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Patients suffering from congestive heart failure (CHF) frequently feel physical suffering and anxiety.The researchers investigated whether back massage could reduce anxiety, discomfort, and physical suffering in patients with CHF. The effects of gender and severity-dependent response of back massage on anxiety and discomfort in patients were also analyzed.The study used a quasi-experimental design with one group pretest and posttest.Sixty-four participants were recruited in southern Taiwan.The modified State Anxiety Inventory, the discomfort Visual Analogue Scale, electronic blood pressure (BP) gauges, stethoscopes and the pulse oximetry were used in this study.The participants' systolic BP (F (3, 189)=18.91, p0.01), diastolic BP (F (3, 189)=13.40, p0.01), heart rate (F (3, 189)=26.28, p0.01), and respiratory rates (F (3, 189)=5.77, p0.01) were significantly decreased after back massage. Oxygen saturation levels showed significant increases (F (3, 189)=42.82, p0.01). Male participants revealed a more significant reduction in anxiety than the female participants (F (1, 50)=7.27, p=0.01). Those with more severe heart failure and greater levels of anxiety (F (2, 61)=4.31, p=0.02) and systolic BP (F (2, 61)=3.86, p=0.03) demonstrated significantly greater responses to back massage.Back massage significantly reduced anxiety in the study population. Systolic BP decreased to a greater degree in the male participants, particularly in those with severe heart failure and greater levels of anxiety and higher systolic BP. This study was conducted without a control group. Randomized clinical trials are needed to validate the effectiveness of back massage on patients with CHF.

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)

This study tested the hypothesis that early extracorporeal membrane oxygenator offered additional benefits in improving 30-day outcomes in patients with acute ST-segment elevation myocardial infarction complicated with profound cardiogenic shock undergoing primary percutaneous coronary intervention.Between May 1993 and July 2002, 920 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 12.5% (115) with cardiogenic shock were enrolled in this study (group 1). Between August 2002 and December 2009, 1650 patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention. Of these patients, 13.3% (219) complicated with cardiogenic shock were enrolled (group 2).The incidence of profound shock (defined as systolic blood pressure remainingor =75 mm Hg after intra-aortic balloon pump and inotropic agent supports) was similar in both groups (21.7% vs. 21.0%, p.5). Extracorporeal membrane oxygenator support, which was available only for patients in group 2, was performed in the catheterization room. The results demonstrated that final thrombolysis in myocardial infarction grade 3 flow in infarct-related artery was similar between the two groups (p = .678). However, total 30-day mortality and the mortality of patients with profound shock were lower in group 2 than in group 1 (all p.04). Additionally, the hospital survival time was remarkably longer in patients in group 2 than in patients in group 1 (p = .0005). Furthermore, multivariate analysis demonstrated that unsuccessful reperfusion, presence of advanced congestive heart failure, profound shock, and age were independent predictors of 30-day mortality (all p.02).Early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention improved 30-day outcomes in patients with ST-segment elevation myocardial infarction with complicated with profound cardiogenic shock.

The efficacy of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has improved dramatically due to the development of new devices. Severe calcification of coronary lesions may be encountered even when the guidewire crosses the CTO, preventing the balloon from penetrating the lesion. A new "Tornus" penetration catheter has been developed for CTO recanalization. The purpose of this study was to evaluate the feasibility and safety of the Tornus catheter compared with traditional rotational atherectomy for CTO lesions. From August 2002 to July 2009, 77 patients with CTO of the coronary artery were selected to undergo PCI. Forty-one patients were treated with rotational atherectomy before the availability of the Tornus catheter when the smallest balloon failed to pass the CTO lesion. Later, 36 patients were treated with a Tornus catheter. Device and angiographic success rates as well as procedural complications were assessed. Device success was defined when the Tornus or Rota burr passed through the lesion. Major complications included death, Q-myocardial infarction, or emergency bypass surgery. Minor complications included perforation, cardiac tamponade, no reflow phenomenon, or long spiral dissection.The mean procedural time was significantly longer in the Tornus group (144 minutes versus 115 minutes, P = 0.01), while the device success rate was significantly lower (77% versus 95%, P = 0.024). Rotational atherectomy was subsequently performed in 3 of 8 Tornus failure cases. There were no between group differences in major complication rate (6% Tornus versus 5% rotational atherectomy). There was an insignificant trend for lower minor complication rates in the Tornus group (17% versus 20%).Use of the Tornus catheter was associated with significantly longer procedural duration and lower device success rates compared to rotational atherectomy. Major and minor complications were not different between the groups. Our findings suggest that Tornus catheter penetration is not superior to conventional rotational atherectomy for CTO recanalization.

Same-day discharge transradial percutaneous coronary intervention (TRI) has been reported to be safe and feasible in Western countries. However, Asia has not produced any reports related to this matter. The present study explored the safety and feasibility of patients with indications for TR coronary angiography and ad hoc PCI with a same-day discharge protocol. Between October 1995 and December 2002, 660 adult patients were admitted to our hospital for ad hoc PCIs. Of these, 214 patients were discharged on the day of their PCI (group A), while the remaining 446 patients were referred for out-patient department (OPD) PCI with subsequent admission (group B). Periprocedural complications were not significantly different between the groups. There were no differences in 1-month major adverse cardiac events including death, myocardial infarction, and target vessel revascularization (1.4% versus 0.2% for groups A and B, respectively; P = 0.068). Three group A cases (1.4%) experienced peri- and post-PCI myocardial infarction and one group B case (0.2%) experienced a post-PCI myocardial infarction. No patient died or required emergency bypass surgery. In group A, 8 cases (3.7%) required cutting balloon angioplasty and 2 cases (0.9%) needed rotational atherectomy. TRI is safe and feasible on an outpatient basis. For select patients, even though PCI can carry the potential risk of subsequent cutting balloon angioplasty or rotational atherectomy, the procedure should still be considered.

Objective The aim of this study was to examine the serum oxidative stress in patients with severe mitral regurgitation. Design and methods This study analyzed serum oxidative stress index in patients with severe mitral regurgitation [persistent atrial fibrillation (AF) or sinus rhythm], paroxysmal lone AF patients and healthy subjects. Results The serum oxidative stress index was significantly higher in the mitral regurgitation AF group and sinus group than in the lone AF group and healthy subjects (p

Background: The aim of the present study was to test the hypothesis that the transradial arterial approach (TRA) is not inferior to the transfemoral arterial approach (TFA) for ≤Killip 3 acute myocardial infarction (AMI) patients undergoing primary percutaneous coronary intervention (PCI). Methods and Results: This study enrolled 506 AMI patients undergoing primary PCI using the TRA (group 1) between March 2002 and May 2007, and 810 AMI patients undergoing primary PCI using TFA (group 2) between May 1993 and February 2002. The results demonstrated that puncture to first balloon-inflation time was similar in both groups; however, the procedure time was shorter in group 1 than in group 2 (P

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)

Aims There is no data about the utilisation of a single guiding catheter for current routine, transradial, right and left coronary diagnosis and intervention. We investigated the feasibility and safety of using 6Fr, Ikari left (IL) 3.5 guiding catheter for this purpose. Methods and results This prospective single-centre study enrolled 621 consecutive patients referred for transradial coronary angiography with ad hoc coronary intervention. The radial artery was successfully accessed in 96.8% of patients. Right and left coronaries were successfully engaged in 98.1% of cases. Engagement with good back-up at right and left coronaries (device success) was achieved in 96.6% of cases. Coronary intervention was performed in 61.2% of the cases, among them, 84.5% had coronary stenting. Procedure success was 98.2%. Procedure time was 21.4+/-15.1 and 65.4+/-36.1 minutes; mean fluoroscopy time was 6.8+/-7.2 and 24.1+/-18.9 minutes and mean contrast volume was 96.2+/-45.3 and 197.9+/-46.2 ml for diagnostic and interventional cases respectively. One patient (0.16%) had catheter related radial artery spasm and three patients (0.48%) encountered a catheter induced RCA dissection. Conclusions Right and left coronary angiography and intervention is feasible and highly successful using IL 3.5 as a single transradial guiding catheter.

Previous study demonstrated that the percentage of circulating endothelial progenitor cells was reduced in patients with coronary artery disease. However, the relationship of the percentage of circulating endothelial progenitor cells to the severity of coronary artery disease has not been investigated. The percentages of circulating endothelial progenitor cells were measured in 78 consecutive patients with unstable angina, as well as in 32 healthy volunteers. Dual-stained cells expressing CD34 and vascular endothelial growth factor receptor-2 were judged to be endothelial progenitor cells and were analyzed using flow cytometry. On stepwise multiple linear regression analysis, the percentages of circulating endothelial progenitor cells were independently decreased in patients with unstable coronary artery disease compared with those in the healthy volunteers (P < 0.05). Among patients with unstable coronary artery disease, the percentage of patients with at least one occluded vessel was significantly higher in patients with multi-vessel disease than in patients with single-vessel disease (P < 0.04). On stepwise multiple linear regression analysis, the percentages of circulating endothelial progenitor cells were independently decreased in patients with multi-vessel coronary artery disease compared with those in patients with single-vessel coronary artery disease (P < 0.03). Among patients with unstable coronary artery disease, the percentage of circulating endothelial progenitor cells was significantly related to the severity of coronary artery disease.

The aim of this study was to confirm that plasma interleukin (IL)-18 level is associated with the extent of coronary artery disease in unstable angina patients. Previous studies have shown that patients with unstable angina have significantly higher plasma IL-18 levels than healthy volunteers. However, the association between IL-18 and the extent of coronary artery atherosclerosis in patients with unstable angina remains unclear. Plasma concentrations of IL-18 and high-sensitivity C-reactive protein (hs-CRP) were measured in 166 consecutive patients admitted for coronary arteriography. One hundred and eighteen patients with unstable angina had coronary artery disease (coronary artery disease group; severity score: 2.32 +/- 1.47; Gensini score: 31.3 +/- 25.9), and 48 patients with coronary risk factors and without coronary artery lesions served as the risk control group. Plasma levels of IL-18 were higher in the coronary artery disease group than in the risk control group (P = 0.062). Additionally, plasma levels of IL-18 were significantly higher in 77 coronary artery disease patients with severity score > or =2 than in the risk control group (242.3 +/- 110.6 vs 209.8 +/- 120.3 pg/ml, P = 0.016). By univariate analysis, log-transformed plasma IL-18 concentration was positively correlated with coronary artery disease severity score (r = 0.244, P = 0.009). By multiple regression analyses, the association between coronary artery disease severity score and IL-18 remained significant (beta = 0.733, P = 0.017) when controlling for age, diabetes mellitus and left ventricular ejection fraction. Additionally, coronary artery disease severity score was greater in the highest tertile (>246 pg/ml) of plasma IL-18 levels than in the middle (176-246 pg/ml) and the lowest (

Second-degree heart block or complete heart block (CHB) is a relatively frequent complication of acute inferior wall myocardial infarction (AIWMI). This study investigated whether the PercuSurge device can prevent procedure-related CHB or can shorten CHB recovery time in patients with AIWMI undergoing primary percutaneous coronary intervention (PCI). Between May 2002 and April 2005, a PercuSurge device was utilized in 113 patients (study population, group 1) with AIWMI due to obstruction of the right coronary artery (RCA) with a reference lumen diameter (RLD)or = 3.5 mm. The control subjects (group 2) consisted of 119 patients who experienced AIWMI due to RCA obstruction with a RLDor = 3.5 mm from May 2000 to April 2002. The combined incidence of new onset of CHB following the interventional procedure was significantly higher in group 2 than in group 1. Additionally, recovery time from CHB to first-degree heart block or normal sinus rhythm was remarkably longer in group 2 than in group 1. Furthermore, the duration of hospitalization in group 2 was significantly longer than in group 1. Multiple stepwise analyses demonstrated that the PercuSurge device was the only independent predictor of preventing new onset of CHB during the procedure. Additionally, this mechanical device along with final TIMI-3 flow and final myocardial blush gradeor = 2 was independently associated with reducing recovery time from CHB. In conclusion, the PercuSurge device can prevent procedure-related CHB and shorten the recovery time for CHB in patients with AIWMI undergoing primary PCI.

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.

While coronary artery dissection caused by a guiding catheter, which is one of the most commonly occurring complications during diagnostic cardiac catheterization or coronary intervention, has various forms, extensive antegrade and retrograde dissections of the right coronary artery (RCA) are rarely observed during these procedures. Within the last three years, we retrospectively reviewed our experience with 12,600 consecutive patients who underwent either diagnostic cardiac catheterization or coronary angioplasty, and found that 17 (0.14%) of the patients displayed extensive antegrade and retrograde RCA dissection. The antegrade dissection always propagated to the distal RCA either on bifurcation of the posterior descending artery and posterolateral artery (PLA) or to the proximal PLA. The retrograde dissection was always observed close to the ostium of the RCA or extending to the ostium of the RCA. TIMI-0 flow in the RCA was immediately observed in all the patients. Chest pain associated with an electrocardiogram showing ST-segment elevation was soon observed in most of the patients. The true lumen could be entered successfully using a single wire in 8 of 17 patients. However, a double-wire technique was required for 7 patients. This technique involved first advancing a wire along to the false lumen and then pulling back the guiding catheter away from the ostium of the RCA for a few millimeters followed by anchoring with the wire. Another wire was then gently inserted into the true lumen from the dissection entrance point, which was located near or at the ostium of RCA, and carefully advanced to the distal RCA. Coronary stenting was successfully deployed in 15 patients. However, the procedure failed in 2 patients. Furthermore, this complication caused 7 patients to have acute myocardial infarctions, 2 patients to develop atrial fibrillation, and 1 to die from ischemic enterocolitis due to cardiac embolism after 7 months of follow-up. In conclusion, with an increase in experience, we now better understand this complication. However, this complication, which is a formidable challenge for coronary intervention, may be a life-threatening complication, and patients with this complication may face the potential risk of a nonfatal myocardial infarction, or even a long-term fatal outcome in the long-term. Accordingly, it is important to learn how to promptly manage this complication.

Background Growing evidence suggests that no-reflow reperfusion after direct percutaneous coronary intervention (d-PCI) is associated with an unfavorable clinical outcome. The purpose of this study was to evaluate whether prerevascularization angiographic morphologic features of infarct-related arteries (IRAs) and timely reperfusion could convey information on slow-flow (Thrombolysis In Myocardial Infarction [TIMI] 2 flow) or no-reflow (TIMI grade ≤ 1 flow) reperfusion after d-PCI. Methods and results Between May 1993 and September 2000, d-PCI was performed in 794 consecutive patients with acute myocardial infarction. Coronary blood flow failed to normalize in 120 patients (15.1%). The incidence of failure to achieve TIMI 3 flow in the IRAs was significantly higher in patients with vs those without the following distinctive prerevascularization angiographic morphologic features: cutoff pattern of occlusion in the IRA (52.4% vs 10.3%, p 5 mm) proximal to the occlusion (37.5% vs 3.4%, p Conclusions Early reperfusion reduces the incidence of slow-flow or no-reflow phenomenon in the IRA and overall 30-day mortality. The specific angiographic morphologic features in the IRAs can be used as a simple and efficacious method to predict slow-flow or no-reflow phenomenon. These findings provide apparently clinically useful information for the selection of patients who are potential candidates for subsequent prepercutaneous coronary intervention adjunctive therapy.

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.

Objective: This study describes a patient with nephrotic syndrome who experienced recurrent pulmonary emboli as renal disease relapsed frequently. Clinical Presentation: A 30-year-old male, who was diagnosed as having nephrotic syndrome at 12, presented with general edema, ascites and hypoalbuminemia. Although the patient responded well to steroid therapy, a common cold frequently caused flare-up of nephrotic syndrome. Histopathological examination of renal tissue revealed minimal disease change. At 17, the patient had a first pulmonary embolism attack with concurrent upper respiratory tract infection. Full-blown manifestations of nephrotic syndrome with low antithrombin III levels were identified at that time. Anticoagulant therapy was administered to treat the pulmonary embolism. Since the first attack, several episodes of pulmonary emboli occurred, which, combined with kidney disease, triggered refractory nephrotic syndrome. The nephrotic syndrome did not remit, and a secondary renal biopsy identified glomerular pathological changes similar to previous biopsy results. To prevent recurrent pulmonary emboli, a Greenfield inferior vena cava filter was implanted in April 2002. No further pulmonary embolism events occurred after interventional filter deployment. Conclusion: The results of this study suggest that inferior vena cava filter implantation can be effective for preventing recurrent pulmonary embolism complicating refractory nephrotic syndrome.

Few studies have reported results for transradial (TR) percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. The purpose of this study was to evaluate the feasibility and safety of bilateral radial PCI for CTO lesions.Eighty-five consecutive patients with CTO lesions received PCI via a bilateral TR approach. A high radial artery puncture (10-15 cm above styloid process) accommodating a 7 Fr catheter (85 cm long) was used for a retrograde approach, and a 6 Fr catheter was used in the other radial artery for an antegrade approach. Retrograde wiring was conducted primarily or after failure of antegrade wiring. Mean duration of CTO was 42.8 ± 54.9 months. Vessels with occlusions attempted were the left anterior descending artery (40.0%; 34/85), right coronary artery (58.8%; 50/85), and left circumflex artery (1/85). PCI re-attempts were made in 41.2% of the cases. The overall success rate was 87.1%. Retrograde wiring was successful in 61/85 cases (71.8%), via septal collaterals followed by epicardial collaterals and saphenous vein graft. There were no major complications (30 day in-hospital death, Q wave myocardial infarction, or emergency bypass surgery), or serious access site complications.For experienced TR-PCI operators who are already doing complex TR coronary interventions, the bilateral radial approach for CTO lesions appears feasible and safe.

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.

Atrial fibrillation arises in 20-30% of patients with sick sinus syndrome, increasing the risk of systemic embolization and mortality. The aim of this study was to examine the clinical determinants of development of paroxysmal atrial fibrillation in sick sinus syndrome patients before implantation of a pacemaker.This case-control survey involved 144 patients (mean age ± SD age: 72 ± 9 years) in whom implantation of a transvenous permanent pacemaker was planned for sick sinus syndrome. Patients were classified into two groups, patients with (n = 71) and without (n = 73) a history of paroxysmal atrial fibrillation before implantation. Clinical characteristics and echocardiographic parameters were analyzed.The peri-implant right atrial area and left atrial area were significantly larger in patients with, than those without, paroxysmal atrial fibrillation. Multiple logistic regression analysis identified that the size of the left atrial area independently correlated with the development of atrial fibrillation: each 1 cm2 increase in left atrial area corresponded to a 44% increase in risk (odds ratio = 1.44 [1.22, 1.71]; p0.001).The left atrial size independently correlates with the development of paroxysmal atrial fibrillation in sick sinus syndrome patients before pacemaker implantation.

Same-day discharge transradial percutaneous coronary intervention (TRI) has been reported to be safe and feasible in Western countries. However, Asia has not produced any reports related to this matter. The present study explored the safety and feasibility of patients with indications for TR coronary angiography and ad hoc PCI with a same-day discharge protocol. Between October 1995 and December 2002, 660 adult patients were admitted to our hospital for ad hoc PCIs. Of these, 214 patients were discharged on the day of their PCI (group A), while the remaining 446 patients were referred for out-patient department (OPD) PCI with subsequent admission (group B). Periprocedural complications were not significantly different between the groups. There were no differences in 1-month major adverse cardiac events including death, myocardial infarction, and target vessel revascularization (1.4% versus 0.2% for groups A and B, respectively; P = 0.068). Three group A cases (1.4%) experienced peri- and post-PCI myocardial infarction and one group B case (0.2%) experienced a post-PCI myocardial infarction. No patient died or required emergency bypass surgery. In group A, 8 cases (3.7%) required cutting balloon angioplasty and 2 cases (0.9%) needed rotational atherectomy. TRI is safe and feasible on an outpatient basis. For select patients, even though PCI can carry the potential risk of subsequent cutting balloon angioplasty or rotational atherectomy, the procedure should still be considered.

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.

The occurrence of central vein total occlusion results in upper arm edema, pain, and hemodialysis access failure in uremic patient. Previous studies have proven the effectiveness of percutaneous balloon angioplasty for central vein total occlusion. Here, we report a rare case of successful revascularization of central vein total occlusion via antegrade and retrograde approach. © 2010 Wiley-Liss, Inc.

and group II (Rastelli n= 4), one patient had an arch repair and Pulmonary Artery Banding then Rastelli. Results: Thirteen patients of Taussig–Bing anomaly underwent total correction. Median age and weight were 5 ± 6 weeks, 3.4 ± 0.7 kg, respectively. Aortic arch abnormalities was present in nine patients (69%), abnormal coronary artery patterns were present in seven patients (54%), side by side great arteries in five patients (38%), dextrotransposition of great arteries in seven patients (54%) and P-malposition in one patient (7.7%). There was no early mortality (one late mortality due to left ventricle dysfunction). Four cases (two from each group) developed right ventricular outflow tract obstruction, one required re-operation. Two patients from group II developed significant left ventricular outflow tract obstruction, one required re-operation. One patient from group I underwent balloon dilatation due to residual coarctation. Conclusion: DORV–TB is often associated with other congenital cardiac anomalies. In general total repair is feasible in majority of cases with satisfactory results and improved outcome. Tracks: Pediatric Cardiology.

Levels of circulating endothelial progenitor cells (EPCs) in acute ST-elevation myocardial infarction (STEMI) patients undergoing primary coronary intervention (PCI) were investigated in this study. Flow cytometric analysis of the circulating EPC level (CD31/CD34 [E(1)], CD62E/CD34 [E(2)], and KDR/CD34 [E(3)]) was determined from blood samples of 161 consecutive patients with STEMI undergoing primary PCI. Angiogenesis was evaluated using mononuclear cell-derived EPCs on Matrigel. The EPC number (E(1-3)) was lower in STEMI patients than in normal subjects (n = 25) (P < 0.005). Patients with high EPCs (E(1-3)) (≥1.2%) had a lower left ventricular ejection fraction, elevated white blood cell count and creatinine level, advanced Killip score (≥class 3), more advanced congestive heart failure (CHF) (≥class 3), and increased 30-day mortality than those with a low EPC (E(1-3)) level (

The aim of this study is to investigate the impact of uric acid on clinical outcomes in patients with angiographically proven coronary artery disease.Six hundred and forty seven consecutive patients with angiographically proven significant coronary artery disease were enrolled in this retrospective study. Patients were assigned to serum uric acid levelor= 6.4 mg/dL and6.4 mg/dL groups based on baseline fasting uric acid levels and determined by a receiver operating characteristic curve. The mean follow-up duration was 4.6 +/- 1.1 years after coronary angiography. The primary endpoints were all cause mortality and death from cardiovascular disease.The five-year survival rates for patients free from all-cause mortality with levels of uric acidor= 6.4 mg/dL and6.4 mg/dL were 82% and 92% respectively (p0.0001). Five-year survival rates for patients free from cardiovascular mortality with levels of uric acid uric acidor= 6.4 mg/dL and6.4 mg/dL were 91% and 97% respectively (p = 0.003). Multivariate Cox regression analysis showed that serum uric acid was an independent predictor of all-cause death (p = 0.01) but was not an independent predictor of cardiovascular mortality (p = 0.063) after adjusting for multi-vessel coronary artery disease, chronic renal insufficiency and a left ventricular ejection fraction40%.After multivariate adjustment, the fasting serum uric acid level was an independent predictor of all-cause mortality, but probably not an independent predictor of cardiovascular mortality in patients with angiographically proven coronary artery disease.

The aim of the present study was to test the hypothesis that the transradial arterial approach (TRA) is not inferior to the transfemoral arterial approach (TFA) foror=Killip 3 acute myocardial infarction (AMI) patients undergoing primary percutaneous coronary intervention (PCI).This study enrolled 506 AMI patients undergoing primary PCI using the TRA (group 1) between March 2002 and May 2007, and 810 AMI patients undergoing primary PCI using TFA (group 2) between May 1993 and February 2002. The results demonstrated that puncture to first balloon-inflation time was similar in both groups; however, the procedure time was shorter in group 1 than in group 2 (P0.0001). Additionally, the incidences of stenting, tirofiban therapy and final normal coronary blood flow of the infarct-related artery were higher, whereas the frequency of intra-aortic balloon pump support was lower in group 1 than in group 2 (all P0.02). Although the 30-day mortality rate did not differ between the 2 groups (P=0.341), the rate of combined major vascular and bleeding complications was higher in group 2 than in group 1 (P0.0001).Initial selection of TRA is not inferior to initial selection of TFA for AMI patients undergoing primary PCI. However, in the present study, the incidence of combined vascular and bleeding complications was lower with the TRA than with the TFA approach.

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.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.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.

We investigated the prognostic risk and the clinical outcome of young-adult patients with ST-segment elevation (ST-se) acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). Between May 1999 and September 2007, primary PCI was performed in 1680 consecutive patients with AMI of onset12 hours (cardiogenic shock within 18 hours) at Kaohsiung Chang Gung Memorial Hospital. Of these patients, 163 (9.7%) young-age patients (defined as male of45 years old and female of55 years old) were enrolled into this study. A comparable number (n = 175) of patientsor = 55 years old, who presented with AMI of12 hours duration having undergone primary PCI between November 2004 and May 2006, were retrospectively reviewed and enrolled as control subjects. The procedural success (defined as normal blood flow achieved in the infract-related artery) was similar between the young-age and old-age patients (P = 1.0). Additionally, the incidence of an advanced Killip score (defined asor = score 3 upon presentation), 30-day and 6-month cumulative mortality did not differ between these two groups of patients (P0.1). However, the 30-day major adverse clinical outcome (MACO) (defined as New York Heart Association Functional Classificationor = 3 or 30-day mortality) was significantly lower in the young-age than in the old-age patients (P0.001). Further, multiple stepwise logistic regression analysis showed that an advanced Killip score along with the peak level of CK-MB was independently predictive of 30-day MACO (P0.05) in young-age patients. In conclusion, the prognostic outcome is favorable in young-adult ST-se AMI undergoing primary PCI. Traditional risk factors remain effective for stratification of young-adult AMI patients into high- or low-risk subgroups.

The transradial artery approach to angioplasty has rarely been reported as a method for treating dysfunctional Brescia-Cimino fistulas. This study evaluated the feasibility, safety, and 1-year efficacy of this method for treating dysfunctional Brescia-Cimino fistulas. We retrospectively evaluated 154 consecutive procedures in 131 patients (age, 58.3 +/- 11.6 years; male, 48.1%) who underwent the transradial approach in dysfunctional Brescia-Cimino fistulas in the 1-year period after the procedure. The operator determined the use of a regular or a cutting balloon (two cases) in combination with urokinase injection (one case) or catheter thromboaspiration. Radial artery puncture was successful in all cases. Fifty-two cases (33.8%) had totally occluded fibrotic lesions. The overall anatomic success rate and clinical success rate were 61% (94/154) and 81.1% (125/154), respectively. In cases with a totally occluded fibrotic lesion, the clinical success rate was 46%. Successful intervention was associated with a significant reduction in the radial arterial systolic and diastolic pressures. There were no complications of symptomatic arterial embolization or pulmonary embolism, and one complication of venous rupture was successfully treated by compression. The primary patency rates based on intention-to-treat were 75.3% at 30 days and 39.0% at 1 year after the procedure. Excluding the cases with a totally occluded lesion, the clinical success rate was 99% (101/102) and the primary patency rates were 84.3% (86/102) and 52.0% (53/102) at 3 months and 1 year after the procedure, respectively. In conclusion, the transradial approach is a feasible, safe, and effective alternative for catheter intervention for dysfunctional Brescia-Cimino fistulas. Its success rate in cases with a totally occluded fibrotic lesion is unsatisfactory.

Ischemic mitral regurgitation indicates a poor prognosis after acute myocardial infarction (AMI). This study addresses the clinical characteristics and contribution of ischemic mitral regurgitation to the midterm survival rate of patients following first AMI in our institution.Between January 2000 and December 2002, patients who underwent 2-dimensional color Doppler echocardiographic quantitation of ischemic mitral regurgitation within 30 days after first myocardial infarction (MI) were analyzed.During the study period, 519 patients were enrolled (mean age 62.7 +/- 12 years, 76% men). The population was divided into 2 groups based on the degree of mitral regurgitation (MR). Group A included 440 subjects with no MR (n = 41), trivial MR (n = 188), and mild MR (n = 211). Group B included 79 subjects with moderate MR (n = 64), and severe MR (n = 15). Group B patients were more likely to be older (p0.05), women (p0.01), and nonsmokers (p0.01). Group B had a higher prevalence of inferior wall MI (p0.01) and lateral wall MI (p0.01). After 6 months of follow-up, 57 deaths had occurred (42 in Group A and 15 in Group B). Group B had a lower survival rate than Group A 180 days post-AMI (19% vs. 9.79%, p0.01).Post-AMI patients with significant ischemic mitral regurgitation were more likely to be older, female, and nonsmokers. There was a positive association between the severity of ischemic mitral regurgitation and inferior MI and lateral wall MI. The severity of ischemic mitral regurgitation showed a significant inverse relationship with the mid-term post-MI survival rate.

The effectiveness of a transradial approach for percutaneous coronary intervention (PCI) is comparable to that of a transfemoral approach. However, few studies have systematically compared the clinical effectiveness of a transradial approach with that of a transfemoral approach for unprotected left main coronary artery (ULMCA) stenoses. We compared success rate, vascular complications and early (in-hospital and six-month) outcomes of transradial PCI for ULMCA stenoses with those of a transfemoral approach.This retrospective study included 131 patients undergoing PCI for ULMCA stenoses between December 2000 and October 2006: 116 (88.5%) patients underwent a transradial approach and fifteen (11.5%) underwent a transfemoral approach.Both angiographic and procedural success were achieved in 114 (98.3%) patients in the transradial group and fourteen (93.3%) patients in the transfemoral group (p = 0.876). Patients in the transfemoral group required more debulking procedures with large guiding catheters and had larger minimal luminal diameter following PCI than those in the transradial group. Transradial PCI produced fewer in-hospital major adverse cardiac events (MACE) (7.8% vs. 33.3%, p = 0.003) and a lower vascular complication rate compared to the transfemoral approach (1.7% vs. 26.6%, p0.001). Six-month MACE was lower in the transradial group than the transfemoral group without statistical significance (8.0% vs. 23.1%, p = 0.299).A transradial approach for ULMCA diseases produced an equal success rate and a lower vascular complication rate when compared to a transfemoral approach. It should be considered as an acceptable alternative to the transfemoral approach for PCI in ULMCA diseases.

An elevated C-reactive protein (CRP) level plays a crucial role in cell biology of atherosclerosis and unstable plaque formation. However, direct evidence of CRP involvement in atherosclerotic plaque development and vulnerability is still limited. We hypothesized that CRP is present in the vulnerable plaques and that CRP staining intensity is stronger in vulnerable plaques compared to stable plaques.Directional coronary atherectomy (DCA) was performed on 58 patients with stable angina (group 1) and 40 patients with unstable angina (group 2). White blood cell (WBC) counts were measured prior to DCA. Immunohistochemical staining (IHCS) was performed to localize CRP in the atheroma. Staining intensity in macrophages and extracellular tissue was graded as: 0, no staining; 1+,30%; 2+, 30%-60%; 3+,60%.The IHCS demonstrated that CRP staining - 1+ intensity in macrophages and extracellular tissue were significantly higher in group 1 than in group 2 patients (all p values0.0001). However, IHCS demonstrated that CRP staining a 2+ intensity in macrophages and extracellular tissue were significantly higher in group 2 than in group 1 patients (all p values0.0001). By multiple analysis, only stable angina was independently associated with CRP staining : 1+ intensity in both macrophages and extracellular tissue (p0.0001), whereas unstable angina and WBC counts were independent predictors of CRP stainingor = 2+ intensity in both macrophages and extracellular tissue (p0.0001).CRP was frequently found in atherosclerotic plaques of patients with unstable angina. This analytical finding suggests that CRP directly mediates an inflammatory process in the atherosclerotic plaque.

This study enrolled 536 patients who underwent successful coronary stenting with bare-metal stents and 6-month angiographic follow-up examinations between 1998 and 2000. Baseline characteristics and angiographic and procedural parameters for these patients were obtained. Primary endpoints were all-cause mortality and nonfatal myocardial infarction. Patients were assigned to instent restenosis or non-instent restenosis groups based on 6-month angiographic follow-up results. Restenosis inside a bare-metal stent was defined as more than 50% stenosis at the intervention site. In total, 178 (33.2%) patients had restenosis inside bare-metal stents, while 358 (66.8%) patients were without. At mean follow-up of 56.8 +/- 20.3 months, 36 (6.7%) patients had a primary endpoint event while 500 (93.3%) patients had no primary endpoint event. Survival rates for patients free from primary endpoints in the instent restenosis and non-instent restenosis groups were 96.0 versus 99.4% at 1 year and 89.8% versus 94.8% at 5 years, respectively (P = 0.0033). Survival rates for patients free of all-cause mortality in the instent restenosis and non-instent restenosis groups were 96.0% versus 99.4% at 1 year and 91.6% versus 96.3% at 5 years, respectively (P = 0.0079). Multivariate Cox regression analysis showed that restenosis inside bare-metal stents was an independent predictor of primary endpoint events (odds ratio: 2.053; 95% CI: 1.048-4.022; P = 0.036) and was a predictor of total mortality with borderline significance (odds ratio: 2.036; 95% CI: 0.936-4.431; P = 0.073). In conclusion, in this study, restenosis inside bare-metal stents at 6-month angiographic follow-up was an independent predictor of long-term outcome-all-cause mortality and nonfatal myocardial infarction. Thus, this study provides clinical evidence that patients with restenosis inside bare-metal stents at 6-month angiographic follow-up likely warrant aggressive follow-up.

Increasing usage of the left internal mammary artery (LIMA) as the graft of choice in coronary artery bypass surgery has led to increased incidence of LIMA graft stenosis.Thirteen patients with LIMA graft stenosis were identified from a review of our institutional database, with intervention approach either from the femoral (n = 6) or radial artery (n = 7). There were no LIIMA orifice lesions and all patients presented with anastomosis site stenoses, except one individual who had combined LIMA shaft stenosis. Clinical outcomes were assessed.The procedural success rate was 92% (12/13). Conventional balloon dilation was performed in seven cases and stenting in five. Two patients developed LIMA body dissection during the procedure, with one requiring bail-out stenting and the other prolonged balloon inflation. The in-hospital major adverse cardiac events included 1 non-Q wave myocardial infarction (7.7%) but no deaths, emergency coronary artery bypass surgery or target lesion revascularization. In the one failure case, the patient died 1 month later at home. Angiographic follow-up of ten patients (83%) revealed a restenosis rate of 20% (2/10). The mean clinical follow-up duration was 34.5 +/- 20.9 months. One patient expired 32 months later due to acute stroke with sepsis.Percutaneous transluminal intervention of LIMA grafts can be performed safely from either the femoral or radial approach. High procedure success and low complication rates are achievable by an experienced cardiologist; long-term clinical results were excellent in our patients. It can be considered as an alternative therapeutic method for a stenosed LIMA graft.

Background Although catheter-induced left main coronary artery (LMCA) dissection is a rare complication of coronary catheterization, it is a common cause of periprocedural mortality. Emergent coronary artery bypass surgery (CABG) is the mainstay for managing this acute complication. However, hemodynamic deterioration may progress while patients await emergent CABG; consequently, a high postoperative mortality rate has been reported. Although the number of cases was small, prompt bail-out stenting for iatrogenic LMCA dissection had reportedly reversed this complication with favorable clinical outcomes. Methods This study included 13 cases of attempted stenting for iatrogenic LMCA dissection classified as grades C–F based on the National Heart, Lung and Blood Institute (NHLBI) classification system. Angiographic success, in-hospital mortality and long-term outcomes were analyzed. Results The incidence of iatrogenic LM dissection was 0.071%. Most of the patients were initially asymptomatic. Angiographic success was achieved in 11 of 13 patients (84.6%). Including one patient who underwent emergent CABG after a failed wiring attempt, two mortalities occurred in this series. Mean follow-up duration of the ten patients discharged was 30.1±11.8 months, and no cardiac deaths occurred. Follow-up angiogram of eight patients with a mean interval of 5.2±2.3 months after initial event demonstrated restenosis in three patients occurring either at the ostiums of the left anterior descending artery or left circumflex artery. Revascularization was performed on two patients. Conclusions Successful bail-out stenting resulted in good long-term survival and should be considered for initial management of iatrogenic LMCA dissection.

Previously, researchers have suggested that Soluble (s) P-selectin mediates the accumulation of leukocytes which in turn promotes fibril deposition. Soluble P-selectin and white blood cell (WBC) counts have been shown to be increased in the systemic circulation after acute myocardial infarction (AMI). However, whether the infarct coronary artery (ICA) and systemic circulation differs with respect to the concentration of sP-selectin and WBC counts following AMI remain unknown. In this study, we investigated whether the concentration of sP-selectin and WBC counts differed between the ICA and the systemic circulation after AMI.Blood samples for circulating sP-selectin and WBC counts were immediately obtained after vascular puncture in 72 patients with AMI of12 h undergoing primary percutaneous coronary intervention (PCI). Additionally, blood samples for ICA sP-selectin and WBC counts were obtained via Export Suction Catheter during PCI. For comparison, blood samples for sP-selectin and WBC counts were obtained once in 30 healthy subjects.The results demonstrated that the circulating sP-selectin [64.7 +/- 18.1 (ng/ml) vs. 29.5 +/- 6.3 (ng/ml), p0.0001] and WBC counts [12.1 +/- 3.6 (x 10(3)/ml) vs. 5.0 +/- 1.0 (x 10(3)/ml), p0.0001] were significantly higher in our patients than in healthy subjects. Furthermore, the sP-selectin [72.7 +/- 23.3 (ng/ml) vs. 64.7 +/- 18.1 (ng/ml), p0.0001] and the WBC counts [16.2 +/- 3.8 (x 10(3/)ml) vs. 12.1 +/- 3.6 (x 10(3)/ml), p0.0001] were markedly higher in the ICA than in the systemic circulation for the patients.The plasma level of sP-selectin and WBC counts were more elevated in the ICA than in the systemic circulation of patients with AMI undergoing primary PCI. These findings strengthen the role of sequestration of WBC and sP-selectin in the ICA as crucial in thrombus formation.

Although sporadic successful cases using the transradial approach (TRA) for carotid stenting have been reported, the safety and feasibility of carotid stenting using either TRA or a transbrachial approach (TBA) have not been fully investigated. Recently, we have developed a safe and feasible method of TRA for cerebrovascular angiographic studies. This study investigated whether a TBA approach using a 7-French (F) Kimny guiding catheter for carotid stenting is safe and feasible for patients with severe carotid stenosis. Thirteen patients were enrolled into this study (age range, 63-78 years). Seven of these 13 patients had severe peripheral vascular disease. A retrograde-engagement technique, involving looping 6-F Kimny guiding catheter, was utilized for carotid angiographic study. For carotid stenting, the 6-F Kimny guiding catheter was replaced with a 7-F Kimny guiding catheter, and the procedure was performed as the follows. First, an extra-support wire was inserted into the middle portion of external carotid artery (ECA). Second, a 0.035-inch Teflon wire was advanced into the common carotid artery. Then, the 6-F guiding catheter was exchanged for a 7-F Kimny guiding catheter. Third, if the first and second steps did not provide adequate support for exchanging the guiding catheter, a PercuSurge GuardWire was inserted into the ECA, followed by distal balloon inflation for an anchoring support. FilterWire EX was used in 9 patients and PercuSurge GuardWire in 4 patients to protect from distal embolization during the procedure. The procedure was successful in all patients. No neurological or vascular bleeding complications were observed and all patients were discharged uneventfully. The TBA for carotid stenting was safe and effective, providing a last resort for patients unsuited to femoral arterial access and surgical intervention.

Platelet activation that results from coronary plaque rupture is important in the pathogenesis of acute myocardial infarction (AMI). Soluble p-selectin (sP-selectin) is crucial in modulating leukocyte adhesion to both platelets and endothelial cells during inflammatory response and thrombus formation. We hypothesized that sP-selectin, an index of both platelet activation and acute inflammation, rapidly increases and modulates the recruitment of circulating white blood cells (WBC) in patients following AMI.We conducted a prospective cohort study of 142 consecutive patients with ST-segment elevated AMI of onset12 h who were undergoing primary percutaneous coronary intervention. Blood samples for plasma levels of sP-selectin were obtained in the catheterization laboratory before coronary angiography was performed. The plasma levels of sP-selectin were also measured in 30 risk control subjects and 20 healthy control subjects.The plasma level of sP-selectin and the circulating WBC count were significantly higher in patients with AMI than in either the risk control or healthy subjects (all of p values0.0001). Additionally, repeated measures of ANOVA demonstrated that there were no significant differences in plasma levels of sP-selectin (p0.10) in three intervals from the start of chest pain to blood sample collection (180 min,or = 180360, andor = 360720) following AMI. Correlation analysis demonstrated that the increase in the plasma level of sP-selectin was significantly related to the circulating WBC count (r = 0.248, p = 0.003).sP-selectin was markedly elevated in an early phase of AMI. sP-selectin may be involved in modulating the recruitment of circulating WBC during AMI. These findings raise the need for a prospective investigation of sP-selectin as a potential reliable clinical tool for rapidly diagnosing AMI.

Background The relationship between platelet activity and myocardial injury in patients with ST-segment elevated (ST-se) acute myocardial infarction (AMI) remains unclear. This study tested the hypothesis that platelet activity (expressed by CD62p) is enhanced and predictive of both the extent of myocardial damage and 30-day clinical outcome in patients with ST-se AMI undergoing primary coronary stenting. Methods and Results Platelet CD62p expression prior to coronary angiographic was prospectively measured using flow cytometry in 45 consecutive patients with AMI undergoing primary coronary stenting. The CD62p expression was also evaluated in 20 healthy and 20 at-risk control subjects. The CD62p expression was significantly higher in AMI patients than in healthy and at-risk control subjects (all p values

While coronary artery dissection caused by a guiding catheter, which is one of the most commonly occurring complications during diagnostic cardiac catheterization or coronary intervention, has various forms, extensive antegrade and retrograde dissections of the right coronary artery (RCA) are rarely observed during these procedures. Within the last three years, we retrospectively reviewed our experience with 12,600 consecutive patients who underwent either diagnostic cardiac catheterization or coronary angioplasty, and found that 17 (0.14%) of the patients displayed extensive antegrade and retrograde RCA dissection. The antegrade dissection always propagated to the distal RCA either on bifurcation of the posterior descending artery and posterolateral artery (PLA) or to the proximal PLA. The retrograde dissection was always observed close to the ostium of the RCA or extending to the ostium of the RCA. TIMI-0 flow in the RCA was immediately observed in all the patients. Chest pain associated with an electrocardiogram showing ST-segment elevation was soon observed in most of the patients. The true lumen could be entered successfully using a single wire in 8 of 17 patients. However, a double-wire technique was required for 7 patients. This technique involved first advancing a wire along to the false lumen and then pulling back the guiding catheter away from the ostium of the RCA for a few millimeters followed by anchoring with the wire. Another wire was then gently inserted into the true lumen from the dissection entrance point, which was located near or at the ostium of RCA, and carefully advanced to the distal RCA. Coronary stenting was successfully deployed in 15 patients. However, the procedure failed in 2 patients. Furthermore, this complication caused 7 patients to have acute myocardial infarctions, 2 patients to develop atrial fibrillation, and I to die from ischemic enterocolitis due to cardiac embolism after 7 months of follow-up. In conclusion, with an increase in experience, we now better understand this complication. However, this complication, which is a formidable challenge for coronary intervention, may be a life-threatening complication, and patients with this complication may face the potential risk of a nonfatal myocardial infarction, or even a long-term fatal outcome in the long-term. Accordingly, it is important to learn how to promptly manage this complication.

C-reactive protein (CRP) has been well recognized as a strong independent predictor of short-term and long-term mortality after non-ST-segment elevation acute coronary syndromes. However, limited studies have been conducted correlating CRP levels within 6 h following the onset of ST-segment elevation (ST-se) acute myocardial infarction (AMI) to mortality. The purpose of this study was to evaluate the predictive value of CRP measured by high-sensitivity CRP assay (hsCRP) on 30-day clinical outcomes in patients with ST-se AMI of onset6 h undergoing primary percutaneous coronary intervention (PCI).We conducted a prospective cohort study in 146 consecutive patients with ST-se AMI of onset6 h who were undergoing primary PCI. Blood samples for hsCRP were obtained in the catheterization laboratory before coronary angiography. Patients were classified into high (group 1: hsCRP2.37 mg/L, n = 73) and low (group 2: hsCRP/= 2.37 mg/L, n = 73) hsCRP groups according to the median value of hsCRP after AMI. Univariate analysis demonstrated that the 30-day composite major adverse cardiac events (MACE) [death, recurrent ischemia, and re-occlusion] were significantly higher in group 1 than in group 2 (23.3% vs 4.1%, p = 0.0008). Multiple stepwise logistic regression analysis demonstrated that high hsCRP (p = 0.001), cardiogenic shock (p = 0.0003), and low left ventricular ejection fraction (p = 0.032) were independent predictors of 30-day MACE.Prospective evaluation of the hsCRP in ST-se AMI of onset6 h allows accurate risk stratification of individuals at risk of 30-day MACE after primary PCI.

The present study investigates whether preintervention thrombectomy with a PercuSurge distal balloon protection device can improve final angiographic results compared with adjunctive tirofiban therapy during primary percutaneous coronary intervention (PCI) in large infarct-related arteries (IRAs) (vessel size ≥3.5 mm) with high-burden thrombus formation (HBTF). Results indicate that this mechanical device is superior to adjunctive tirofiban therapy during primary PCI in large IRAs with HBTF in terms of final epicardial flow, microvasculature integrity, and 30-day clinical outcomes.

Background: Recently, we demonstrated that angiographic morphologic features of high-burden thrombus formation are independent predictors of combined slow flow ( ie , Thrombolysis in Myocardial Infarction [TIMI] grade 2) and no reflow ( ie , ≤ TIMI grade 1) in the infarct-related artery (IRA) after direct percutaneous coronary intervention (d-PCI) for the treatment of acute myocardial infarction (AMI). Current data have demonstrated that when administered in conjunction with PCI for acute coronary syndrome, platelet glycoprotein IIb/IIIa inhibitors can provide additional clinical benefits. Thus, we hypothesized that after pretreatment with tirofiban, angiographic morphologic features of high-burden thrombus formation would no longer be independent predictors of combined slow flow and no reflow after treatment with d-PCI. Methods and results: Between January 2001 and April 2002, tirofiban was administered to 210 consecutive patients with ST-segment elevated AMI before coronary angiography was performed, and 84 patients (40.0%) were found to have high-burden thrombus formation in the IRA. The TIMI flow grade of the IRA was assessed immediately after the performance of d-PCI, and the 30-day clinical outcomes were evaluated prospectively. The incidence of restoration of normal coronary flow in the IRA was 83.6%. Three baseline angiographic morphologic features indicating high-burden thrombus formation, including (1) the cutoff pattern of occlusion in the IRA (p = 0.0001), (2) the accumulated thrombus proximal to the occlusion (p = 0.0001), and (3) a reference lumen diameter of the IRA of ≥ 4.0 mm (p = 0.001), were independent predictors of combined slow flow and no reflow. In stratified analysis, the rates of slow flow and no reflow after d-PCI rose rapidly as the number of independent predictors increased (0 predictors, 3.8%; 1 predictor, 29.0%; and 2 predictors, 70.6%). The overall 30-day mortality rate was 6.7%. The mortality rate was significantly higher in patients with TIMI flow lower than or equal to grade 2 than in those with TIMI grade 3 flow (15% vs 1.3%, respectively; p=0.003). Conclusions: Tirofiban did not provide additional clinical benefits when administered in conjunction with d-PCI for AMI, even in the subgroup of patients with a high-burden thrombus. Those distinct angiographic morphologic features of high-burden thrombus formation remained as independent predictors of combined slow flow and no reflow after d-PCI, and were independent of the use of tirofiban.

Excellent results have been described for surgical relief of left ventricular outflow tract obstruction in patients with hypertrophic obstructive cardiomyopathy. Transaortic septal myectomy is technically demanding, especially when the lesion extends deep to the midcavity of left ventricle. A loop electrosurgical electrode is used to satisfactorily circumvent this problem.