Impact of current smoking on 2-year clinical outcomes between durable-polymer-coated stents and biodegradable-polymer-coated stents in acute myocardial infarction after successful percutaneous coronary intervention: Data from the KAMIR

Objective

Data concerning the effect of current smoking on solely new-generation drug-eluting stents (DES) are limited. We investigated the impact of current smoking on 2-year clinical outcomes between durable-polymer (DP)-coated DES (zotarolimus-eluting [ZES] and everolimus eluting [EES]) and biodegradable-polymer (BP)-coated biolimus-eluting stent (BES) in acute myocardial infarction (AMI) patients after successful percutaneous coronary intervention (PCI).

Methods

Finally, a total of 8357 AMI patients with current smoking underwent successful PCI with new-generation DES (ZES, EES, and BES) were enrolled and divided into three groups as ZES (n = 3199), EES (n = 3987), and BES group (n = 1171). The primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death (cardiac death [CD] or non-cardiac death), recurrent AMI (re-MI), any revascularization (target lesion revascularization [TLR], target vessel revascularization [TVR], and non-TVR). The secondary endpoint was the incidence of definite or probable stent thrombosis (ST).

Results

The 2-year adjusted hazard ratio (HR) of MACE for ZES vs. EES (1.055; 95% confidence interval [CI], 0.843–1.321; p = 0.638), ZES vs. BES (HR, 0.885; 95% CI, 0.626–1.251; p = 0.488), EES vs. BES (HR, 0.889; 95% CI, 0.633–1.250; p = 0.499), and ZES/EES vs. BES (HR, 0.891; 95% CI, 0.648–1.126; p = 0.480) were similar. The occurrence of ST after adjustment were also comparable. In addition, the 2-year adjusted HR for all-cause death, CD, re-MI, TLR, TVR, and non-TVR were not different.

Conclusions

In this study, DP-DES and BP-DES showed comparable safety and efficacy during 2-year follow-up periods. Therefore, DP-DES or BP-DES are equally acceptable in AMI patients with current smoking undergoing PCI.

Favorable neurological outcome after ischemic cerebrovascular events in patients treated with percutaneous left atrial appendage occlusion compared with warfarin

OBJECTIVES

This study sought to investigate neurological disability after ischemic cerebrovascular events in patients treated with left atrial appendage (LAA) occlusion compared with those on warfarin.

BACKGROUND

Prior studies demonstrated that cerebrovascular events after LAA occlusion in patients with nonvalvular atrial fibrillation (NVAF) is largely nondisabling.

METHODS

From the 1,189 patients in the Korean LAA Occlusion and European Amplatzer Cardiac Plug Multi-Center Registry, 24 patients who experienced ischemic cerebrovascular events after LAA occlusion were enrolled. The neurological outcomes were compared with those in 68 patients who experienced an ischemic cerebrovascular event while on warfarin (Yonsei Stroke Registry). A modified Rankin scale (mRS) score of 3-6 categorized the cerebrovascular event as disabling. The mRS at discharge and at 3 and 12 months postcerebrovascular event in the two groups was compared.

RESULTS

The percentages of disabling cerebrovascular events were 37.5% and 58.8% at discharge (P = 0.07), 20.8% and 42.6% at 3 months (P = 0.08), and 12.5% and 39.7% at 12 months (P = 0.02) in the LAA occlusion and warfarin groups, respectively. The mRS was significantly lower in the LAA occlusion group at discharge and at 3 months (P < 0.01) and 12 months (P < 0.01) postcerebrovascular event despite no significant difference in mRS before cerebrovascular events (P = 0.98). Patients in the LAA occlusion group demonstrated a significant reduction in mRS between discharge and 12 months (P < 0.01), unlike patients in the warfarin group (P = 0.10).

CONCLUSIONS

Ischemic cerebrovascular events in patients who previously underwent percutaneous LAA occlusion for NVAF were more favorable than in patients on warfarin.

Two-year clinical outcomes of zotarolimus- and everolimus-eluting durable-polymer-coated stents versus biolimus-eluting biodegradable-polymer-coated stent in patients with acute myocardial infarction with dyslipidemia after percutaneous coronary intervention: data from the KAMIR

There are limited data comparing the clinical outcomes among new-generation drug-eluting stents (DES) in acute myocardial infarction (AMI) patients with dyslipidemia after percutaneous coronary intervention (PCI). We thought to investigate 2-year clinical outcomes among durable-polymer (DP)-coated stents [zotarolimus eluting (ZES) and everolimus eluting (EES)] and biodegradable-polymer (BP)-coated biolimus-eluting stent (BES) in dyslipidemic AMI patients after PCI. Finally, a total 2403 enrolled patients were divided into ZES (n = 953), EES (n = 1145) or BES (n = 305) group. The primary endpoint was major adverse cardiac events (MACE) defined as total death (TD), cardiac death (CD), myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR) and non-TVR. The secondary endpoint was the incidence of definite or probable stent thrombosis (ST). The 2-year adjusted hazard ratio (HR) of MACE for ZES vs. EES [HR, 1.066; 95% confidence interval (CI) 0.752-1.511; p = 0.720], ZES vs. BES (HR 0.933; 95% CI 0.565-1.541; p = 0.786), EES vs. BES (HR 1.876; 95% CI 0.535-1.436; p = 0.600) and ZES/EES vs. BES (HR 0.929; 95% CI 0.591-1.462; p = 0.751) was similar. The cumulative incidences of ST were comparable (ZES vs. EES vs. BES = 1.1% vs. 0.9% vs. 1.1%, p = 0.675) and adjusted HR was not different. In addition, the 2-year adjusted HR of TD, CD, MI, TLR, TVR, and non-TVR was similar. The AMI patients with dyslipidemia receiving ZES, EES, or BES after PCI showed comparable safety and efficacy during 2-year follow-up periods. Therefore, DP-DES or BP-DES is equally acceptable in dyslipidemic AMI patients during PCI.

Risk Factors for Restenosis after Drug-coated Balloon Angioplasty for Complex Femoropopliteal Arterial Occlusive Disease

BACKGROUND

Currently, there exist limited data on patient outcomes following the use of drug-coated balloons (DCBs) to treat complex femoropopliteal arterial occlusive lesions. The aim of the this study is to investigate the outcomes of patient treated with DCBs and to identify the predictors of restenosis.

METHODS

We retrospectively investigated medical records from 120 patients (137 limbs) treated with DCBs for femoropopliteal lesions at a single center between 2013 and 2016. Primary patency, target lesion revascularization (TLR), and risk factors of restenosis were analyzed.

RESULTS

There were 80 de novo and 57 in-stent restenosis lesions. Mean lesion length was 22.2 ± 11.6 cm. The clinical primary patency was 85.2% at 1 year and 65.3% after 2 years. The TLR-free survival rate was 93.0% at 1 year and 87.1% after 2 years. Critical limb ischemia (CLI; hazard ratio [HR] 5.80, 95% confidence interval [CI] 1.26-26.68, P = 0.024) and hypercholesterolemia (HR 4.66, 95% CI 1.30-16.76, P = 0.018) were identified as independent predictors of restenosis. In addition, nonuse of cilostazol and popliteal artery involvement showed trends toward an increased risk of restenosis.

CONCLUSIONS

Treatment with DCBs showed excellent primary patency and TLR-free survival at 1 year after the procedure. However, the primary patency continuously deteriorated beyond 1 year, suggesting a late catch-up phenomenon. The risk of restenosis after treatment with DCBs was significantly associated with CLI and hypercholesterolemia.

Determinants and Long-Term Outcomes of Percutaneous Coronary Interventions vs. Surgery for Multivessel Disease According to Clinical Presentation

BACKGROUND

The long-term outcome of percutaneous coronary intervention (PCI) vs. coronary artery bypass graft (CABG), particularly for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), remains controversial.Methods and Results:We retrospectively analyzed 2,827 patients (stable coronary artery disease [SCAD], n=1,601; NSTE-ACS, n=1,226) who underwent either PCI (n=1,732) or CABG (n=1,095). The 8-year composite of cardiac death and myocardial infarction (MI) was compared between PCI and CABG before and after propensity matching. For patients with NSTE-ACS, PCI was performed more frequently for those with higher Thrombolysis in Myocardial Infarction risk score and 3-vessel disease, and PCI led to significantly higher 8-year composite of cardiac death and MI than CABG (14.1% vs. 5.9%, hazard ratio [HR]=2.22, 95% confidence interval [CI]=1.37-3.58, P=0.001). There was a significant interaction between clinical presentation and revascularization strategy (P-interaction=0.001). However, after matching, the benefit of CABG vs. PCI was attenuated in patients with NSTE-ACS, whereas it was pronounced in those with SCAD. Interactions between clinical presentation and revascularization strategy were not observed (P-interaction=0.574).

CONCLUSIONS

Although the determinants of PCI vs. CABG in real-world clinical practice differ according to the clinical presentation, a significant interaction between clinical presentation and revascularization strategy was not noted for long-term outcomes. The revascularization strategy for patients with NSTE-ACS can be based on the criteria applied to patients with SCAD.

Effect of Adjunct Balloon Dilation after Long Everolimus-eluting Stent Deployment on Major Adverse Cardiac Events

Background and Objectives

The effectiveness of adjunct balloon dilation after drug-eluting stent (DES) deployment has not been sufficiently evaluated. We evaluated whether adjunct balloon dilation was associated with a reduction in major adverse cardiac events (MACEs) after long everolimus-eluting stents (EESs) implantation.

Subjects and Methods

Drawing from 2 randomized trials, a total of 1,672 patients treated with long EES were analyzed. Of 1,672 patients, 1,061 patients (64%) received post-stent adjunct balloon dilation. MACE, defined as a composite of cardiac death, myocardial infarction, and target-lesion revascularization (TLR), was compared between patients who received post-stent adjunct balloon dilation and patients who did not in 595 propensity score-matched pairs.

Results

For the matched population, MACE occurred in 29 patients (4.9%) who received adjunct balloon dilation and in 29 patients (4.9%) who did not (hazard ratio [HR], 1.01; 95% confidence interval [CI], 0.60–1.69; p=0.972). However, significant interactions were observed among the subgroups for clinical presentation and vessel size. Adjunct balloon dilation was more favored within the subset of patients with stable angina vs. the subset of patients with acute coronary syndrome (p for interaction=0.037), and within the subset of lesions with small vessel diameter (reference vessel diameter [RVD] <3 mm) vs. the subset of lesions with larger vessel diameter (RVD ≥3 mm; p for interaction=0.027).

Conclusion

Adjunct balloon dilation was not associated with MACE reduction at 1 year among patients requiring long EES implantation. However, post-stent adjunct balloon dilation may be necessary for patients requiring long EES implantation who present with stable angina or for lesions with small vessel diameters.

The 100 Most-Cited Articles Focused on Ultrasound Imaging: A Bibliometric Analysis

Purpose The number of citations that an article has received reflects its impact on a particular research area. The aim of this study was to identify the 100 most-cited articles focused on ultrasound (US) imaging and to analyze the characteristics of these articles. Methods We determined the 100 most-cited articles on US imaging via the Web of Science database, using the search term. The following parameters were used to analyze the characteristics of the 100 most-cited articles: publication year, journal, journal impact factor, number of citations and annual citations, authors, department, institution, country, type of article, and topic. Results The number of citations for the 100 most-cited articles ranged from 1849 to 341 (median: 442.0) and the number of annual citations ranged from 108.0 to 8.1 (median: 22.1). The majority of articles were published in 1990 - 1999 (39 %), published in radiology journals (20 %), originated in the United States (45 %), were clinical observation studies (67 %), and dealt with the vessels (35 %). The Department of Internal Medicine at the University of California and the Research Institute of Public Health at the University of Kuopio (n = 4 each) were the leading institutions and Salonen JT and Salonen R (n = 4 each) were the most prolific authors. Conclusion Our study presents a detailed list and analysis of the 100 most-cited US articles, which provides a unique insight into the historical development in this field.

Impact of Vessel Diameter Measured by Preprocedural Computed Tomography Angiography on Immediate and Late Outcomes of Endovascular Therapy for Iliac Artery Diseases

BACKGROUND

We evaluated whether vessel diameters measured by preprocedural computed tomography angiography (CTA) affects the immediate and late outcomes of endovascular therapy for iliac artery diseases.Methods and Results:A total of 254 patients who underwent endovascular treatment for iliac artery diseases were retrospectively evaluated. Minimum vessel diameters were measured on preprocedural CTA images at target lesions, common iliac arteries, and external iliac arteries (EIA). Predictors of immediate and late procedural outcomes were analyzed. Procedural failure or vessel-specific complications occurred in 29 patients (11%): wire passage failure (n=10), rupture (n=8), and distal embolization (n=11). Target lesion revascularization (TLR) was required in 6.0% at 2 years. Independent predictors of procedural failure or vessel-specific complications were small minimum vessel diameter of the target lesion (odds ratio [OR]=0.68, P=0.008) or EIA (OR=0.67, P=0.008), and chronic total occlusions (OR=3.78, P=0.036). Small minimum EIA diameter (hazard ratio [HR]=0.66, P=0.017) and chronic total occlusions (HR=4.45, P=0.024) were independent predictors of TLR in patients with technical success.

CONCLUSIONS

Small vessel diameter of the target lesion or EIA was an independent predictor of procedural failure or vessel-specific complications. Small vessel diameter, particularly of the EIA, was also associated with increased TLR after successful endovascular therapy for iliac artery lesions.

[Forensic Analysis of 20 Dead Cases Related to Heroin Abuse]

OBJECTIVES

To perform retrospective analysis on 20 dead cases related to heroin abuse, and to provide references for the forensic assessment of correlative cases.

METHODS

Among 20 dead cases related to heroin abuse, general situation, using method of drug, cause of death and result of forensic examination were analyzed by statistical analysis for summarizing the cause of death and pathologic changes.

RESULTS

The dead were mostly young adults, with more male than female. The results of histopathological examinations showed non-specific pathological changes. There were four leading causes of death, including acute poisoning of heroin abuse or leakage （13 cases, 65%）, concurrent diseases caused by heroin abuse （3 cases, 15%）, inspiratory asphyxia caused by taking heroin （2 cases, 10%）, and heroin withdrawal syndrome （2 cases, 10%）.

CONCLUSIONS

The forensic identification on dead related to heroin abuse must base on the comprehensive autopsy, and combine with the qualitative and quantitative analysis of heroin and its metabolites in death and the case information, as well as the scene investigation.

Risk factors for recurrence in patients with papillary thyroid carcinoma undergoing modified radical neck dissection

BACKGROUND

This study evaluated the impact of lymph node-related factors on the risk of and site of recurrence in patients who had papillary thyroid carcinoma with lymph node metastasis in the lateral compartment (classified as pN1b).

METHODS

Patients underwent total thyroidectomy with unilateral modified radical neck dissection for classical papillary thyroid carcinoma. Risk factors for recurrence were evaluated according to the pattern of recurrence.

RESULTS

A total of 324 patients were included in the study. The median follow-up was 63 (range 14-181) months. Recurrence was detected in 47 patients (14·5 per cent). In the multivariable analysis, a maximum diameter of metastatic lymph nodes larger than 2·0 cm (hazard ratio (HR) 1·15, 95 per cent c.i. 1·06 to 1·25; P = 0·033) and a central compartment metastatic lymph node ratio of more than 0·42 (HR 3·35, 1·65 to 6·79; P < 0·001) were identified as independent risk factors for locoregional recurrence. Age 45 years or older (HR 5·69, 1·24 to 26·12; P = 0·025) and extranodal extension of metastasis (HR 12·71, 1·64 to 98·25; P = 0·015) were risk factors for distant metastasis. In subgroup analysis of locoregional recurrence, several lymph node-related factors affected the risk of recurrence according to the specific site of metastasis.

CONCLUSION

Lymph node-related factors are of importance for the risk of recurrence in patients with classical papillary thyroid carcinoma classified as pN1b.

Association between catechol-O-methyl transferase gene polymorphisms and fibromyalgia in a Korean population: A case-control study

BACKGROUND

Although polymorphisms of the catechol-O-methyl transferase (COMT) gene have been implicated in altered pain sensitivity, results concerning the association between COMT gene polymorphisms and fibromyalgia (FM) are equivocal. We assessed the associations between COMT single-nucleotide polymorphisms (SNP) and FM risk and symptom severity.

METHODS

In total, 409 FM patients and 423 controls were enrolled. Alleles and genotypes at five positions [rs6269 (A>G), rs4633 (C>T), rs4818 (C>G), rs4680 (C>G) and rs165599 (A>G)] in the COMT gene were genotyped from peripheral blood DNA.

RESULTS

Alleles and genotypes of the rs4818 COMT gene polymorphism were significantly associated with increased susceptibility to FM. The rs4818 GG genotype was more strongly associated with FM compared to the CC genotype (OR = 1.680, 95% CI: 1.057, 2.672, p = 0.027). Although allele and genotype frequencies did not differ among groups, the rs4633 CT genotype was not associated with the presence of FM following adjustment for age and sex (OR = 0.745; 95% CI: 0.558, 0.995; p = 0.046). However, no association was observed between clinical measures and individual COMT SNPs. In haplotype analysis, there was a significant association between ACG haplotype and FM susceptibility sex (OR = 2.960, 95% CI: 1.447, 6.056, p = 0.003) and the number of tender points (p = 0.046).

CONCLUSIONS

This large-scale study suggests that polymorphisms of the COMT gene may be associated with FM risk and pain sensitivity in Korean FM patients. However, our results differed to those of previous studies, suggesting ethnic variation in COMT gene polymorphisms in FM.

WHAT DOES THIS STUDY ADD

By contrast to Caucasian and Latin-American populations, the COMT gene polymorphisms are associated with FM risk and pain sensitivity in Korean FM patients, suggesting ethnic variation in COMT gene polymorphisms.

Effect of Intravascular Ultrasound-Guided vs Angiography-Guided Everolimus-Eluting Stent Implantation: The IVUS-XPL Randomized Clinical Trial

IMPORTANCE

Use of intravascular ultrasound (IVUS) promotes better clinical outcomes for coronary intervention in complex coronary lesions. However, randomized data demonstrating the clinical usefulness of IVUS are limited for lesions treated with drug-eluting stents.

OBJECTIVE

To determine whether the long-term clinical outcomes with IVUS-guided drug-eluting stent implantation are superior to those with angiography-guided implantation in patients with long coronary lesions.

DESIGN, SETTING, AND PARTICIPANTS

The Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions (IVUS-XPL) randomized, multicenter trial was conducted in 1400 patients with long coronary lesions (implanted stent ≥28 mm in length) between October 2010 and July 2014 at 20 centers in Korea.

INTERVENTIONS

Patients were randomly assigned to receive IVUS-guided (n = 700) or angiography-guided (n = 700) everolimus-eluting stent implantation.

MAIN OUTCOMES AND MEASURES

Primary outcome measure was the composite of major adverse cardiac events, including cardiac death, target lesion-related myocardial infarction, or ischemia-driven target lesion revascularization at 1 year, analyzed by intention-to-treat.

RESULTS

One-year follow-up was complete in 1323 patients (94.5%). Major adverse cardiac events at 1 year occurred in 19 patients (2.9%) undergoing IVUS-guided and in 39 patients (5.8%) undergoing angiography-guided stent implantation (absolute difference, -2.97% [95% CI, -5.14% to -0.79%]) (hazard ratio [HR], 0.48 [95% CI, 0.28 to 0.83], P = .007). The difference was driven by a lower risk of ischemia-driven target lesion revascularization in patients undergoing IVUS-guided (17 [2.5%]) compared with angiography-guided (33 [5.0%]) stent implantation (HR, 0.51 [95% CI, 0.28 to 0.91], P = .02). Cardiac death and target lesion-related myocardial infarction were not significantly different between the 2 groups. For cardiac death, there were 3 patients (0.4%) in the IVUS-guided group and 5 patients (0.7%) in the angiography-guided group (HR, 0.60 [95% CI, 0.14 to 2.52], P = .48). Target lesion-related myocardial infarction occurred in 1 patient (0.1%) in the angiography-guided stent implantation group (P = .32).

CONCLUSIONS AND RELEVANCE

Among patients requiring long coronary stent implantation, the use of IVUS-guided everolimus-eluting stent implantation, compared with angiography-guided stent implantation, resulted in a significantly lower rate of the composite of major adverse cardiac events at 1 year. These differences were primarily due to lower risk of target lesion revascularization.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01308281.

Impact of Coronary Plaque Characteristics on Late Stent Malapposition after Drug-Eluting Stent Implantation

PURPOSE

To evaluate the impact of pre-procedural coronary plaque composition assessed by virtual histology intravascular ultrasound (VH-IVUS) on late stent malapposition assessed by optical coherence tomography (OCT) following drug-eluting stent (DES) implantation.

MATERIALS AND METHODS

The study population consisted of 121 patients (121 lesions) who underwent both pre-procedural VH-IVUS and follow-up OCT after DES implantation. The association between pre-procedural plaque composition [necrotic core (NC), dense calcium (DC), fibrotic (FT), and fibro-fatty (FF) volumes] assessed by VH-IVUS and late stent malapposition (percent malapposed struts) or strut coverage (percent uncovered struts) assessed by follow-up OCT was evaluated.

RESULTS

Pre-procedural absolute total NC, DC, FT, and FF plaque volumes were 22.9±19.0, 7.9±9.6, 63.8±33.8, and 16.5±12.4 mm³, respectively. At 6.3±3.1 months post-intervention, percent malapposed and uncovered struts were 0.8±2.5% and 15.3±16.7%, respectively. Pre-procedural absolute total NC and DC plaque volumes were positively correlated with percent malapposed struts (r=0.44, p<0.001 and r=0.45, p<0.001, respectively), while pre-procedural absolute total FT plaque volume was weakly associated with percent malapposed struts (r=0.220, p=0.015). Pre-procedural absolute total DC plaque volume was the only independent predictor of late stent malapposition on multivariate analysis (β=1.12, p=0.002). There were no significant correlations between pre-intervention plaque composition and percent uncovered struts.

CONCLUSION

Pre-procedural plaque composition was associated with late stent malapposition but not strut coverage after DES implantation. Larger pre-procedural absolute total DC plaque volumes were associated with greater late stent malapposition.

Influence of arm position on catheter placement during real-time ultrasound-guided right infraclavicular proximal axillary venous catheterization

BACKGROUND

Real-time ultrasound-guided infraclavicular proximal axillary venous catheterization is used in many clinical situations and provides the advantages of catheter stabilization, a reduced risk of catheter-related infection, and comfort for the patient without limitation of movement. However, unintended catheter tip dislocation and accidental arterial puncture occur occasionally. This study was designed to investigate the influence of arm position on catheter placement and complications.

METHODS

Patients were randomized to either the neutral group (n=240) or the abduction group (n=241). In the neutral group, patients were positioned with the head and shoulders placed in an anatomically neutral position and the arms kept by the side during catheterization. In the abduction group, the right upper arm was abducted at 90° from the trunk during catheterization. After real-time ultrasound-guided catheterization was carried out in the right infraclavicular proximal axillary vein, misplacement of the catheter and all complications were evaluated with ultrasound and chest radiography.

RESULTS

The success rate of complete catheterization before evaluating the placement of the catheter was high in both groups (97.1 vs 98.8%, P=not significant). The incidence of accidental arterial puncture was not different (1.7 vs 0%, P=not significant). The incidence of misplacement of the catheter was higher in the neutral group than in the abduction group (3.9 vs 0.4%, P=0.01). There were no complications, such as haemothorax, pneumothorax, or injury to the brachial plexus and phrenic nerve, in either group.

CONCLUSIONS

Upper arm abduction may minimize the risk of misplacement of the catheter during real-time ultrasound-guided infraclavicular proximal axillary venous catheterization.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Clinical Trial Registry of Korea: https://cris.nih.go.kr/cris/index.jsp. Identifier: KCT0001417.

Microporous carbon nanosheets with redox-active heteroatoms for pseudocapacitive charge storage

We report microporous carbon nanosheets containing numerous redox active heteroatoms fabricated from exfoliated waste coffee grounds by simple heating with KOH for pseudocapacitive charge storage. We found that various heteroatom combinations in carbonaceous materials can be a redox host for lithium ion storage. The bio-inspired nanomaterials had unique characteristics, showing superior electrochemical performances as cathode for asymmetric pseudocapacitors.

Limitations of coronary computed tomographic angiography for delineating the lumen and vessel contours of coronary arteries in patients with stable angina

AIMS

We sought to evaluate whether coronary computed tomographic angiography (CCTA) could accurately and reproducibly delineate the lumen and vessel contours of coronary arteries.

METHODS AND RESULTS

One hundred coronary stenotic lesions representing 91 patients with stable angina who received both CCTA and intravascular ultrasound (IVUS) were analysed. Three segments with minimal lumen cross-sectional area (CSA), proximal reference, and distal reference on IVUS images were selected for each lesion. Five observers measured lumen and vessel CSAs at three matching segments on CCTA images. These CSAs were compared with the IVUS-measured CSAs as a reference standard. All five observers underestimated lumen CSA at the three selected segments by CCTA. The minimal lumen CSA assessed by CCTA exhibited very weak correlations with those obtained by IVUS (r =0.23, 0.24, 0.15, 0.25, and 0.28, respectively). In contrast to the lumen CSA, the vessel CSA at the three segments was overestimated by all observers when assessed by CCTA. At the segment with minimal lumen CSA, the vessel CSA obtained by CCTA showed weak correlations with those assessed by IVUS (r = 0.43, 0.33, 0.44, 0.37, and 0.42, respectively). Moreover, intra-class correlation coefficients ranged from 0.44 to 0.73 among the five observers for lumen or vessel CSA measurements by CCTA at the segment with minimal lumen CSA.

CONCLUSION

CCTA has potential limitations in the accurate delineation of lumen and vessel contours in patients with angina, as there was a high level of discordance with the IVUS-measured lumen and vessel CSAs and high inter-observer variability.

Rate and associated factors of solifenacin add-on after tamsulosin monotherapy in men with voiding and storage lower urinary tract symptoms

AIM

To explore the rate of add-on therapy with solifenacin in men with voiding and storage lower urinary tract symptoms (LUTS) after tamsulosin monotherapy and to explore predictive factors for starting solifenacin add-on therapy.

METHODS

Men aged ≥ 45 years with IPSS ≥ 12 and symptoms of OAB (OAB-V8 ≥ 8, micturition ≥ 8/24 h, urgency ≥ 2/24 h) were enrolled to receive tamsulosin 0.2 mg once daily. After 4 weeks, men with residual symptoms of OAB and reported 'dissatisfied' or 'a little satisfied' were received solifenacin 5 mg in combination with tamsulosin monotherapy. Subjects completed an IPSS, a Quality of life (QoL) index, OAB V8, and an International Consultation of Incontinence Questionnaire (ICIQ)-Male LUTS, and patient perception of bladder condition (PPBC) at baseline and week 4.

RESULTS

Of a total of 305 patients, 254 patients completed 4 weeks of tamsulosin treatment. For 176 patients, solifenacin was added (69.3%). Significant predictive factors of solifenacin add-on therapy included long LUTS duration, high IPSS, number of micturitions per 24 h, more urgency episodes, high urgency severity score in a voiding diary and high OAB V8 score. Based on multivariable analysis, potential predictive factors of solifenacin add-on therapy included long LUTS duration (OR = 1.008, 95% CI: 1.001-1.014), high serum PSA (OR = 1.543, 95% CI: 1.136-2.095) and small prostate size (OR = 0.970, 95% CI: 0.947-0.994) (p < 0.05). IPSS, daytime micturitions and urgency episodes, OAB V8 scores, ICIQ and PPBC were improved after tamsulosin monotherapy.

CONCLUSIONS

Two thirds of men with voiding and storage LUTS needed to add anticholinergics after 4 weeks of tamsulosin monotherapy. Patients with longer lasting symptoms and storage symptoms with small prostate volume may require the anticholinergic add-on.

Multidisciplinary team approach for identifying potential candidate for transcatheter aortic valve implantation

PURPOSE

We sought to evaluate the clinical usefulness of decision making by a multidisciplinary heart team for identifying potential candidates for transcatheter aortic valve implantation (TAVI) in patients with symptomatic severe aortic stenosis.

MATERIALS AND METHODS

The multidisciplinary team consisted of two interventional cardiologists, two cardiovascular surgeons, one cardiac imaging specialist, and two cardiac anesthesiologists.

RESULTS

Out of 60 patients who were screened as potential TAVI candidates, 31 patients were initially recommended as appropriate for TAVI, and 20 of these 31 eventually underwent TAVI. Twenty-two patients underwent surgical aortic valve replacement (AVR), and 17 patients received only medical treatment. Patients who underwent TAVI and medical therapy were older than those who underwent surgical AVR (p<0.001). The logistic Euroscore was significantly highest in the TAVI group and lowest in the surgical AVR group (p=0.012). Most patients in the TAVI group (90%) and the surgical AVR group (91%) had severe cardiac symptoms, but only 47% in the medical therapy group had severe symptoms. The cumulative percentages of survival without re-hospitalization or all-cause death at 6 months for the surgical AVR, TAVI, and medical therapy groups were 84%, 75%, and 28%, respectively (p=0.007, by log-rank).

CONCLUSION

TAVI was recommended in half of the potential candidates following a multidisciplinary team approach and was eventually performed in one-third of these patients. One-third of the patients who were initially considered potential candidates received surgical AVR with favorable clinical outcomes.

Usefulness of intravascular ultrasound guidance in percutaneous coronary intervention with second-generation drug-eluting stents for chronic total occlusions (from the Multicenter Korean-Chronic Total Occlusion Registry)

Despite the usefulness of intravascular ultrasound (IVUS) in percutaneous coronary intervention (PCI), the impact of IVUS guidance on clinical outcomes, particularly for chronic total occlusion (CTO) intervention, has rarely been studied. We sought to investigate the clinical usefulness of IVUS-guided CTO intervention with second-generation drug-eluting stent implantation. From 2007 to 2009, a total of 2,568 patients were enrolled in the Korean-CTO registry and 534 patients with successful implantation of second-generation drug-eluting stents were analyzed. IVUS-guided PCI was performed on 206 patients (39%). Clinical outcomes at 2 years were compared between the IVUS-guidance group and the angiography-guidance group in 201 propensity score-matched pairs. The primary end point was the occurrence of definite or probable stent thrombosis. Clinical characteristics were similar between both groups after matching. At 2 years, the IVUS-guidance group showed significantly less stent thrombosis than the angiography-guidance group (0% vs 3.0%, p = 0.014) and a lesser trend toward myocardial infarction (1.0% vs 4.0%, p = 0.058). Target lesion revascularization (TLR) and major adverse cardiovascular event rates were similar. However, a significant interaction was observed between the use of IVUS and lesion length for predicting the TLR (p = 0.037), suggesting usefulness of IVUS in long-lesion (≥3 cm) relative to short-lesion CTO. In conclusion, although IVUS-guided CTO PCI was not associated with a reduction in overall major adverse cardiovascular events, IVUS guidance appears to be associated with a reduction of stent thrombosis and myocardial infarction compared with angiography-guided CTO PCI. Additionally, TLR occurred less frequently in the IVUS-guidance group, especially for long lesions.

Feasibility of using auto Mod-MPI system, a novel technique for automated measurement of fetal modified myocardial performance index

OBJECTIVES

To evaluate the reproducibility of measurement of the fetal left modified myocardial performance index (Mod-MPI) determined using a novel automated system.

METHODS

This was a prospective study of 116 ultrasound examinations from 110 normal singleton pregnancies at 12 + 1 to 37 + 1 weeks' gestation. Two experienced operators each measured the left Mod-MPI twice manually and twice automatically using the Auto Mod-MPI system. Intra- and interoperator reproducibility were assessed using intraclass correlation coefficients (ICCs) and the manual and automated measurements obtained by the more experienced operator were compared using Bland-Altman plots and ICCs.

RESULTS

Both operators successfully measured the left Mod-MPI in all cases using the Auto Mod-MPI system. For both operators, intraoperator reproducibility was higher when performing automated measurements (ICC = 0.967 and 0.962 for Operators 1 and 2, respectively) than when performing manual measurements (ICC = 0.857 and 0.856 for Operators 1 and 2, respectively). Interoperator agreement was also better for automated than for manual measurements (ICC = 0.930 vs 0.723, respectively). There was good agreement between the automated and manual values measured by the more experienced operator.

CONCLUSIONS

The Auto Mod-MPI system is a reliable technique for measuring fetal left Mod-MPI and demonstrates excellent reproducibility.

Red cell distribution width as an independent predictor of exercise intolerance and ventilatory inefficiency in patients with chronic heart failure

PURPOSE

Peak oxygen uptake (peak VO₂) and ventilatory inefficiency (VE/VCO₂ slope) have proven to be strong prognostic markers in patients with chronic heart failure (CHF). Recently increased red cell distribution width (RDW) has emerged as an additional predictor of poor outcome in CHF. We sought to evaluate the relationship between RDW and cardiopulmonary exercise test (CPET) parameters in CHF patients and healthy controls.

MATERIALS AND METHODS

85 ambulatory CHF patients (68 men, 54±10 years) and 107 healthy controls, who underwent a symptom-limited CPET on a treadmill according to the modified Bruce ramp protocol, were enrolled. CHF patients and healthy controls were divided into RDW tertile groups and laboratory, echocardiographic, and CPET results were analyzed.

RESULTS

For patients with CHF, compared with patients in the lowest RDW tertile, those in the highest tertile had lower peak VO₂ (22 mL/kg/min vs. 28 mL/kg/min, p<0.001) and higher VE/VCO₂ slope (31 vs. 25, p=0.004). Multivariate regression analysis revealed RDW to be an independent predictor for peak VO₂ (β=-0.247, p=0.035) and VE/VCO₂ slope (β=0.366, p=0.004). The optimal cutoff value of RDW for predicting peak VO₂ ≤20 mL/kg/min and VE/VCO₂ slope ≥34 was 13.6% (sensitivity 53%, specificity 89%) and 13.4% (sensitivity 75%, specificity 82%), respectively. In contrast, for healthy controls, RDW was not related to both peak VO₂ and VE/VCO₂ slope.

CONCLUSION

Higher RDW is independently related to peak VO₂ and VE/VCO₂ slope only in patients with CHF. RDW assessment, an inexpensive and simple method, might help predict functional capacity and ventilatory efficiency in these patients.

High-resolution impedance manometry facilitates assessment of pharyngeal residue and oropharyngeal dysphagic mechanisms

The utility of high-resolution impedance manometry (HRIM) for evaluating oropharyngeal dysphagia (OPD) has been investigated. These approaches are limited because of the sophisticated methodology. A method of transforming HRIM into a simple and useful diagnostic tool for evaluating OPD is needed. A videofluoroscopic swallowing study (VFSS) and HRIM were performed by independent blinded examiners in 26 consecutive healthy volunteers (12 men; median age, 56.5 years) and 10 OPD patients (five men; median age, 59.5 years). Upper esophageal sphincter (UES) relaxation parameters were measured using a standard HRIM protocol. Peristalsis and bolus transit of the pharyngoesophageal (PE) segment were assessed using an HRIM-modified protocol in which the catheter was pulled back 10 cm. PE bolus transits were evaluated with an impedance contour pattern (linear vs. stasis) method. A significant difference was observed between the manometric measures of healthy volunteers and OPD patients for only the duration of pharyngeal contraction (0.49 ± 0.19 vs. 0.76 ± 0.33 s, P = 0.04). The percentage agreement and kappa value for detecting pharyngeal residue between the VFSS and the impedance analysis were 100% and 1.00, respectively. HRIM allowed for comprehensive assessment of abnormal pharyngeal components that caused pharyngeal residue on VFSS in two patients; reduced base of the tongue versus weak pharyngeal contraction in one, and reduced relaxation of the UES versus reduced laryngeal elevation in the remaining patient. Our findings demonstrated that HRIM using a simple methodology (i.e., pull-back of the catheter) detected pharyngeal residue through a simple analysis of the impedance contour pattern (linear vs. stasis). Furthermore, HRIM facilitated a comprehensive assessment of OPD mechanisms and recognition of subtle abnormalities not yet visible to the naked eye on VFSS.

Prognostic usefulness of metabolic syndrome compared with diabetes in Korean patients with critical lower limb ischemia treated with percutaneous transluminal angioplasty

PURPOSE

Metabolic syndrome (MS) is a clinical condition that shares many common characteristics with diabetes. However, unlike diabetes, the usefulness of MS as a prognostic entity in peripheral arterial disease is uncertain. This study evaluated the prognostic usefulness of MS in critical lower limb ischemia (CLI) patients.

MATERIALS AND METHODS

We compared the 2-year clinical outcomes in 101 consecutive CLI patients (66±14 years; 78% men) with 118 affected limbs treated with percutaneous transluminal angioplasty (PTA) according to the presence of MS and diabetes.

RESULTS

The number of MS patients was 53 (52%), of which 45 (85%) had diabetes. During a 2-year follow-up, the incidence of clinical outcomes, including reintervention, major amputation, minor amputation, and survival, was not significantly different between MS and non-MS patients; however, the incidence of minor amputation was significantly higher in diabetic than in non-diabetic patients (42% vs. 17%; p=0.011). Cox regression analysis for the 2-year primary patency demonstrated no association between MS and 2-year primary patency [hazard ratio (HR), 1.02; 95% confidence interval (CI), 0.45-2.30; p=0.961], whereas there was a significant association between diabetes and 2-year primary patency (HR, 2.81; 95% CI, 1.02-7.72; p=0.046). Kaplan-Meier analysis revealed no significant difference in the 2-year primary patency between MS and non-MS patients; however, the 2-year primary patency was lower in diabetic than in non-diabetic patients (p=0.038).

CONCLUSION

As a prognostic concept, MS might conceal the adverse impact of diabetes on the prognosis of CLI patients treated with PTA.

Rapid and Simple Identification ofOrientia tsutsugamushifrom Other Group Rickettsiae by Duplex PCR Assay UsinggroELGene

In this study, two new duplex PCR methods based on the groEL gene were developed and investigated for the diagnosis of rickettsiae. The first duplex PCR assay amplified the 229-bp and the 366-bp DNAs of 6 strains including typhus group (TG) and spotted fever group (SFG) rickettsiae, and 5 scrub typhus group (STG) rickettsiae, respectively. The second duplex PCR assay amplified the 397-bp and the 213-bp DNAs of 6 Rickettsia strains and 5 STG strains. These duplex PCR methods could simultaneously perform the rapid identification of rickettsiae and the differential diagnosis of STG and other group rickettsiae in a single reaction.

Impact of atherosclerosis detection by carotid ultrasound on physician behavior and risk-factor management in asymptomatic hypertensive subjects

BACKGROUND

There are limited data regarding the impact of atherosclerosis detection by carotid ultrasound (CUS) on physician prevention efforts and risk-factor management for cardiovascular disease.

HYPOTHESIS

Atherosclerosis detection by CUS in asymptomatic hypertensive patients would lead to physician prevention efforts, including target low-density lipoprotein cholesterol (LDL-C) level and prescription. Also, it may improve risk-factor management.

METHODS

A total of 347 asymptomatic hypertensive subjects (age 61 ± 8 years, 189 men) were prospectively recruited from 22 hospitals. Prior to CUS, physicians were surveyed regarding target LDL-C level. After CUS, patients were classified into positive CUS (n = 182) and negative CUS (n = 165) groups based on CUS results. Physicians were resurveyed to assess whether the initial target LDL-C goals were changed. At 6 months, cardiovascular risk-factor modification status was reassessed.

RESULTS

The proportion of lowered target LDL-C levels was significantly larger in the positive CUS group than in the negative CUS group (52% vs 23%, P < 0.001). These results were observed even in subjects who had low and moderate risk according to National Cholesterol Education Program-Adult Treatment Panel III guidelines. Lipid-lowering agents were similarly added or switched to another class in both groups (7% in the positive CUS group vs 11% in the negative CUS group, P = 0.153). LDL-C was significantly decreased in the positive CUS group (Δ = -24 ± 38 mg/dL, P < 0.001), whereas it was not significantly decreased in the negative CUS group (Δ = -6 ± 31 mg/dL, P = 0.105).

CONCLUSIONS

Atherosclerosis detection by CUS lowered physicians' target LDL-C level and improved cardiovascular risk management in terms of LDL-C reduction.

A rare case of interparietal incisional hernia from 8 mm trocar site after robot-assisted laparoscopic prostatectomy

Trocar site hernia arising from 8 mm robotic port is very rare despite the increasing prevalence of robot-assisted surgeries. To date, there had been only a single case reported in the literature. We report a case of small bowel obstruction secondary to an interparietal trocar site incisional hernia after robot-assisted laparoscopic prostatectomy. Meticulous closure of 8 mm robotic trocar sites associated with large peritoneal defect at the end of surgery should be performed.

Impact of atorvastatin treatment in first-degree relatives of patients with premature coronary artery disease with endothelial dysfunction: a double-blind, randomized, placebo-controlled crossover trial

BACKGROUND

A family history of premature coronary artery disease (CAD) is a well-known risk factor for cardiovascular events.

HYPOTHESIS

Atorvastatin may improve endothelial dysfunction (ED) in the first-degree relatives (FDRs) of patients with premature CAD with ED.

METHODS

Thirty-five FDRs (median age, 52 years [interquartile range (IQR), 46-57 years], 21 male) of patients with premature CAD with ED were recruited in a prospective trial with a crossover double-blind design: 6 weeks of treatment with atorvastatin 40 mg/day followed by placebo, or vice versa. After each treatment, the digital pulse wave amplitude was determined by EndoPAT to obtain the reactive hyperemia index (RHI), a measure for endothelial function. The primary outcome was the difference of RHI between atorvastatin and placebo treatment.

RESULTS

Low-density lipoprotein cholesterol was lower after atorvastatin compared with placebo treatment (124 [102-145] mg/dL vs 67 [50-73] mg/dL, P < 0.001). However, RHI was not different after atorvastatin compared with placebo treatment (1.9 [1.5-2.4] vs 1.9 [1.6-2.2], P = 0.902). Also, the augmentation index was similar after each treatment. These results were observed both in subjects who had indications for statin treatment (31%) and those who did not (69%) according to National Cholesterol Education Program Adult Treatment Panel III guidelines.

CONCLUSIONS

Despite improvement in the lipid profile, atorvastatin failed to improve ED in the FDRs of patients with premature CAD with ED. Although we identified those with ED in FDRs of patients with premature CAD as a high-risk group for future cardiovascular events, atorvastatin treatment may not be a beneficial primary prevention strategy for this population.