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The global coronavirus disease-2019 (COVID-19) pandemic is associated with reduced rate of percutaneous coronary intervention (PCI). However, there were a few data showing how emergency medical system (EMS) and management strategies for acute coronary syndrome (ACS) changed during the pandemic. We sought to clarify changes on characteristics, treatments, and in-hospital mortality of patients with ACS transported via EMS between pre- and post-pandemic. We examined consecutive 656 patients with ACS admitted to Sapporo City ACS Network Hospitals between June 2018 and November 2021. The patients were divided into pre- and post-pandemic groups. The number of ACS hospitalisations declined significantly during the pandemic (proportional reduction 66%, coefficient − 0.34, 95% CI -0.50 to -0.18, p

Aims Guidewire (GW) tracking in a collateral channel (CC) is an important step during retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The aim of this study was to create a prediction score model for CC GW crossing success. Methods and results We analysed data on 886 CCs included in the Japanese CTO PCI Expert Registry during 2016. CCs were categorised as septal (n=610) and non-septal (n=276). CCs were randomly assigned to derivation and validation sets in a 2:1 ratio. The score was developed by multivariate analysis with angiographic findings. Small vessel, reverse bend, and continuous bends were independent predictors in the septal CC subset. Small vessel, reverse bend, and corkscrew were independent predictors in the non-septal CC subset. The extent of intervention was easy, intermediate, and difficult in 92.9%, 57.4%, and 16.7% in the septal CC subset and 91.7%, 54.3%, and 19.0% in the non-septal CC subset, respectively, in the validation set. The area under the receiver operating characteristic curve was >0.7 in the derivation and validation sets of both CC subsets. Conclusions The prediction score model can suggest grading of the difficulty of CC GW crossing based on angiographic findings for each type of CC.

Purpose To evaluate the efficacy and safety of thrombectomy using myocardial biopsy forceps for the treatment of acute limb ischemia (ALI). Materials and Methods A retrospective review of 11 ALI patients (12 affected limbs, 18 affected vessels) who underwent thrombectomy using biopsy forceps between November 2011 and April 2016 was performed. Of the 12 affected limbs, 2 limbs had stent thrombosis, 1 limb had thrombotic occlusion at a de novo stenosis site, and 9 limbs had embolic ALI. Biopsy forceps were used for angiographically limited arterial flow that persisted after the use of an aspiration catheter and conventional balloon angioplasty. The general technique for use of the biopsy forceps included advancement in parallel to a guidewire to the thrombus site, grasping of the thrombus with the forceps, and confirmation of grasping the thrombus with injection of a contrast medium prior to thrombus extraction. Results Partial or total retrieval of the thrombus was angiographically confirmed in 12 of the 18 affected vessels, with restoration of normal blood flow in 11 vessels. Unsuccessful results in the remaining 6 affected vessels appeared to be due to friction at the aortoiliac bifurcation caused by the contralateral approach, small vessel size, or curvature of the anterior tibial artery. None of the 18 treated vessels had any complications such as dissection or perforation of the target vessel wall and distal emboli. None of the surviving patients required major or minor amputation. Conclusions Thrombectomy using biopsy forceps is a feasible technique for removal of an arterial thrombus in patients with ALI.

To describe the feasibility of balloon angioplasty using a long balloon for chronic femoropopliteal occlusions by evaluating angiographic dissection patterns for optimization of outcomes in balloon angioplasty.A retrospective, single-center analysis examined 101 symptomatic patients (mean age 75.6±9.9 years; 65 men) with single de novo femoropopliteal occlusive lesions treated with balloon angioplasty between August 2012 and October 2016. The patients were classified into 2 groups for comparison of angiographic dissection patterns: 51 patients were treated with balloon angioplasty using long balloons (L-BA; defined as ≥220 mm in length) and 50 patients were treated with short balloon angioplasty (S-BA; defined as150-mm-long balloons).Severe vessel dissection patterns, defined as type C or higher, were fewer in the L-BA group (47.1% vs 70.0% in the S-BA group, p=0.019) and the total dissection length was shorter (92.7±72.6 vs 160.4±84.6 mm in the S-BA group, p0.001). Although the results showed no significant differences between the two groups regarding the length of chronic total occlusions (L-BA: 228.6±73.2 vs S-BA: 226.0±53.8 mm, p=0.83), inflation pressure (L-BA; 8.2±2.6 vs S-BA: 8.1±2.9 atm, p=0.86), and the other lesion characteristics, inflation time was significantly longer in the L-BA group (161.2±68.7 seconds vs 51.1±54.0 seconds in the S-BA group, p0.001). Multivariate analysis identified a balloon length ≥220 mm as an independent negative predictor of severe vessel dissection (odds ratio 0.29, 95% confidence interval 0.11 to 0.83, p=0.02).Using long balloons for balloon angioplasty may help prevent severe vessel dissection in chronic femoropopliteal occlusions.

To describe the feasibility and safety of an anterolateral popliteal puncture technique as a retrograde access to chronic total occlusions (CTOs) in the femoropopliteal segment.Twenty consecutive patients (mean age 75.1±10.9 years; 13 women) with symptomatic femoropopliteal occlusive disease underwent endovascular therapy via a retrograde access using the anterolateral popliteal puncture technique. With the patient supine, the P3 segment of the popliteal artery was accessed with a sheathless technique intended to provide minimally invasive access. Subsequent to a wire rendezvous technique in the CTO, the antegrade guidewire was advanced to the below-the-knee artery. Hemostasis across the P3 segment was secured with balloon inflation alone or combined with thrombin-blood patch (TBP) injection.Both the anterolateral popliteal puncture technique and subsequent revascularization were successful in all patients. Mean hemostasis time for balloon inflation only was 7.73±4.03 vs 4.78±0.78 minutes for balloon inflation with TBP injection. There were no in-hospital deaths or complications, including pseudoaneurysms, arteriovenous fistulas, hematomas, embolic complications, or nerve damage.The anterolateral popliteal puncture technique is useful as an alternative retrograde access vs a conventional transpopliteal approach for CTOs in the femoropopliteal segment if antegrade recanalization has failed. This technique may become one option for retrograde access in patients with severe below-the-knee lesions or with CTOs that extend to the P2 segment of the popliteal artery. Furthermore, this technique has the added benefit of allowing patients to remain in the supine position throughout treatment.

AIMS The aim of this study was to assess the incidence and impact on midterm outcomes of intimal versus subintimal tracking with both antegrade and retrograde approaches in patients undergoing successful percutaneous coronary intervention for chronic total occlusion (CTO). METHODS AND RESULTS In 2012, a total of 1,573 CTO cases from 30 hospitals were enrolled in the Japanese CTO registry. Successful guidewire crossing was performed in 1,411 cases (89.7%). Among them, the guidewire penetration position was clearly identified using intravascular ultrasound (IVUS) imaging in 352 cases, and clinical follow-up at 12 months was performed in 323 cases. These 323 cases were enrolled in this retrospective study: 242 cases were treated with the antegrade approach (antegrade group) and 81 cases were treated with the retrograde approach (retrograde group). The endpoint of this study was target vessel revascularisation (TVR) and major adverse cardiac events (MACE) at 12-month follow-up. Subintimal tracking occurred more frequently in the retrograde group (11.6% vs. 30.9%, p

Objectives This study was performed to determine the complications occurring during retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) based on analysis of the multicenter, prospective, nonrandomized Retrograde Summit registry. Background Retrograde PCI for CTO has improved treatment success rates, but several complications related to the retrograde approach have been reported, including collateral channel injury and donor artery injury due to their use as retrograde roots. Methods This registry included data from 1,166 patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2011. Results Overall procedure success and retrograde procedure success were achieved in 985 (84.5%) and 838 (71.9%) of the 1,166 patients, respectively. In-hospital major adverse cardiac and cerebrovascular events (MACCE) occurred in 18 (1.5%) of the 1,166 patients. With regard to complications related to the retrograde approach, channel injury occurred in 111 (9.5%) of the 1,166 patients, but treatment was required in only 24 (2.1%) patients and subsequent cardiac tamponade occurred in only 4 (0.3%) patients. Donor artery problems occurred in only 10 (0.9%) of the 1,166 patients. In sub-analysis regarding the types of collateral channels, the septal channel was significantly safer than epicardial channel because of the lower frequency of non-Q-wave myocardial infarction (non-QMI) and channel injury requiring treatment. Conclusions The MACCE rate during retrograde PCI for CTO determined from the Retrograde Summit registry was low and the frequency of complications related to the retrograde approach was acceptable. © 2015 Wiley Periodicals, Inc.

The standard therapy of coronary bifurcation lesions is drug-eluting stent (DES) to the main branch with provisional side branch stenting; however, the optimal strategy for the treatment of bifurcations has not been established yet even in the DES era. Directional coronary atherectomy (DCA) was used

Objectives This registry evaluated the current trends and outcomes associated with retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Background Since its introduction, several techniques and technologies have been introduced for retrograde PCI for CTO. Methods Eight hundred and one patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2010 were enrolled in this registry. Results Overall procedural and clinical success rates were 84.8 and 83.8%, respectively, of which, retrograde procedures accounted for 71.2 and 70.3%, respectively. The use of channel dilators increased in 2010 compared to that in 2009 (36 vs. 95.3%, P

The Crosser catheter is a unique device that facilitates antegrade intraluminal recanalization by high-frequency vibration energy and cavitation. We used this device not only as a chronic total occlusion (CTO) crossing device, but also as a flossing device in stenotic lesions and we also evaluated the efficacy of this device when used with both the “Crosser preceding” and the “Guidewire preceding” in CTOs. Complications related to this device were investigated, too. We retrospectively analyzed a total of 90 consecutive patients with peripheral artery disease in the femoropopliteal artery and below-the-knee artery (BTA). Primary technical success was defined as the successful delivery of this device into the distal true lumen. Secondary technical success was defined as successful revascularization. The safety endpoints were events of angiographic complications, including the occurrence of detachment of the metal tip from the shaft, slow flow, dissections, and perforations. Overall primary technical success rate was 93.3% and the secondary technical success rate was 96.7%. Detachment and slow flow occurred 14.4 and 4.4%, respectively, with no occurrences of either dissection or perforation. A predictor of detachment was Proposed Peripheral Arterial Calcium Scoring System (PACSS) grade 4 (OR 14.6; CI 1.26–168.5; P = 0.032). The Crosser catheter is useful not only as a CTO crossing device used with both the “Crosser preceding” and the “Guidewire preceding”, but also as a flossing device in stenotic lesions. But we have to pay attention to complications related to the Crosser.

Objectives To evaluate factors for predicting retrograde CTO-PCI failure after successful collateral channel crossing. Background: Successful guidewire/catheter collateral channel crossing is important for the retrograde approach in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). Methods A total of 5984 CTO-PCI procedures performed in 45 centers in Japan from 2009 to 2012 were studied. The retrograde approach was used in 1656 CTO-PCIs (27.7%). We investigated these retrograde procedures to evaluate factors for predicting retrograde CTO-PCI failure even after successful collateral channel crossing. Results Successful guidewire/catheter collateral crossing was achieved in 77.1% (n = 1,276) of 1656 retrograde CTO-PCI procedures. Retrograde procedural success after successful collateral crossing was achieved in 89.4% (n = 1,141). Univariate analysis showed that the predictors for retrograde CTO-PCI failure were in-stent occlusion (OR = 1.9829, 95%CI = 1.1783 – 3.3370 P = 0.0088), calcified lesions (OR = 1.9233, 95%CI = 1.2463 – 2.9679, P = 0.0027), and lesion tortuosity (OR = 1.5244, 95%CI = 1.0618 – 2.1883, P = 0.0216). On multivariate analysis, lesion calcification was an independent predictor of retrograde CTO-PCI failure after successful collateral channel crossing (OR = 1.3472, 95%CI = 1.0614 – 1.7169, P = 0.0141). Conclusions The success rate of retrograde CTO-PCI following successful guidewire/catheter collateral channel crossing was high in this registry. Lesion calcification was an independent predictor of retrograde CTO-PCI failure after successful collateral channel crossing. Devices and techniques to overcome complex CTO lesion morphology, such as lesion calcification, are required to further improve the retrograde CTO-PCI success rate. © 2016 Wiley Periodicals, Inc.

症例は29歳女性．肺塞栓のため入院．肥満とインターネットで個人輸入した経口避妊薬の服用が発症の危険因子であった．初日の心エコー図検査で右室圧負荷所見を認め，翌日の心エコー図検査にて右房から左房に繋がる蛇状の可動性ひも状エコーを認めた．第3病日に低酸素血症が増悪し，施行した経食道心エコー図検査では血栓は消失しており，右房拡大ならびに卵円孔開存，右‐左シャントを認めた．入院時，CTにより上下大静脈内に多量の血栓の存在が疑われたため外科的治療は行わず，抗凝固・血栓溶解療法を行った．肺塞栓による肺高血圧が小さな卵円孔開存を介する右‐左シャントをもたらし，右房内に流入した浮遊血栓が卵円孔に捕捉され，その後，肺動脈に新たな塞栓を来たしたと推測された．肺塞栓に卵円孔開存が合併した場合予後不良とされているが，本症例は幸いにも内科的治療が著効し，無事退院することが出来た． 肺塞栓における刻一刻と変化する血栓や血行動態を経胸壁心エコー図で繰り返し評価することは，より迅速な治療法選択や治療の効果判定に有用であると考えられた．

Background There have been no reports about the diagnostic ability of coronary computed tomography angiography (CTA) in evaluating collateral channels used for retrograde chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Objective We investigated the ability and diagnostic accuracy of coronary CTA compared with invasive coronary angiography to detect collaterals used in retrograde CTO PCI and to compared the success rates for wire crossing between collaterals that are detectable and not detectable in coronary CTA. Methods We retrospectively reviewed data from 43 patients (55 collaterals) who underwent coronary CTA and PCI for CTO with the retrograde approach. We compared the ability of coronary CTA to visualize collaterals to invasive coronary angiography and evaluated the rates of successful wire crossing between CTA-visible and invisible collaterals. Results The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of coronary CTA for detecting collaterals which were used for the retrograde approach was 100.0%, 50.0%, 65.9%, 100.0%, and 74.5%, respectively. Guidewire collateral crossing was more successful in CT-visible collaterals than those not detectable in CT (74.1% vs. 46.4%, p = 0.034). There were fewer collateral vessel injuries in CTA-visible collaterals (11.1% vs. 32.1%, p = 0.041). Conclusion Coronary CTA provides good visualization of collaterals used in retrograde CTO PCI. For retrograde guidewire crossing, a higher success rate with fewer complications was observed in CTA-visible collaterals than in those not detectable in coronary CTA.

Since 2009, the Retrograde Summit has organized a multicenter registry by to examine the efficacy and safety of retrograde PCI for chronic total occlusion (CTO) by Japanese physicians. Total of 2194 retrograde CTO-PCI cases were enrolled between Jan. 2009 and Dec. 2013 from 57 centers in Japan.

This study was performed to determine the complications occurring during retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) based on analysis of the multicenter, prospective, nonrandomized Retrograde Summit registry.Retrograde PCI for CTO has improved treatment success rates, but several complications related to the retrograde approach have been reported, including collateral channel injury and donor artery injury due to their use as retrograde roots.This registry included data from 1,166 patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2011.Overall procedure success and retrograde procedure success were achieved in 985 (84.5%) and 838 (71.9%) of the 1,166 patients, respectively. In-hospital major adverse cardiac and cerebrovascular events (MACCE) occurred in 18 (1.5%) of the 1,166 patients. With regard to complications related to the retrograde approach, channel injury occurred in 111 (9.5%) of the 1,166 patients, but treatment was required in only 24 (2.1%) patients and subsequent cardiac tamponade occurred in only 4 (0.3%) patients. Donor artery problems occurred in only 10 (0.9%) of the 1,166 patients. In sub-analysis regarding the types of collateral channels, the septal channel was significantly safer than epicardial channel because of the lower frequency of non-Q-wave myocardial infarction (non-QMI) and channel injury requiring treatment.The MACCE rate during retrograde PCI for CTO determined from the Retrograde Summit registry was low and the frequency of complications related to the retrograde approach was acceptable. © 2015 Wiley Periodicals, Inc.

AIMS The retrograde approach to CTO is promising, but questions remain with regard to its wider application and the potential risks. This study evaluated the feasibility and efficacy of retrograde recanalisation of chronic total occlusion (CTO) of the coronary arteries. METHODS AND RESULTS A total of 378 consecutive patients (previously failed PCI 32.0%) who enrolled in 27 institutions in Japan underwent retrograde recanalisation for CTO. We analysed the data on lesion characteristics, procedural materials, technique used, complications and clinical outcomes. Successful retrograde recanalisation was achieved in 70.4% and the overall procedural success was 83.6%. Collateral crossing was achieved via a septal route in 68.9%, epicardial in 27.2% and bypass grafts in 2.6%, respectively. The retrograde approach was completed with implementation of reverse CART in 42.5%, direct wire crossing in 23.1%, bilateral wiring in 22.7%, and CART in 11.7%. Major and minor collateral injuries and coronary perforations were noted in 1.3%, 10.3% and 2.9% of cases, respectively. Stroke occurred in 0.3%, QWMI and emergency PCI in 0.3% of patients with successful recanalisation. CONCLUSIONS Wider application of retrograde CTO PCI achieved a high rate of success in recanalisation with an acceptable rate of complications in Japan.

This registry evaluated the current trends and outcomes associated with retrograde percutaneous coronary intervention (PCI) for chronic total occlusion (CTO).Since its introduction, several techniques and technologies have been introduced for retrograde PCI for CTO.Eight hundred and one patients who underwent retrograde PCI for CTO in 28 Japanese centers between January 2009 and December 2010 were enrolled in this registry.Overall procedural and clinical success rates were 84.8 and 83.8%, respectively, of which, retrograde procedures accounted for 71.2 and 70.3%, respectively. The use of channel dilators increased in 2010 compared to that in 2009 (36 vs. 95.3%, P0.0001), attributed improving collateral channel crossing using a wire and catheter (70.6% vs. 81.1%, P = 0.0005) and increased availability of epicardial channels (27.6% vs. 36.9%). The use of the reverse controlled antegrade and retrograde tracking technique also increased (41.9 vs. 66.5%). Although these changes decreased procedure time (203.3 min vs. 187.9 min, P = 0.024), they did not significantly improve overall procedural success rate (84.1% vs. 85.3%, P = 0.63). Multivariate analysis identified age 65 years or more and lesion calcification as unfavorable factors and the use of a channel dilator as a favorable factor for retrograde procedural success.Increased availability of channel dilators has altered strategies for retrograde PCI for CTO. However, retrograde PCI for CTO could be improved by overcoming its main obstacle of severe calcification.

In recent years, we attained higher procedural success in percutaneous coronary interventions (PCI) for chronic total occlusions (CTO) due to the development of new devices and techniques. We have established the Retrograde Summit with Japanese investigators for the purpose of promoting these

糖尿病患者におけるCohnI型無症候性心筋虚血 (SMI) について検討した。狭心症の既往のないインスリン非依存性糖尿病 (NIDDM) 入院患者96例を対象とし, 症候限界性多段階トレッドミル運転負荷試験を行った。1mm以上のST低下をきたすとともに201TI心筋シンチグラフィ (SPECT撮像) で灌流欠損を認めたものをSMIと診断し, この虚血群と非虚血群との間で糖尿病歴, 合併症および他の冠危険因子について比較検討した。13例 (14%) にSMIを認めた。虚血群と非虚血群 (83例) では, 糖尿病罹病期間, 入院時空腹時血糖・HbAlc値, 糖尿病性腎症・網膜症・神経障害および高脂血症の合併率に差は認めなかった。しかし高血圧合併例 (77%vs27%;P

Epidemiological studies have investigated the prevalence of acute myocardial infarction (AMI) in towns, medium cities and counties in Japan. The prevalence of AMI in a large city such as Sapporo has never been reported because of the difficulty of monitoring all patients with AMI. The population of middle-aged and senior residents has increased dramatically in Japan, and the impact of aging population on the prevalence of AMI is unknown.This study determined the prevalence of AMI in Sapporo in 2003, and investigated the relationship between the population of older citizens and the prevalence of AMI within individual regions of Sapporo.A questionnaire designed to focus on AMI was sent to every hospital in Sapporo offering services in internal medicine, cardiology, cardiovascular surgery, or surgery. Clinical and epidemiological data was requested on all patients presenting with AMI in 2003, including: municipal ward of patient's address, age, sex, whether hospitalization occurred via ambulance or through the out-patient clinic, whether the patient was transferred to another hospital for further treatment, whether the patient died, or was discharged alive.Responses were received from 114 of 140 hospitals (81.4%), including all 32 hospitals performing cineangiography. As 799 patients were reported with AMI in 2003, the prevalence of AMI of Sapporo in 2003 was 42.9/100,000 residents. Forty-six patients was excluded because the absence of data on the questionnaire. Data was available for analysis in 753 AMI patients (537 males and 216 females, range 30-101 years, mean age 67.9 years). The prevalence of AMI was 60.8/100,000 in males and 22.1/100,000 in females (p0.05). Ninety-four deaths (57 males and 37 females) were attributed to AMI (range 48-99 years, mean age 75.2 years), for an overall mortality rate of 12.5%. AMI was a less frequent cause of death in the female population than the male population (male 6.5/100,000 and female 3.8/100,000, p0.05), but AMI was more frequently fatal in women (10.6% in males vs 17.1% in females, p0.05). Both AMI and fatality were more common with increasing age. Sapporo has 10 municipal wards. The prevalence of AMI in 3 wards was significantly higher than in the other municipal wards, these differences were more prominent when the prevalence of AMI was corrected for the population distribution of patientsor = 50 years old (p0.05). Significant correlations between the number of citizens and number of patients with AMI were observed in every age cohort divided into 10 years oldor = 50 years old, and the slopes of those regression lines increased with age cohort. Admission was via the outpatient clinic for 364 patients and 341 patients arrived by ambulance. The fatality rate did not differ between the two routes for admission.AMI was more frequent in men than women in Sapporo, but AMI was more frequently fatal in females. Prevalence and fatality rate of AMI increased with age, and prevalence of AMI was determined by the number of senior citizens in certain wards.

Objectives: Percutaneous cardiopulmonary bypass (PCPB) is a powerful tool for rescuing the emergency patients (pts) with out-of-hospital cardiogenic cardiac arrest (OHCCA), who are not responding to advanced cardiovascular life support (ACLS). But the system under which the decision to apply PCPB is made at the hospital and preparations then made could exceed the time limitations imposed for cerebral resuscitation. Thus, we have collaborated with the physician-manned ambulance system, and we introduced a pre-hospital PCPB order treatment strategy for patients with out-of-hospital cardiogenic cardiopulmonary arrest, who do not respond to drug administration or electrical cardioversion. Methods: In 174 pts with OHCA treated with PCPB in a single institution, from April 1991 to May 2007. 135 consecutive pts with cardiogenic cardiac arrest refractory to ACLS, who had been treated with PCPB, were included. 135 Pts were divided into two groups. Pre-hospital order groups (n=42) were treated under the pre-hospital PCPB order system, and in-hospital order groups (n=93) were treated under the decision to initiate PCPB was made at the hospital. Rate of return of spontaneous circulation (ROSC), weaning of PCPB, survival to discharge, and favorable neurological recovery were assessed. Results: Pre-hospital order groups showed increases in ROSC, weaning of PCPB, survival to discharge, and significant increases in favorable neurological recovery compared to in-hospital order groups. Conclusions: These results suggest that a pre-hospital PCPB order treatment strategy for patients after CPA significantly improves the neurological function in pts with OHCCA. Table

Objectives The purpose of this study was to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) before drug-eluting stent (DES) implantation for bifurcated coronary lesions. Background The introduction of DES significantly reduces restenosis and repeated revascularization. However, percutaneous coronary intervention of bifurcated lesions using DES alone remains challenging regardless of whether simple or complex stenting is used. Methods Patients with bifurcated lesions were recruited in this prospective multicenter registry. Pre-DES plaque debulking by DCA was conducted. All patients were scheduled to undergo a 9-month coronary angiography. The primary end point was the 9-month binary angiographic restenosis rate. Secondary end points included procedure-related events and major adverse cardiac events (MACE) at 1 year. Results A total of 99 patients with bifurcated lesions were enrolled in this registry. Directional coronary atherectomy was performed successfully in all cases without any major procedure-related events. Simple stenting was achieved in all but 2 cases. No in-hospital MACE were observed. The 9-month binary restenosis rates in the main branch and side branch were 1.1% and 3.4%, respectively. Target lesion revascularization was performed in 2 patients (1 for the main branch and the other for the side branch). No deaths, no coronary artery bypass grafting, and no myocardial infarctions were reported in the patients within the first year. Conclusions Directional coronary atherectomy before DES implantation can possibly avoid complex stenting. This strategy may provide a good long-term outcome in patients with bifurcated lesions.

Cardiac tamponade due to coronary artery rupture, as a consequence of blunt trauma, is a rare but usually fatal condition. We successfully obtained primary hemostasis with emergency room thoracotomy, followed by delayed definitive treatment of the ruptured right coronary artery ostium in a motor vehicle accident victim with multifocal hemorrhagic lesions. Survival of patients with the described serious trauma has not been reported, and we discuss herein our treatment strategy.

The aim of Retrograde Summit is to clarify the clinical results which specialize in percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) by retrograde approach. 1166 cases have been registered by 28 hospitals in Japan from 2009 to 2011. We compared successful CTO cases

We report two cases that the combination of amiodarone and nifekalant hydrochloride (NIF) is useful against electrical storm (ES). The first patient is 81-year-old man with CRT-D because of ischemic cardiomyopathy (ICM). He was admitted to add class III antiarrhythmic agent due to frequent ICD therapy. On admission day he felt palpitation followed by strong shock. Electrocardiogram showed frequent sustained VT accompanying ICD therapy. The injection of amiodarone followed by continuous intravenous injection (CIV) reduced the frequency of VT, but not suppressed completely. After additional CIV of NIF the patient no longer experienced the VT. During the ES 60 times of antitachycardia pacing, 13 times of 15 J cardioversion, and nine times of 35 J direct current were recorded in no more than 19 minutes. The second one is 56-year-old man with chronic heart failure due to ICM. He was admitted to control heart failure (HF). In spite of the treatment for HF, he had sustained VT with circulatory collapse and CRT-D was implanted. After the implantation, even taking oral amiodarone, he had ES and underwent the treatment with ICD shocks. Also in this case, additional CIV of NIF suppressed the VT and reduced ICD shock dramatically.

It is well known that failing hearts show diminished responsiveness (desensitization) to catecholamines. In this study, 2 different animal models were used to investigate the alterations in the hormone sensitive cardiac adenylyl cyclase system in a congestive heart failure. In the first model, cardiomyopathic Syrian hamsters (BIO53.58), we found reduced activity of the catalytic protein of adenylyl cyclase; this reduction was more prominent in an older animals (28-week-old vs 16-week-old). At both ages, the amount of inhibitory GTP-binding protein (Gi) was markedly increased in BIO53.58 compared to control healthy hamsters. Moreover the increased Gi was shown to be fully functional in the inhibitory pathway of the adenylyl cyclase system. In the second model, chronically norepinephrine-infused rats, we found a decrease in beta-adrenergic receptor density at an early stage of injection (3 days), while the activity of catalytic protein decreased beyond 14 days of injection, and the amount of Gi increased after 7 days of injection. These results suggest that increased plasma catecholamine concentrations in the setting of congestive heart failure might be a major trigger for qualitative and quantitative alterations observed in various components of cardiac adenylyl cyclase system, and that GTP-binding proteins and catalytic protein of adenylyl cyclase are involved in the mechanism of desensitization especially after chronic in vivo stimulation of adrenergic receptors.

Various diseases and clinical settings can induce congestive heart failure (CHF). As such, it is unlikely that a single mechanism can explain the cardiac dysfunction observed in CHF. However, CHF patients (or animals) share several similar features: reduced cardiac contractility, increased sympathetic nerve activity, and activation of several hormonal systems (e.g., renin-angiotensin system, vasopressin, and atrial natriuretic factor) to compensate for the impaired cardiac function. In this setting, cardiac receptor, GTP-binding proteins, and their effector molecules (adenylyl cyclase, phospholipase C, several ion channels) are inevitably exposed to chronically elevated neurohormonal stimulation. A widely recognized concept is that a chronic increase in such stimulation can desensitize target cell receptors and post-receptor signal transducing pathways (1). It is therefore likely that in CHF one or more types of desensitization contributes to a reduction in signal transducing efficiency in order to maintain intracellular homeostasis. To date, several laboratories have reported a decrease in β-adrenergic receptor (βAR) density in CHF patients and model animals (2–4, 5 for review). Recently, reports of several studies have indicated that the inhibitory GTP-binding protein (Gi) can be increased in CHF patients (6,7) and animal models (8). Although direct evidence for a change in the catalytic protein of adenylyl cyclase has not been available, limited information have suggested a reduced catalytic activity in terminally failing hearts (9). In this study, we have suggested changes of βAR, GTP-binding protein and catalytic protein using two different animal models with an emphasis on defining the kinetics for the desensitization process of adenylyl cyclase system.