Manual compression hemostasis using a hemostatic pad for the distal radial artery approach

BACKGROUND

The method of hemostasis for the distal radial approach has not been standardized, although this approach has become increasingly popular due to its advantages. In this study, we investigated the feasibility of manual compression hemostasis using a calcium alginate pad after coronary angiography via the distal radial approach.

METHODS

We retrospectively collected 150 consecutive patients (mean age, 74.9 ± 8.0 years; male, 75 %) who underwent coronary angiography via the distal radial artery with a predominantly 4 Fr sheath from April 2021 to December 2022 and were hemostatic according to the following methods. After sheath removal, hemostasis was achieved by manual compression for 10 min using a hemostatic pad containing calcium alginate. When hemostasis was confirmed, a small log-shaped gauze was placed over the pad and fixed using a self-adhesive elastic bandage for 2 h. All procedures were performed by four fellows just beginning the distal radial approach.

RESULTS

The mean compression time was 12.4 ± 4.8 min, and hemostasis was successfully achieved in all patients, allowing the release of the elastic bandage after 2 h, with only one patient oozing the next morning. There were no major complications, while one patient had a >10 cm hematoma. Compared to that of the first 15 patients, for each fellow, the compression time of the subsequent patients was significantly shorter (14.5 ± 6.7 vs 11.1 ± 2.1 min, p < 0.01).

CONCLUSIONS

Manual compression hemostasis using calcium alginate pads for the distal radial artery approach appears feasible with a simple learning.

Mapping of Purkinje-related ventricular arrhythmias by a multispline catheter with small and close-paired electrodes: Comparison with conventional catheters

BACKGROUND

Precise mapping of the Purkinje fiber network is essential in catheter ablation of Purkinje-related ventricular arrhythmias (PrVAs). We sought to evaluate the mapping ability of a multi-spline duodecapolar catheter (PentaRay) for PrVAs.

METHODS

Mappings of Purkinje fibers by PentaRay catheters were compared with those by conventional mapping catheters in consecutive patients undergoing catheter ablation of PrVAs from 2015 to 2022.

RESULTS

Sixteen PrVAs (7 premature ventricular contractions or non-reentrant fascicular tachycardias [PVCs/NRFTs] and 9 fascicular ventricular tachycardias [FVTs]) were retrospectively studied. In PVCs/NRFTs, earliest preceding Purkinje potentials (PPs) could be recorded by the PentaRay catheters but not by the mapping and ablation catheters in 5 cases. At the earliest PP sites, the precedence from the QRS onset was greater, and the amplitude of the preceding potentials was higher in the PentaRay catheter compared with those in the mapping and ablation catheter (-62.0 ± 42.8 vs. -29.4 ± 34.2 ms, P = 0.02; 0.45 ± 0.43 vs. 0.09 ± 0.08 mV, P = 0.02). In FVTs, late diastolic potentials (P1) were recorded by the PentaRay catheters but not by the mapping and ablation catheters or the linear duodecapolar catheter in 2 cases. The amplitude of P1 was higher in the PentaRay catheter compared with that in the linear duodecapolar catheter and the mapping and ablation catheters (0.72 ± 0.49 vs. 0.17 ± 0.18 vs. 0.27 ± 0.21 mV, P = 0.0006, P = 0.002). The localized critical PPs, defined as the earliest preceding potentials in PVCs/NRFTs and P1 in FVTs, could be recorded in all the patients by the PentaRay catheter. The mapping ability of critical PPs of PrVAs was better with the PentaRay catheter than with the conventional mapping catheters (16/16 vs. 9/16, P = 0.004 by McNemar exact test).

CONCLUSIONS

The PentaRay catheter has clinical advantages in mapping of the Purkinje fiber network to reveal critical PPs as ablation targets of PrVAs.

Association between Serum Oxysterols and Coronary Plaque Regression during Lipid-Lowering Therapy with Statin and Ezetimibe: Insights from the CuVIC Trial

AIM

Several clinical trials using intravascular ultrasound (IVUS) evaluation have demonstrated that intensive lipid-lowering therapy by statin or a combination therapy with statin and ezetimibe results in significant regression of coronary plaque volume. However, it remains unclear whether adding ezetimibe to statin therapy affects coronary plaque composition and the molecular mechanisms of plaque regression. We conducted this prospective IVUS analysis in a subgroup from the CuVIC trial.

METHODS

The CuVIC trial was a prospective randomized, open, blinded-endpoint trial conducted among 11 cardiovascular centers, where 260 patients with coronary artery disease who received coronary stenting were randomly allocated into either the statin group (S) or the combined statin and ezetimibe group (S＋E). We enrolled 79 patients (S group, 39 patients; S＋E group, 40 patients) in this substudy, for whom serial IVUS images of nonculprit lesion were available at both baseline and after 6-8 months of follow-up.

RESULTS

After the treatment period, the S＋E group had significantly lower level of low-density lipoprotein cholesterol (LDL-C; 80.9±3.7 vs. 67.7±3.8 mg/dL, p=0.0143). Campesterol, a marker of cholesterol absorption, and oxysterols (β-epoxycholesterol, 4β-hydroxycholesterol, and 27-hydroxycholesterol) were also lower in the S＋E group. IVUS analyses revealed greater plaque regression in the S＋E group than in the S group (-6.14% vs. -1.18% for each group, p=0.042). It was noteworthy that the lowering of campesterol and 27-hydroxycholesterol, but not LDL-C, had a significant positive correlation with plaque regression.

CONCLUSIONS

Compared with statin monotherapy, ezetimibe in combination with statin achieved significantly lower LDL-C, campesterol, and 27-hydroxycholesterol, which resulted in greater coronary plaque regression.

Association of Serum Oxysterols with Cholesterol Metabolism Markers and Clinical Factors in Patients with Coronary Artery Disease: A Covariance Structure Analysis

Oxysterols have been implicated in the pathogenesis of cardiovascular diseases. Serum levels of oxysterols could be positively correlated with cholesterol absorption and synthesis. However, physiological regulation of various serum oxysterols is largely unknown. The aim of this study was to investigate the relationship between clinical factors and cholesterol metabolism markers, and identify oxysterols associated with cholesterol absorption and synthesis in patients with coronary artery disease. Subjects (n = 207) who underwent coronary stenting between 2011 and 2013 were studied cross-sectionally. We measured lipid profiles including serum oxysterols. As for the serum biomarkers of cholesterol synthesis and absorption, oxysterol levels were positively correlated with campesterol and lathosterol. Covariance structure analysis revealed that dyslipidemia and statin usage had a positive correlation with "cholesterol absorption". Statin usage also had a positive correlation with "cholesterol synthesis". Several oxysterols associated with cholesterol absorption and/or synthesis. In conclusion, we elucidated the potential clinical factors that may affect cholesterol metabolism, and the associations between various oxysterols with cholesterol absorption and/or synthesis in patients with coronary artery disease.

Practical utilization of cardiac computed tomography for the success in complex coronary intervention

Percutaneous coronary intervention (PCI) for complex lesions is still technically demanding and is associated with less favorable procedural parameters such as lower success rate, longer procedural time, higher contrast volume and unexpected complications. Because the conventional angiographic analysis is limited by the inability to visualize the plaque information and the occluded segment, cardiac computed tomography has evolved as an adjunct to invasive angiography to better characterize coronary lesions to improve success rates of PCI. Adding to routine image reconstructions by coronary computed tomography angiography, the thin-slab maximum intensity projection method, which is a handy reconstruction technique on an ordinary workstation, could provide easy-to-understand images to reveal the anatomical characteristics and the lumen and plaque information simultaneously, and then assist to build an in-depth strategy for PCI. Especially in the treatment of chronic total occlusion lesion, these informations have big advantages in the visualization of the morphologies of entry and exit, the occluded segment and the distribution of calcium compared to invasive coronary angiography. Despite of the additional radiation exposure, contrast use and cost for cardiac computed tomography, the precise analysis of lesion characteristics would consequently improve the procedural success and prevent the complication in complex PCI.

Meteorological and chronobiological factors and the occurrence of acute aortic dissection

Although a number of studies have demonstrated seasonal variations in acute cardiovascular events, the association between winter and low temperatures and the incidence rate of acute aortic dissection has not been fully elucidated. In this study, we investigated the association between meteorological and chronobiological factors and the occurrence of acute aortic dissection classified by the Stanford type, sex and age. We retrospectively collected 131 patients who had been admitted consecutively to our institution with acute aortic dissection, including 58 type A patients and 73 type B patients, from January 2013 to December 2017. The meteorological data were downloaded from the homepage of the Japan Meteorological Agency. The daily incidence of aortic dissection was higher in winter (10.2%) than in fall (5.3%) (P = 0.04), and a significant winter peak was also observed in the sub-groups of males and type B, while there were no significant differences in the proportions of type A, female, and ≤ 70- and > 70-year-old patients. The maximum, mean and minimum temperatures on the days with aortic dissection were significantly lower than on the days without aortic dissection. Divided into four seasons, lower temperatures were found only in spring. The most significant and greatest difference was observed between the maximum temperature on the day of aortic dissection and that at 2 days earlier. The multivariate logistic regression analysis showed that the difference in the maximum temperature between the day of and 2 days before the incident (odds ratio 0.91; 95% confidence interval 0.87-0.96; P < 0.01) as well as the maximum temperature (odds ratio 0.97; 95% confidence interval 0.95-0.99; P = 0.02) were significantly associated with the incidence of aortic dissection. Cold weather and a sudden decrease in temperature might trigger aortic dissection, although the influence might differ among sub-groups.

Initial medical management in acute type A aortic dissection patients with a thrombosed false lumen in the ascending aorta combining intramural hematoma and retrograde dissection from the descending to the ascending aorta

BACKGROUND

The feasibility of medical management for select patients with acute type A aortic dissection has been reported from a few institutions. In this study, we retrospectively investigated the safety and feasibility of our conservative approach for patients with type A aortic dissection in daily practice.

METHODS

From January 2013 to December 2017, 131 consecutive patients were admitted to our institution for acute aortic dissection, including 58 patients of type A. Initial medical management was attempted in select patients who were clinically stable and had a thrombosed false lumen of the ascending aorta without ulcer-like projections in the ascending aorta.

RESULTS

Except for nine patients contraindicated for surgery, urgent surgery was performed in 26 patients (SRG group), while 23 patients (MED group) were treated with the initial medical management. The maximum diameter of the ascending aorta was significantly larger in the SRG group than in the MED group. In the MED group, the heart rate and blood pressures were well-controlled at admission to the intensive-care unit, and the systolic blood pressure was further reduced at 24 h after. The in-hospital mortality rates of the MED and SRG groups were 0% and 15%, respectively. During the follow-up period, the survival rate was significantly higher in the MED group than in the SRG group, and the aortic event-free survival at one year was 80%.

CONCLUSIONS

The initial medical management for select patients with a thrombosed false lumen in the ascending aorta was a safe and feasible strategy in real-world practice.

Ezetimibe in Combination With Statins Ameliorates Endothelial Dysfunction in Coronary Arteries After Stenting

Objectives—

We sought to investigate whether treatment with ezetimibe in combination with statins improves coronary endothelial function in target vessels in coronary artery disease patients after coronary stenting.

Approach and Results—

We conducted a multicenter, prospective, randomized, open-label, blinded-end point trial among 11 cardiovascular treatment centers. From 2011 to 2013, 260 coronary artery disease patients who underwent coronary stenting were randomly allocated to 2 arms (statin monotherapy, S versus ezetimibe [10 mg/d]+statin combinational therapy, E+S). We defined target vessel dysfunction as the primary composite outcome, which comprised target vessel failure during treatment and at the 6- to 8-month follow-up coronary angiography and coronary endothelial dysfunction determined via intracoronary acetylcholine testing performed in cases without target vessel failure at the follow-up coronary angiography. Coadministration of ezetimibe with statins further lowered low-density lipoprotein cholesterol levels (83±23 mg/dL in S versus 67±23 mg/dL in E+S; P <0.0001), with significant decreases in oxidized low-density lipoprotein and oxysterol levels. Among patients without target vessel failure, 46 out of 89 patients (52%) in the S arm and 34 out of 96 patients (35%) in the E+S arm were found to have coronary endothelial dysfunction ( P =0.0256), and the incidence of target vessel dysfunction at follow-up was significantly decreased in the E+S arm (69/112 (62%) in S versus 47/109 (43%) in E+S; P =0.0059). A post hoc analysis of post-treatment low-density lipoprotein cholesterol–matched subgroups revealed that the incidence of both target vessel dysfunction and coronary endothelial dysfunction significantly decreased in the E+S arm, with significant reductions in oxysterol levels.

Conclusions—

The CuVIC trial (Effect of Cholesterol Absorption Inhibitor Usage on Target Vessel Dysfunction after Coronary Stenting) has shown that ezetimibe with statins, compared with statin monotherapy, improves functional prognoses, ameliorating endothelial dysfunction in stented coronary arteries, and was associated with larger decreases in oxysterol levels.

Coronary Artery Disease Screening With Carotid Ultrasound Examination by a Primary Care Physician

Background

In this study, we investigated the feasibility of primary care physicians using carotid ultrasound to perform coronary artery disease screening in asymptomatic patients with multiple coronary risk factors.

Methods

We retrospectively collected the data of 135 consecutive asymptomatic patients (mean age: 68.5 ± 8.4 years; male, 75%) who were referred to our institution due to abnormal findings on a carotid ultrasound performed by a primary care physician and who underwent coronary computed tomography angiography.

Results

The mean number of risk factors was 4.1 ± 1.2 and the mean intima-media thickness was 2.00 ± 0.63 mm. Mild (≤ 50%), moderate (51-75%), and severe (> 76%) coronary stenosis was observed in 54 (40%), 27 (20%), and 25 patients (19%), respectively, while no plaque was found in 24 patients (18%), and five patients (4%) could not be evaluated due to calcification. Consequently, coronary angiography was performed in 56 (41%) patients and coronary intervention was required in 31 patients (23%). A multivariate logistic regression analysis demonstrated that the ratio of low-density lipoprotein cholesterol levels to high-density lipoprotein cholesterol levels, the use of calcium channel blockers and the value of the diastolic blood pressure were related to > 50% coronary stenosis.

Conclusions

The use of carotid ultrasound in the coronary artery disease screening by primary care physicians resulted in a high prevalence of coronary artery disease and high probabilities of coronary angiography and revascularization, and thus it is considered to be a useful and feasible strategy for the screening of asymptomatic patients.

The Effect of Low Frame Rate Fluoroscopy on the X-ray Dose during Coronary Intervention

Objective The aim of this study was to investigate whether the use of low frame rate fluoroscopy at 7.5 frames per second during coronary intervention could reduce radiation exposure in Japanese patients. Methods From December 10, 2014 to March 20, 2015, 84 consecutive patients with coronary artery disease who underwent coronary intervention in our institution were retrospectively collected and then divided into two groups: the LR group (fluoroscopy at 7.5 frames per second) and the OR group (fluoroscopy at 15 frames per second), according to the frame rate of fluoroscopy that was used in their treatment. Results There were no differences in the patient backgrounds or the procedural characteristics of the two groups. Although there were no differences in the contrast volume or fluoroscopy time, the total air kerma at the interventional reference point, which is used to monitor the patient's radiation dose, was significantly lower in the LR group than in the OR group (701.4±427.9 vs. 936.8±623.9 mGy, p=0.02). Conclusion Low frame rate fluoroscopy at 7.5 frames per second is safe and feasible for use during coronary interventions and an easy and useful strategy for reducing the radiation to which patients are exposed during coronary intervention.