was found between the baseline clinical variables and echocardiographic changes within 24 months in the generalized linear regression analysis. Multivariate models were used to investigate changes in the four primary endpoints, namely, myocardial performance index (MPI), left ventricular ejection fraction (LVEF), deceleration time (DT), and E/e′ ratio. These primary endpoints show no significant association with the baseline values in both the ICO and GLU groups. Conclusion The present study demonstrates that long-dwell icodextrin solution can maintain reasonable cardiac structure and function in incident-APD patients. Trial registration ISRCTN14931270 (retrospectively registered on 23/03/2018).

Hepatocellular carcinoma (HCC) with intracavitary metastasis to the heart is rare. The incidence of HCC with right atrial metastasis is less than 6% at autopsy. Reports of HCC with right ventricular metastasis without inferior vena cava and right atrial metastasis are rarer. The diagnosis of metastasis of HCC into the cardiac cavity might be overlooked because the symptoms are neither apparent nor specific. Here, we report a patient with metastasis of HCC into the right ventricle cavity. The patient was in a disease-free status and experienced lower limbs oedema and gradual shortness of breath.

Varied methods for total chordal preservation in mitral valve replacement (MVR) have been presented with significant long-term advantage. However, it is difficult to preserve whole the mitral apparatus in the case of rheumatic mitral valvulopathy. Previously, we reported a technique for redo MVR referred to as conduit-onvalve replacement with satisfactory result. Based on the same concept, a procedure wherein a valved conduit is implanted on the undisturbed mitral apparatus was developed for preserving the whole mitral apparatus in the most physiologic orientation with minimal technical demand.

Background Angiotensin II (AngII) reportedly enhances stem cell proliferation, and type 1 angiotensin II receptor (AT1R) antagonists reduce angiogenesis in a rodent hindlimb ischemic model. Whether AT1R antagonists can alter the angiogenic activity of bone-marrow mesenchymal stem cells (BMSCs) is unknown. The purpose of this study is to investigate whether AT1R antagonists can alter the angiogenic activity of BMSCs and explore the potential mechanism for such an action. Methods Mouse BMSCs were isolated and treated with AngII, an AT1R antagonist, and a type 2 angiotensin II receptor (AT2R) antagonist. Angiogenic activity of BMSCs was detected by vascular endothelial growth factor (VEGF) secretion and tube formation of human umbilical vein endothelial cells (HUVECs). BMSCs isolated from enhanced green fluorescent protein (eGFP)-transgenic mice were allografted into ischemic hindlimbs in mice. Results The BMSCs constitutively expressed AT1Rs and AT2Rs. AngII treatment significantly increased VEGF secretion by BMSCs. Valsartan (AT1R antagonist) but not PD123319 (AT2R antagonist) treatment attenuated the AngII-induced promotion of VEGF synthesis by BMSCs. The AngII and AngII receptor antagonist control of angiogenic activity of BMSCs were confirmed by tube formation of HUVECs. AngII treatment promoted phosphorylated Ser473 Akt abundance in BMSCs. RNA interference of an isoform of AT1R, valsartan, and wortmannin treatments attenuated AngII-induced Akt phosphorylation. Allograft of BMSCs significantly increased blood flow and VEGF expression in the gastrocnemius muscles of ischemic hindlimbs, which was attenuated after valsartan treatment. Conclusions AT1R antagonists, via AT-1R/PI3K/Akt pathways, impair the AngII-induced promotion of angiogenic activity of mouse BMSCs.

Early pulmonary edema is common after orthotopic liver transplantation. Associated pathogenic mechanisms might involve increased activity of cardiac-inhibitory systems due to increased vasodilator production, mainly nitric oxide (NO). NO is primarily responsible for flow-mediated vasodilatation (FMD). We investigated the incidence of pulmonary edema in liver transplant patients and its correlation with FMD.We prospectively evaluated traditional risk factors, Doppler echocardiographic findings, derived hemodynamic data, and brachial artery nitroglycerin-induced vasodilatation (NTD) and FMD within 1 week prior to liver transplantation in 54 consecutive liver transplant patients with cirrhosis. Post-transplantation chest roentgenography was performed daily. In-hospital outcomes, transfusion volume of blood components, and hemodynamic data during surgery and at the intensive care unit were analyzed.Twenty-nine patients (53.7%) developed radiological pulmonary edema within 1 week of transplantation. Diffuse-type interstitial and alveolar pulmonary edema constituted 13 cases (24.1%). Patients with pulmonary edema had higher pretransplantation Child-Turcotte-Pugh scores (p = 0.01), cardiac output (p = 0.03), FMD (p0.01), NTD (p = 0.01), and FMD/NTD ratio (p = 0.02). Although the total volume of intravenous fluid transfused was higher in the pulmonary edema group, the net fluid retention during surgery was statistically insignificant. The lengths of intensive care unit stay and hospitalization, as well as mortality rates, were not different in these groups.The high incidence of pulmonary edema after living donor liver transplantation was associated with a high FMD and FMD/NTD ratio at pretransplantation. FMD is the only significant predictor associated with pulmonary edema. However, we observed no alteration in mortality rates.Cirrhotic cardiomyopathy; Flow-mediated vasodilatation; Liver transplantation; Pulmonary edema.

Background: Percutaneous coronary intervention (PCI) with stent implantation is now considered a safe and feasible treatment for stenosis of the unprotected left main coronary artery (ULMCA). Because few studies have focused on de novo distal ULMCA lesions, a propensity score-matched cohort study was conducted to compare bare metal stents (BMS) with drug-eluting stents (DES) for long-term outcomes following PCI. Methods and Results: This study reviewed the outcomes of patients undergoing PCI with DES (n=127) or BMS (n=51) for distal de novo ULMCA stenosis. The baseline demographic, angiographic and procedural characteristics differed between the 2 groups, indicating potential selection bias. The propensity score-matched cohort showed that the DES group had significantly less target lesion revascularization (TLR) and major adverse cardiovascular events (MACE) following PCI than the BMS group. Furthermore, heart failure (HF) of New York heart Association functional class III/IV was associated with an increased risk of TLR and MACE, whereas implantation of DES in patients with significant HF led to more favorable outcomes. Conclusions: Lower rates of TLR and MACE occurred in patients following PCI with DES implantation than with BMS implantation for distal ULMCA stenosis. Implantation of DES in patients with significant HF may improve the unfavorable outcome. When PCI is chosen to manage distal ULMCA stenosis, DES is the preferred stent type. (Circ J 2011; 75: 290-298)

Background: Long-term follow-up studies revealed a significant decline in the benefits of intracoronary radiation for in-stent restenosis. Methods and Results: A total of 25 study and 25 contemporaneous control patients with diffuse in-stent restenosis who underwent cutting balloon angioplasty (CBA) transradially, followed by subsequent intracoronary irradiation with a liquid β-emitter Rhenium-188 (188Re)-filled balloon were enrolled in the study. The mean clinical follow-up durations were 64.9±13.0 and 66.3±13.8 months for the irradiated and control patients, respectively. Six-month angiographic restenosis was observed in 16% (4 of 25) of the patients in the irradiated group and 48% (12 of 25) of the patients in the control groups (P=0.03). The 6-month major adverse cardiac events (MACE) rate was 12% and 44%, respectively (P=0.025). The 3-year follow-up angiography was performed in 16 of 21 (76%) irradiated patients and in 4 of 13 (31%) control patients who had no significant restenosis at the 6-month angiographic follow-up. Restenosis occurred in 1 of 16 (7%) irradiated patients and 2 of 4 (50%) control patients. Late target lesion revascularization was performed in 1 irradiated and 2 control patients. The MACE rate within 6 years was significantly reduced in the irradiated group (20% vs. 56%, P=0.019). Conclusions: Brachytherapy using 188Re-filled balloon following CBA for diffuse in-stent restenotic native coronary arteries is effective in reducing target lesion restenosis and improving long-term outcomes. (Circ J 2011; 75: 113-120)

We tested whether shock wave (SW) offers additional benefits in improving left ventricular (LV) function after acute myocardial infarction (AMI) in rabbits receiving SW-treated autologous bone marrow-derived mononuclear cells (BMDMNCs) transplantation.Saline (750 microL; group 2), BMDMNCs (1.0 x 10(7); group 3), or preimplant SW-treated BMDMNCs (group 4) were implanted into the infarct area of male rabbits 15 minutes after left coronary artery ligation, whereas eight rabbits without AMI served as controls (group 1; n = 8 per group). The results showed that in infarct area of LV, protein expressions of Cx43 and cytochrome C in mitochondria and endothelial nitric oxide synthase mRNA expression were lower in group 2 than in other groups, and decreased in group 3 as compared with groups 1 and 4 (all p values0.01). Conversely, mRNA expressions of endothelin-1 and matrix metalloproteinase-9, mitochondrial oxidative stress, and total fibrotic area were higher in group 2 than in other groups (all p values0.05). Furthermore, 6-month LV function by 2-D echo/angiogram showed significant impairment in group 2 than in other groups and in group 3 than in groups 1 and 4 (all p values0.005).Application of SW-treated autologous BMDMNCs is superior to BMDMNCs alone for preserving LV function after AMI.

Objectifs Nous avons examine si une onde de choc (OC) offre un benefice additionnel pour ameliorer la fonction ventriculaire gauche (VG) apres un infarctus du myocarde aigu (AMI) chez des lapins recevant une transplantation de cellules mononucleees de moelle osseuse autologue traitees par OC (BMDMNCs). Methodes et resultats Du serum physiologique (750 μL ; groupe 2), des BMDMNCs (1,0 × 107 ; groupe 3), ou des BMDMNCs traitees par OC avant implant (groupe 4) ont ete implantes dans la zone d’infarctus de lapins males 15 min apres ligature de l’artere coronaire gauche, tandis que huit lapins sans IMA servaient de controles (groupe 1 ; n = 8 par groupe). Les resultats ont montre que dans la region infarcie du VG, l’expression de la proteine Cx43 et du cytochrome C dans les mitochondries et l’expression endotheliale de l’ARNm de la synthetase de l’oxyde nitrique etaient moindres dans le groupe 2 que dans les autres groupes, et diminuees dans le groupe 3 par rapport aux groupes 1 et 4 (toutes valeurs de p Conclusions L’application de BMDMNCs autologues traitees par OC est superieure aux BMDMNCs seules pour preserver la fonction VG apres IMA.

We hypothesize that sildenafil attenuates pulmonary hypertension through suppressing pulmonary vascular remodeling. Thirty male adult Sprague-Dawley rats were randomized to receive saline injection (Group 1), subcutaneous monocrotaline (MCT) (60 mg/kg) (Group 2), and MCT plus oral sildenafil (30 g/kg per day) (Group 3) 5 days after MCT administration. By Day 35, Western blot showed lower connexin43 and membranous protein kinase C epsilon expressions but higher oxidative stress in right ventricle in Group 2 compared with the other groups. Additionally, pulmonary Smad1/5 was lowest, whereas connexin43 and Smad3 were highest in Group 2. Pulmonary mRNA expressions of tumor necrosis factor-alpha, caspase-3, plasminogen activator inhibitor-1, and transforming growth factor-beta were higher, whereas bone morphogenetic protein Type II receptor, Bcl-2, and endothelial nitric oxide synthase were lower in Group 2 than in the other groups. Similarly, mRNA expressions of tumor necrosis factor-alpha, caspase-3, and beta-myosin heavy chain were increased, whereas Bcl-2, endothelial nitric oxide synthase, and alpha-myosin heavy chain expressions in right ventricle were reduced in Group 2 compared with the other groups. Number of lung arterioles was lowest, whereas number of arterioles with muscularization of the medial layer was highest in Group 2. Right ventricle systolic pressure and weight were elevated in Group 2 compared with the other groups. In conclusion, sildenafil effectively alleviates MCT-induced pulmonary hypertension through suppressing pulmonary vascular remodeling.

The optimal right ventricular pacing site remains controversial. The aim of this study was to assess how acute right ventricular outflow tract (RVOT) pacing affects global left ventricular function and intraventricular dyssynchrony of the left ventricle.Thirty-six patients with sick sinus syndrome and intact intrinsic atrioventricular conduction were enrolled. All patients underwent dual-chamber permanent pacemaker implantation, with the atrial lead placed in the right atrial appendage and the right ventricle lead positioned at the septal site of the RVOT. Chamber size, dyssynchrony index, myocardial performance index, and global left ventricular ejection fraction were determined using transthoracic two-dimensional echocardiography, tissue Doppler echocardiography, and real-time three-dimensional echocardiography.RVOT pacing increased the myocardial performance index (0.42 +/- 0.21 with RVOT pacing vs 0.35 +/- 0.21 without RVOT pacing, P = .002) and decreased the global left ventricular ejection fraction on real-time 3-dimensional echocardiography (51.4 +/- 6.2% with RVOT pacing vs 55.9 +/- 7.1% without RVOT pacing, P = .001). Intraventricular dyssynchrony of the left ventricle induced by RVOT pacing was determined by increased septal-to-posterior wall motion delay (69.7 +/- 54.0 ms with RVOT pacing vs 22.8 +/- 22.3 ms without RVOT pacing, P.0001), increased systolic and diastolic dyssynchrony by tissue Doppler echocardiography, and increased systolic dyssynchrony index when assessed using real-time three-dimensional echocardiography (5.56 +/- 1.74% with RVOT pacing vs 4.05 +/- 1.61% without RVOT pacing, P.0001).Acute RVOT pacing adversely affects left ventricular function and increases intraventricular dyssynchrony in patients with sick sinus syndrome.

Background: Although recent studies suggest that percutaneous coronary intervention (PCI) with drug-eluting stents (DES) achieves clinical outcomes comparable to coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (ULMCA) disease, long-term studies are rarely performed. Methods and Results: This study reviewed outcomes in 363 patients undergoing CABG (n=216), PCI with DES (n=94) or PCI with bare-metal stent (BMS) (n=53) for ULMCA stenosis between January 2000 and March 2007. The CABG group had more patients with diabetes (50.5%) and 3- or 4-vessel disease (77.3%) than the PCI group. Kaplan-Meier survival estimates showed higher TLR-free survival and revascularization-free survival in CABG group. Although cardiac-death-free survival did not significantly differ between the 3 groups, the DES group had the highest overall survival. Age (hazard ratio (HR): 1.060; 95% confidence interval (CI): 1.017-1.104) and diffuseness score (HR: 1.157; 95%CI: 1.019-1.313) were significant independent risk factors for cardiac death. Conclusions: There was higher TLR in the PCI group with either DES or BMS, but cardiac death did not significantly differ between the 3 groups. Advanced age and diffuse coronary atherosclerosis may increase the risk of cardiac death following revascularization. (Circ J 2009; 73: 705 - 712)

Background Acute ST-segment elevation myocardial infarction (STEMI) caused by left main coronary artery (LMCA) obstruction is uncommon. Although the link between this catastrophic disease and very high mortality is well recognized, even after undergoing emergent revascularization, the systemic risk stratification and long-term outcome are currently unclear. The clinical presentation, parameter-related in-hospital death and long-term outcomes of these patients with acute LMCA obstruction undergoing emergency revascularization were carefully reviewed. Methods and Results From January 2000 through December 2007, 1,588 patients were diagnosed to have STEMI and received emergent cardiac catheterization. The 38 (2.4%) of these 1,588 patients were enrolled into the present study due to LMCA obstruction. The analytical results identified the 30-day mortality rate as 42.1% (16/38). Multivariate analysis demonstrated that renal insufficiency was independently predictive of in-hospital mortality (odds ratio (OR): 5.642; p=0.029), whereas successful revascularization was independently predictive of freedom from in-hospital mortality (OR: 0.174; p=0.044). The cut-off value of a Parsonnet score >20 was strongly associated with 30-day mortality (p=0.002). Conclusions Even undergoing emergency revascularization for patients with acute LMCA obstruction, the in-hospital mortality remains very high. Additionally, the worse clinical outcome was observed in those with renal insufficiency and Parsonnet score of >20. (Circ J 2008; 72: 1598 - 1604)

Background Percutaneous coronary intervention (PCI) is considered an excellent alternative treatment for unprotected left main coronary artery (ULMCA) stenoses. Most PCIs for ULMCA stenoses are performed via the transfemoral approach. The feasibility and safety of the transradial approach for this particular entity are unknown. The present study assessed the feasibility, safety and 1-year outcomes of the transradial approach for stenting of ULMCA stenoses. Methods and Results Of 131 consecutive patients who underwent coronary stenting for ULMCA stenoses, 113 patients (86.3%) received stenting using the transradial approach. All 113 procedures were performed with 6 or 7 French (Fr) catheters except 1 procedure requiring an 8 Fr guiding catheter for directional atherectomy. The technical success rate was 100%, and angiographic success was achieved in 96 patients (85.9%). Two patients had local hematoma (1.8%), and no procedure-related deaths, Q-wave myocardial infarction, repetitive PCI, stroke or emergent coronary artery bypass graft surgery during hospitalization were noted. One (0.9%) in-hospital cardiac death occurred due to ventricular tachyarrhythmia. More than half of our patients stayed in hospital by ≤3 days. The 1-year target lesion revascularization and cardiac death rate were 14.2% and 3.5%, respectively. Conclusions This investigation demonstrated the feasibility, safety and accepted short-term clinical outcomes of transradial stenting for ULMCA stenosis. This procedure may offer a feasible alternative to the transfemoral approach. (Circ J 2007; 71: 855 - 861)

Background Because of different dosages, the efficacy of adjunctive tirofiban therapy for primary percutaneous coronary intervention (PCI) is currently unclear. The hypothesis that a double bolus regimen of tirofiban will improve angiographic and clinical outcomes in patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing PCI was tested in the present study. Methods and Results Primary PCI was performed in 217 STEMI patients: 80 received standard PCI (control group) and 137 received tirofiban (tirofiban group). Tirofiban was given as a bolus (10 mg/kg) in the emergency room and again upon arrival at the cardiac catheterization laboratory, followed by infusion of 0.15 mg · kg-1 · min -1 until the total dose reached 12.5 mg. The primary endpoint was emergency target vessel revascularization, recurrent myocardial infarction, or cardiovascular mortality at 30 days and 1 year. Baseline clinical and angiographic variables of the 2 groups were similar, as were angiographic results after PCI and bleeding complications at 30 days. The primary 30-day and 1-year endpoints were 5.1% and 11.7% in the tirofiban group, respectively, vs 10.0% (p=0.171) and 18.8% (p=0.151) in the control group. Conclusion Although angiographic and clinical benefits were not demonstrated, the results suggest that research into an effective and uniform dosing regimen of adjunctive tirofiban therapy for PCI is warranted. (Circ J 2006; 70: 536 - 541)

Inflammation plays an important pathogenic role in the initiation and progression of atherosclerotic plaque lesions. C-reactive protein (CRP), which directly participates in plaque inflammation, induces vascular cell adhesion molecule-1 (VCAM-1) expression in endothelial cells. However, the levels and values of high-sensitivity (hs)-CRP, white blood cell (WBC) count, and VCAM-1 in both stable and unstable angina pectoris (AP) have not been fully investigated. This study examines the levels and values of these inflammatory markers in patients with stable or unstable AP. From March 2003 to December 2003, a prospective cohort study was conducted in 128 consecutive patients, including unstable AP patients (class I: n = 59; combined class II and III: n = 16) and stable AP patients (n = 53) undergoing elective coronary stenting. Blood samples for hs-CRP, WBC count, and VCAM-1 were obtained in the catheterization laboratory before coronary angiography. The circulating levels of hs-CRP and VCAM-1 were also evaluated in 40 healthy volunteers. The circulating levels of these three inflammatory markers were substantially higher in patients than in healthy volunteers (all P values < 0.0001). Additionally, circulating levels of hs-CRP and the WBC count were significantly higher in patients with unstable AP than in patients with stable AP (all P value < 0.0001). However, only those patients with class II and III unstable AP had significantly higher circulating levels of VCAM-1 than patients with stable AP (P < 0.0001). On the other hand, the circulating levels of VCAM-1 did not differ between patients with class I unstable AP and patients with stable AP (P = 0.782). Multiple stepwise logistic regression analysis showed that only hs-CRP level was independently associated with unstable AP (P = 0.0002). In conclusion, circulating levels of hs-CRP, WBC count, and VCAM-1 were significantly increased in patients with AP. The circulating level of hs-CRP was strongly associated with the clinical setting of unstable AP.

The purpose of this randomised, double-blind, double-dummy, parallel-group study was to evaluate the efficacy and tolerability of telmisartan 40 mg once daily vs. enalapril 10 mg once daily in 147 Taiwanese patients with mild-to-moderate essential hypertension (diastolic blood pressure [DBP] 90-109 mmHg). After 6 weeks' treatment, telmisartan produced a significantly greater reduction from baseline in the primary endpoint of trough seated DBP compared with enalapril 10 mg (11.7 vs. 8.7 mmHg, respectively; p = 0.02). Numerically greater reductions compared with baseline in seated systolic blood pressure (SBP), standing DBP, and standing SBP were achieved with telmisartan compared with enalapril. Also, numerically greater proportions of patients achieved blood pressure control (DBP/systolic blood pressure [SBP] or = 10 mmHg and/or post-treatment DBP or = 10 mmHg and/or post-treatment SBP

Study objective To assess the feasibility and short-term outcome of intracoronary irradiation after pure balloon angioplasty (POBA) of de novo and post-POBA restenotic lesions with a liquid β-emitter 188 Re-filled balloon. Design and setting Nonrandomized prospective study with contemporaneous control group in a single medical center. Patients and methods In the Taiwan Radiation in Prevention of Post-Pure Balloon Angioplasty Restenosis study, 40 patients underwent 14-Gy irradiation and 15 patients underwent 20-Gy irradiation at a tissue depth of 0.5 mm after POBA. Thirty control patients received a 5-min inflation with a perfusion balloon catheter after POBA. Results No procedural or in-hospital complications, or 30-day major adverse cardiac events were noted. Six-month angiographic restenosis rates were 49% in the 14-Gy group, 20% in the 20-Gy group, and 57% in the control group (p = 0.05, 20-Gy group vs control group). In the lesions with an arc of calcification of Conclusions Post-POBA, catheter-based brachytherapy in nonstented native coronary artery with a 188 Re-filled balloon can effectively reduce target lesion restenosis with 20-Gy irradiation at a tissue depth of 0.5 mm and seems to be more effective in the treatment of lesions with an arc of calcification

Background: Simultaneous ST-segment elevation in the precordial and inferior leads is a rare ECG finding in patients with acute myocardial infarction (AMI) and its clinical implications rarely have been reported. The purpose of this study was to evaluate the clinical features of this distinctive ECG manifestation and its impact on clinical outcome. Methods and results: Between May 1993 and July 2001 in our hospital, direct percutaneous coronary intervention (dPCI) was performed in 924 patients with AMI. Of these 924 consecutive patients, 37 patients (4.0%) who had simultaneous ST-segment elevation (≥ 1 mm) in the precordial and inferior leads were retrospectively analyzed. Eight of these 37 patients who had a wrapped left anterior descending artery (LADA) occlusion were placed into group 1 ( ie , wrapped LADA). Twenty-nine of the 37 patients who had anatomic lesions other than a wrapped LADA in the coronary arteries were placed into group 2 ( ie , “nonwrapped” LADA). Group 2 patients had significantly higher incidences of cardiogenic shock (58.6% vs 0%, respectively; p = 0.004), pulmonary edema (43.8% vs 0%, respectively; p = 0.02), and sustained sudden cardiac death due to malignant ventricular tachyarrhythmias (44.8% vs 0%, respectively; p = 0.03) than did group 1 patients. Group 1 patients usually had ST-segment elevations of ie , stenosis of > 85%) [93.1% vs 0%, respectively; p = 0.0001] were significantly higher in group 2 than in group 1 patients. Although there was no significant difference in the rate of unsuccessful reperfusion (24% vs 13%, respectively; p = 0.38) between group 2 and group 1 patients, the 30-day mortality rate was significantly higher in group 2 patients than in group 1 patients (48.3% vs 0%, respectively; p = 0.015). Conclusions: AMI with ECG manifestation of simultaneous ST-segment elevation in precordial and inferior leads can be caused by either a wrapped LADA occlusion or a nonwrapped LADA occlusion. While patients with wrapped LADA occlusions usually have favorable clinical outcomes, patients with nonwrapped LADA occlusions usually have serious clinical presentations and unfavorable clinical outcomes. Specific clinical and ECG features identifying high-risk patients in this clinical setting would be extremely important for early, aggressive, and appropriate management.

It has long been established that advanced age is not only associated with greater myocardial infarction frequency but also greater mortality and morbidity. The treatment of acute myocardial infarction (AMI) in 80 year old patients remains problematic with conflicting results; in these patients, the risks of conservative treatment are high and the risks and benefits of thrombolytic therapy are still controversial. The purpose of this study was to evaluate whether primary angioplasty can offer an important alternative method to improve short- and long-term outcomes in octogenarian or older patients who experience AMI. Between May 1986 and March 2000, 171 consecutive 80 year old patients hospitalized for AMI were not randomized to be registered and divided into a medical therapy group (group 1: an historical control group, n=11) and a primary angioplasty group (group 2, n=60). In-hospital mortality was markedly increased with advanced Killip scores (Killip 3 or 4) in both groups. Twenty-four hours after admission, group 1 patients had a significantly higher incidence of progression to higher Killip scores than did group 2 patients (P=0.006). The 30-day overall mortality of group 2 patients was significantly lower than in group 1 patients (30.0% vs 54.1%, P=0.003). Patients without cardiogenic shock treated by primary angioplasty had a significantly lower incidence of overall mortality at 30 days than patients without cardiogenic shock treated conservatively [3.1% vs 24.3%, P=0.016 (Killip 1 and 2); 18.2% vs 52.6%, P=0.044 (Killip 3)]. However, the mortality rate of cardiogenic shock was extremely high and did not differ significantly between groups I and 2 (86.1% vs 88.2%, P=0.99). The 3-year cumulative survival rate was significantly higher in group 2 than in group 1 patients (P=0.0009). In conclusion, primary angioplasty is feasible and effective, and can improve short-and long-term mortalities in octogenarian or older patients with AMI but without cardiogenic shock.

Case report A 79-year-old housewife experienced sudden-onset chest tightness and was diagnosed with an inferoposterior wall myocardial infarction (MI). Coronary angiography showed two-vessel coronary artery disease with lesions of 70–80 % stenosis of the proximal left anterior artery (LAD) and total occlusion of the proximal left circumflex artery (LCX). An emergent percutaneous coronary intervention (PCI) was performed for the culprit lesion of the proximal LCX. It took about 6 h from chest tightness to revascularization. Transthoracic echocardiogram (TTE) showed impaired left ventricular performance (LVP), with mild mitral regurgitation. Two weeks later, a chest radiography showed progressive left lower lung consolidation. Uncontrolled pneumonia was resent initially; however, symptoms of advanced heart failure progressed. Therefore, PCI was performed for the lesion of the proximal LAD. Unfortunately, symptoms of heart failure did not improve after total coronary revascularization and optimal medical treatment. The anteroposterior view showed delayed regression of the left lower lung consolidation (Fig. 1a), and the lateral view showed a giant bulging mass in the posterior wall of the heart (Fig. 1b). Follow-up TTE showed poor LVP (LV ejection fraction: 36 %), posterior and lateral wall near akinesia, and moderate mitral regurgitation. A huge pseudoaneurysm (diameter 5.5 cm) of the inferoposterior aspect of the lateral wall of the LV (Fig. 2a, b; supplemental Fig. S1) presented with a narrow base and was contained by the pericardium. Chest computed tomography showed a single 7.4 9 8.0-cm lobulated pseudoaneurysm abutting the posterior wall of the LV (Fig. 2c). The surgical intervention performed was concomitant LV repair and mitral valve repair. Then, the patient died due to uncontrolled heart failure one month after surgery.

Background Although acute left main coronary artery (LMCA) occlusion is a rare clinical entity, it carries a very high mortality rate. The purposes of this study were to evaluate the effect of primary angioplasty for a severely obstructed or totally occluded LMCA, and to determine the incidence, clinical features, outcome, and prognostic determinants in this clinical setting. Materials and methods Between May 1993 and July 2000, a total of 740 patients with acute myocardial infarction underwent primary angioplasty in our hospital. Eighteen of 740 patients (2.4%) with a severely obstructed or totally occluded LMCA constituted the population of this study. Results Seventeen of 18 patients (94.4%) experienced pulmonary edema (including 14 patients in cardiogenic shock). Six patients (33.3%) sustained sudden death due to malignant ventricular tachyarrhythmias. Coronary angiography showed that there were variable grade flow of intercoronary collaterals in 12 patients (66.7%), a totally occluded LMCA in 8 patients (44.4%), an incompletely occluded LMCA in 10 patients (55.6%), and a dominant right coronary artery (RCA) in 16 patients (88.9%). Primary angioplasty of the LMCA was performed with a 72.2% procedural success rate. Four patients (22.2%) received coronary artery bypass surgery after angioplasty. Six patients (33.3%) died in the hospital. Two patients died after discharge. Ten of 18 patients (55.6%) survived in long-term follow-up (mean ± SD, 44 ± 14 months). Those patients who survived to be discharged had significantly higher combined coexisting incidence of intercoronary collaterals, dominant RCA, and incompletely occluded LMCA (100% vs 0.0%, p = 0.0006) than those patients who died in the hospital. Conclusions Acute obstructive LMCA disease generally presented as pulmonary edema, cardiogenic shock, or sudden death. Only those who had combined coexistence of intercoronary collaterals, a dominant RCA, and an incompletely occluded LMCA could survive to be discharged. Our experience suggests that primary LMCA angioplasty is a feasible and effective procedure, and it may save lives in this clinical setting.

Background While coronary dissection, which is one ofthe most frequently occurring complications during interventionalprocedures, has various forms, extensive coronary dissection retrogradeto the coronary sinus of Valsalva (CSV) is very rarely observed. Methods and results Within the last 5 years, weretrospectively reviewed our experience with 4,700 consecutive patientswho underwent angioplasty procedures, 7 of whom (0.15%) developedextensive coronary dissection retrograde to the CSV. Six of the sevenpatients developed retrograde dissection of the right CSV duringangioplasty to the right coronary artery. One of the seven patentsdeveloped retrograde dissection of the left CSV during angioplasty tothe left anterior descending artery. Retrograde dissection, whichextended to the ascending aorta in two patients, was observed bytransthoracic echocardiography and surgical findings, respectively. Five patients were successfully treated by coronary stenting. However, this complication caused four patients to have acute myocardialinfarctions, resulting in emergency surgery for one patient andin-hospital death for another. Conclusions Ourexperience increased our understanding of this very rarecomplication. However, this complication may be lifethreatening, and patients in this clinical setting may have a potentialrisk for acute myocardial infarction, emergency surgery, or even suddencardiac death. Therefore, it is important to learn how to promptlydiagnose and manage this complication.

Bipolar leads are most commonly used in the current practice of pacemaker therapy. In our study of 124 patients implanted with Guidant/Cardiac Pacemakers (CPI) Vigor dual chamber pacemakers, 5 patients had unexpectedly abrupt increases in bipolar lead impedance and pacing threshold 2 weeks to 18 months postimplantation without changes in sensing function. With the lead configuration reprogrammed to unipolar, the lead impedance and pacing threshold were restored to appropriate ranges. The changes in bipolar lead parameters can be caused by the CPI's "Quick Connect" (QC1) header lead system incorporated in these pacemakers.

The aim of this study was to obtain data on the outcomes of chronic hemodialysis patients who underwent percutaneous transluminal coronary angioplasty (PTCA). A retrospective chart analysis identified 31 such patients between August 1992 and October 1996. The mean follow-up period was 12.4 +/- 11.7 months. Angiographic success was achieved in 39 of 41 (95.1%) stenoses attempted. There were three in-hospital deaths. Clinical success was achieved in 28 of 31 patients (90%). Two of the 28 survivors were lost to follow-up. Recurrent angina developed within 6 months in 14 of 26 patients (53.8%). Eleven and 17 of the 26 patients (42.3% and 65.4%) died within 6 and 14 months, respectively, after the PTCA procedure. Ten of the 17 deaths (58.8%) were due to cardiovascular events. Our study suggests that PTCA is technically feasible with high angiographic success rate in chronic hemodialysis patients. In-hospital mortality rate and rate of recurrent angina are high. Long-term prognosis is poor.

Background. Previous studies have shown that the maze operation can restore sinus rhythm and atrial transport function in patients with chronic atrial fibrillation. The purpose of this study was to test the feasibility of the application of radiofrequency and cryoablation as an alternative to the classic maze operation. Methods. Twelve patients undergoing mitral valve procedures were included in this study. Radiofrequency and cryoablation were applied to create lesions in both atria to simulate the classic maze operation. Results. There were two surgical deaths. At the mean follow-up of 10.25 months for the remaining 10 patients; 6 were in sinus rhythm, 2 in atrial rhythm, 1 in paroxysmal atrial tachycardia, and 1 in atrial fibrillation. Doppler echocardiography at 6-month follow-up showed emergence of biatrial transport function in 3 patients and right atrial contractility in 8. At 12-month follow-up of 5 patients, Doppler echocardiography showed biatrial transport function in 3 and right atrial contractility in 4. Conclusions. Our modified maze procedure during valvular operation is effective for achieving an acceptable success rate to restore sinus rhythm and atrial transport function in patients with chronic atrial fibrillation.

We report on a rare case of anomalous origin of left coronary artery from the noncoronary sinus of Valsalva. Intraaortic intravascular ultrasound study identified the origin of the left coronary artery and facilitated subsequent selective coronary angiography of the artery.

Radial artery punctures for diagnostic coronary angiography or coronary balloon angioplasty were performed in 211 patients with a success rate of 98% (207 patients). In the four failed transradial accesses, the procedure was accomplished via the transfemoral route. Major local vascular complications included one arteriovenous fistula, one pseudoaneurysm, and one ischemic contracture of the right hand. Reduced radial pulses were noted in 25 (12%) patients at follow-up without ischemic manifestations. Transradial diagnostic coronary angiography was successfully completed in 184 (98%) of 187 patients. The technical success for balloon angioplasty was obtained in 73 (97%) of 75 patients. Clinical success was observed in 68 (91%) patients; balloon angioplasty resulted in one nonfatal myocardial infarction and four late deaths (3 cardiac and 1 stroke). We believe that transradial catheterization for diagnostic coronary angiography and balloon angioplasty in our relatively small built Chinese population is a safe and practical alternative approach. Cathet. Cardiovasc. Diagn. 40:159–163, 1997. © 1997 Wiley-Liss, Inc.

Objective To examine the utility of intracardiac echocardiography in guiding complex transseptal catheterization of patients undergoing percutaneous transvenous mitral commissurotomy. Design We assessed this procedure in high-risk patients in whom transseptal catheterization is technically complex and more demanding. Material and Methods Fifteen patients with mitral stenosis were studied. Twelve patients had giant left atria (70 mm or more), two had atrial septal aneurysms, and one had severe kyphoscoliosis. A newly developed 8-F 10-MHz intracardiac transducer catheter was placed in the right atrium through an 8-F Mullins sheath inserted from the left femoral vein. Echocardiographic images were used to confirm the septal position of the Brockenbrough needle tip before septal punctures. Results Transseptal puncture was successful and uncomplicated in all 15 patients. Use of intracardiac echocardiography eliminated the need for atrial angiography. Before transseptal puncture, the needle tip was identified to be in contact with the atrial septum, as an echogenic point with its acoustic shadow and septal indentation. In addition, in the two patients with aneurysms, puncture of the thin-walled aneurysms was avoided. Conclusion Intracardiac echocardiography facilitates safe complex transseptal catheterization in patients with mitral stenosis and giant left atria, atrial septal aneurysms, or severe kyphoscoliosis.

Background This study tested the hypothesis that autologous transplantation of adipose-derived mesenchymal stem cells (ADMSCs) can effectively attenuate acute pulmonary ischemia-reperfusion (IR) injury. Methods Adult male Sprague-Dawley (SD) rats (n = 24) were equally randomized into group 1 (sham control), group 2 (IR plus culture medium only), and group 3 (IR plus intravenous transplantation of 1.5 × 106 autologous ADMSCs at 1h, 6h, and 24h following IR injury). The duration of ischemia was 30 minutes, followed by 72 hours of reperfusion prior to sacrificing the animals. Blood samples were collected and lungs were harvested for analysis. Results Blood gas analysis showed that oxygen saturation (%) was remarkably lower, whereas right ventricular systolic pressure was notably higher in group 2 than in group 3 (all p < 0.03). Histological scoring of lung parenchymal damage was notably higher in group 2 than in group 3 (all p < 0.001). Real time-PCR demonstrated remarkably higher expressions of oxidative stress, as well as inflammatory and apoptotic biomarkers in group 2 compared with group 3 (all p < 0.005). Western blot showed that vascular cell adhesion molecule (VCAM)-1, intercellular adhesion molecule (ICAM)-1, oxidative stress, tumor necrosis factor-α and nuclear factor-κB were remarkably higher, whereas NAD(P)H quinone oxidoreductase 1 and heme oxygenase-1 activities were lower in group 2 compared to those in group 3 (all p < 0.004). Immunofluorescent staining demonstrated notably higher number of CD68+ cells, but significantly fewer CD31+ and vWF+ cells in group 2 than in group 3. Conclusion ADMSC therapy minimized lung damage after IR injury in a rodent model through suppressing oxidative stress and inflammatory reaction.

Background This study evaluated the 30-day clinical outcome of patients with acute inferior wall ST-elevation myocardial infarction (AIW-STEMI) from occlusion of the left circumflex artery (LCX) vs the right coronary artery (RCA) undergoing primary percutaneous coronary intervention (PCI). Hypothesis The clinical outcomes of AIW-STEMI caused by RCA and LCX occlusion may be different for patients undergoing primary PCI. Methods Between May 2002 and September 2009, 646 consecutive patients with AIW-STEMI undergoing primary PCI were enrolled. Of these patients, 520 (80.5%) with AIW-STEMI caused by RCA occlusion were categorized into group 1, whereas the remaining 126 (19.5%) whose AIW-STEMI was caused by LCX occlusion served as group 2. Results The results demonstrated that the frequency of advanced congestive heart failure, respiratory failure requiring mechanical ventilatory support, and 30-day mortality were remarkably higher in group 2 than in group 1 (all P < 0.01). Conversely, the incidence of right ventricular infarction and complete heart block were notably higher in group 1 than in group 2 (all P < 0.001). Additionally, the peak level of creatine kinase-isoenzyme MB was significantly higher, whereas the left ventricular ejection fraction was notably lower in group 2 than in group 1. Multivariate analysis demonstrated that advanced CHF, high serum creatinine level, low systolic blood pressure, low left ventricular ejection fraction, and LCX as the infarct-related artery were significantly and independently predictive of 30-day mortality (all P < 0.05). Conclusions The 30-day prognostic outcome was less favorable in LCX-related AIW-STEMI compared with RCA-related AIW-STEMI undergoing primary PCI. Copyright © 2011 Wiley Periodicals, Inc. Chi-Ling Hang, MD, contributed equally in this study with Yung-Lung Chen, MD. Morgan Fu, MD, contributed equally in this study with Hon-Kan Yip, MD. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Objectives: Little is known about the outcomes of patients with Killip class III acute ST-segment elevation myocardial infarction in the reperfusion era. This study investigated the short- and long-term outcomes of these patients who underwent primary percutaneous coronary intervention. Methods: Between January 2002 and November 2009, a total of 1,278 consecutive patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 230 (17.0%) with Killip III, 216 (16.9%) with Killip II, and 832 (65.1%) with Killip I upon presentation were prospectively recruited. Results: Angiographic study showed significantly lower final thrombolysis in myocardial infarction 3 flow in patients with Killip III compared with those with Killip II and I (83.5% vs. 94.9% vs. 95.7%, p < .0001). The incidence of multiple vessel disease was also notably higher in Killip III than in Killip II and I (65.7% vs. 13.9% vs. 53.8%, p < .001). Besides, the incidence of advanced congestive heart failure (defined as greater than or equal to New York Heart Association functional class 3) during hospitalization was remarkably higher in Killip III compared to Killip II and I (71.3% vs. 13.9% vs. 6.6%, p < .001). Furthermore, the 30-day mortality and 1-yr cumulative mortality were notably higher in Killip III than in Killip II and I (20.0% vs. 4.2% vs. 1.7%, p < .001 and 31.7% vs. 7.9% vs. 4%, p < .001, respectively). Multivariate analysis showed that Killip III was independently predictive of 30-day and 1-yr mortality (all p < .04). Conclusion: Killip III remains strongly and independently predictive of 30-day and 1-yr mortality in ST-segment elevation myocardial infarction patients even undergoing primary percutaneous coronary intervention.

An optimal treatment for patients with diffuse obstructive arterial disease unsuitable for catheter-based or surgical intervention is still pending. This study tested the hypothesis that extracorporeal shock wave (ECSW) therapy may be a therapeutic alternative under such clinical situation. Myocardial ischemia was induced in male mini-pigs through applying an ameroid constrictor over mid-left anterior descending artery (LAD). Twelve mini-pigs were equally randomized into group 1 (Constrictor over LAD only) and group 2 (Constrictor over LAD plus ECSW [800 impulses at 0.09 mJ/mm(2)] once 3 months after the procedure). Results showed that the parameters measured by echocardiography did not differ between two groups on days 0 and 90. However, echocardiography and left ventricular (LV) angiography showed higher LV ejection fraction and lower LV end-systolic dimension and volume in group 2 on day 180 (p

Percutaneous coronary intervention (PCI) with stent implantation is now considered a safe and feasible treatment for stenosis of the unprotected left main coronary artery (ULMCA). Because few studies have focused on de novo distal ULMCA lesions, a propensity score-matched cohort study was conducted to compare bare metal stents (BMS) with drug-eluting stents (DES) for long-term outcomes following PCI.This study reviewed the outcomes of patients undergoing PCI with DES (n=127) or BMS (n=51) for distal de novo ULMCA stenosis. The baseline demographic, angiographic and procedural characteristics differed between the 2 groups, indicating potential selection bias. The propensity score-matched cohort showed that the DES group had significantly less target lesion revascularization (TLR) and major adverse cardiovascular events (MACE) following PCI than the BMS group. Furthermore, heart failure (HF) of New York heart Association functional class III/IV was associated with an increased risk of TLR and MACE, whereas implantation of DES in patients with significant HF led to more favorable outcomes.Lower rates of TLR and MACE occurred in patients following PCI with DES implantation than with BMS implantation for distal ULMCA stenosis. Implantation of DES in patients with significant HF may improve the unfavorable outcome. When PCI is chosen to manage distal ULMCA stenosis, DES is the preferred stent type.

Sildenafil and bone marrow-derived endothelial progenitor cells (BMDEPCs) have been shown to ameliorate monocrotaline (MCT)-induced pulmonary arterial hypertension (PAH) in the rat. We test whether combined sildenafil and BMDEPC treatment exerts additional protection against MCT-induced PAH in rats.Male Sprague-Dawley rats were randomized to receive saline injection only (group 1), MCT (70 mg/kg) only (group 2), MCT plus autologous BMDEPC (2.0×10(6) cells) transplantation (group 3), MCT with sildenafil (30 mg/kg/day) (group 4), and MCT with combined BMDEPCs-sildenafil (30 mg/kg/day) (group 5). Intravenous BMDEPC and oral sildenafil were given on day 3 after MCT administration. Hemodynamics were analyzed using Labchart software, whereas cellular and molecular parameters were measured using flow cytometry, real-time PCR, TUNEL assay, Western blot, and immunohistochemical staining.By day 35 following MCT treatment, lower expression of connexin43, protein kinase C-ε, Bcl-2, and endothelial nitric oxide synthase and higher expression of tumor necrosis factor-α and caspase 3 were found in right ventricle (RV) and lung in group 2 compared with other groups (all p0.05). The number of alveolar sacs and lung arterioles were also lower in group 2 than in other groups (all p0.05). Furthermore, RV systolic pressure (RVSP), RV weight, and RV-to-final body weight ratio were substantially increased in group 2 than in other groups, and notably higher in groups 3 and 4 than in groups 1 and 5 (all p0.0001).Combined therapy with autologous BMDEPC and sildenafil is superior to either BMDPEC or sildenafil alone for preventing MCT-induced PAH.

Background: The impact of primary percutaneous coronary intervention (PCI) for acute ST-elevated myocardial infarction (STEMI) on the incidence of ischemic mitral regurgitation (IMR) is unclear. Methods and Results: Between January 2000 and December 2004, 318 patients presenting with first acute STEMI were enrolled in this study. Two hundred and twelve (66.67%) patients received PCI (PCI group), and 106 age- and Killip class-matched patients received medical management (non-PCI group). The median duration of follow up was 40.46 months. Compared to the non-PCI group, the PCI group had 14.6% (9.9% vs 24.5%) fewer patients with moderate or severe IMR (P