Dental Implants Acting as External Fixation for the Fracture of Severe Atrophic Mandible: A Case Report

Treatment of edentulous and atrophic mandibular fractures is extremely difficult. Generally, mandibular fractures are repaired and fixed as internal fixation using a reconstruction plate or miniplates with intra- or extraoral approach. Few cases in which external fixation including a transmucosal fixation was performed have also been reported. We report a case of atrophic and edentulous mandibular fracture which was healed by the fixation using dental implants and implant-supported bridge.

The role of cellular senescence in aortic dissection

Background

Aortic dissection (AD) is a catastrophic disease that occurs suddenly. The acute mortality is high and those who survived frequently suffer from serious complications such as aneurysm formation and distal ischemia due to progressive destruction of the aortic walls. Currently, no predictor of AD onset is available nor therapeutic intervention to specifically prevent the progressive destruction in AD, because the molecular pathogenesis is largely unknown. Clinical and experimental studies highlighted the importance of inflammation in AD, although the regulatory mechanism of inflammation remains unclear. Recently, we found that cell proliferation precedes the inflammatory response in AD. Because cell proliferation causes cellular senescence that can induce inflammatory response, we hypothesized that cellular senescence participates in AD pathogenesis.

Objective

We investigated if cellular senescence contributes to AD development and progression in mouse AD model.

Methods and results

A mouse AD model was created by continuous infusion of beta-aminopropionitrile and angiotensin II (BAPN+AngII), where AD starts to develop in 3 days and occurs to most of the mice in 14 days accompanied by frequent AD rupture and death. Infusion of BAPN+AngII resulted in the induction of senescence markers Ink4a from day 3 before AD onset and persisted for the 14 days of the observational period.

Cellular senescence, as demonstrated by the expression of senescence-associated beta-galactosidase, was evident in intimal endothelial cells, medial smooth muscle cells, adventitial macrophages and fibroblasts. We examined the role of cellular senescence in AD pathogenesis by oral administration of ABT263 which is known as “senolytics” that eliminates senescent cells. ABT263 treatment reduced the expression of the senescence marker, prevented the death by AD rupture, and ameliorated the severity of AD lesion compared to the vehicle treatment. Transcriptome analysis revealed that ABT treatment suppressed the immune and inflammatory response in AD. Quantitative RT-PCR confirmed that ABT treatment prevented the induction of p21Cip1, interleukin-6, several chemokines and their receptors by 3-day infusion of BAPN+AngII.

Conclusions

These findings demonstrated that senescence of multiple cell types precedes AD development, which is likely to induce the inflammatory response. Elimination of senescent cells effectively prevented AD progression and death. Therefore, cellular senescence represents a potential predictor and a therapeutic target for AD.

Funding Acknowledgement

Type of funding sources: None.

The role of cellular senescence in aortic dissection

Background

Aortic dissection (AD) is a catastrophic disease that occurs suddenly. The acute mortality is high and those who survived frequently suffer from serious complications such as aneurysm formation and distal ischemia due to progressive destruction of the aortic walls. Currently, no reliable predictor is available for AD development and surgical intervention is the only therapeutic option to prevent the fatal events after AD development, because the pathogenesis of AD is largely unknown.

Clinical and experimental studies highlighted the importance of inflammation in AD pathogenesis, although the trigger of inflammation remains unclear. Recently, we found that cell proliferation precedes the inflammatory response in AD. Because cell proliferation triggers cellular senescence and senescent cells secrete of proinflammatory cytokines and matrix metalloproteinases, we hypothesized that cellular senescence may participate in AD pathogenesis.

Objective

We investigated if cellular senescence contributes to AD development and progression in a mouse model of AD.

Methods and results

A mouse AD model was created by continuous infusion of beta-aminopropionitrile and angiotensin II (BAPN+AngII), where AD starts to develop in 3 days and occurs to most of the mice in 14 days accompanied by frequent AD rupture and death. Infusion of BAPN+AngII resulted in the appearance of senescent cells that are positive for senescence-associated beta-galactosidase, and expression of senescence markers Arf and Ink4a in the aortic walls. Appearance of cellular senescence occurred in one day of BAPN+AngII infusion and continued throughout the observational period of 14 days. We examined the role of cellular senescence in AD pathogenesis by oral administration of ABT263 which is known as “senolytics” that eliminates senescent cells. ABT263 treatment reduced the expression of the senescence markers. In the vehicle-treated group, the mortality was 66.7% (12/18), whereas that of ABT263-treated group was 35% (14/20, P<0.05 by log-rank test). The severity of AD, as assessed by the lesion length in vehicle group was33.2±3.1 mm, whereas that in ABT263 group was 24.6±1.8 mm (P<0.05).

Conclusions

These findings demonstrated that cellular senescence precedes AD development, and ABT263 effectively prevented AD progression and death, indicating the involvement of cellular senescence in AD pathogenesis. Therefore, cellular senescence represents a potential predictor and a therapeutic target for AD.

Funding Acknowledgement

Type of funding sources: None.

Involvement of FAK in aortic dissection: potential role in aortic interstitial cells

Background

Aortic dissection (AD) is a fatal disease where the intimomedial layer of the aorta suddenly fail. Although it is widely accepted that hemodynamic stress on the aortic wall triggers its destruction that is further promoted by inflammatory response as exemplified by the infiltration of neutrophils and macrophages, molecular mechanism is unknown for the link of aortic wall stress, inflammation and tissue destruction. In general, mechanical stress to the tissue is converted to the cellular response through the cell adhesion molecules and the activation of focal adhesion kinase (Fak). Although it has been reported that Fak is involved in pathogenesis of aortic aneurysm by promoting migration and activation of macrophages, its role in AD is unknown. We hypothesized that Fak may be involved in AD pathogenesis.

Purpose

We investigated the involvement of Fak in AD pathogenesis, focusing on its role in inflammatory cells.

Methods and results

We created a mouse model of AD by continuous infusion of beta-aminopropionitrile, a collagen crosslink inhibitor, and angiotensin II (BAPN + Ang II). Immunostaining for activated Fak revealed that Fak was not activated in normal aorta, but was activated in the infiltrating inflammatory cells and in interstitial cells of the aortic wall after AD development. We examined the role of Fak by oral administration of PND-1186, a specific Fak inhibitor, in mouse AD model. Vehicle-treated group showed 63.6% mortality, whereas PND-1186-treated group showed 20% mortality (P<0.01, n=20 for each group) in 14 days of the observational period. The aortic arch lesion, the most critical part in AD, was improved from 1.96±0.41 mm in vehicle group to 0.66±0.29 mm in PND group (P<0.05). We next examined the cell type-specific role of Fak in AD by creating macrophage and granulocyte-specific deletion of Fak driven by LysM-Cre and floxed Fak system. Unexpectedly, the genetic deletion of Fak in macrophages and granulocytes had no impact on the mortality nor the severity of AD.

Conclusions

These findings proved that Fak plays a critical role in AD progression and death. Because Fak is dispensable for macrophages and granulocytes, other cell types, possibly aortic wall interstitial cells, may be regulated by Fak in AD pathogenesis. Deciphering the role of Fak would provide the fundamental understanding of AD pathogenesis.

Funding Acknowledgement

Type of funding sources: None.

Comparison between optical frequency domain imaging and intravascular ultrasound in PCI guidance for Biolimus A9 eluting stent implantation

Background

It has been reported that intravascular ultrasound (IVUS) guided PCI reduced a risk of major adverse cardiac event compared to conventional angiography guided PCI, while comparison between IVUS-guided and optical frequency domain imaging (OFDI)-guided PCI specifically in long-term clinical outcomes (>1 year) has been unexplored.

Purpose

We sought to compare imaging surrogates at 8 months and clinical outcomes beyond 1 year after drug-eluting stent implantation between IVUS and OFDI guidance.

Methods

The MISTIC-1 is a prospective, multi-centre, single-blinded, randomised-controlled, non-inferiority trial comparing OFDI-guided and IVUS-guided PCI using Biolimus A9 eluting Nobori stent. We enrolled patients with stable coronary artery disease who have symptoms or clinically relevant myocardial ischemia. Stent landing zones were selected in the most normal looking sites with largest lumen and without percentage plaque area >50% in IVUS group while without lipidic plaque of >2 quadrants or suggestive thin-cap fibroatheroma in OFDI group. Stent sizing was based on external elastic lamina (EEL) in IVUS group, while by taking 10% or 0.25mm larger than mean lumen diameter at reference sites in OFDI group. Stent optimisation with in-stent minimum lumen area ≥80% of the average lumen area at proximal and distal reference sites was encouraged in both groups. Primary efficacy endpoint is in-segment minimum lumen area (MLA) assessed by OFDI at 8 months. Secondary safety endpoint is a composite of cardiovascular death, target vessel myocardial infarction, or target lesion revascularisation. Based on the assumption that mean in-segment MLA at follow-up was 4.5mm2 with a standard deviation of 2.0mm2 in the control (IVUS) group and a non-inferiority limit of 1.2mm2 for OFDI group, sample size was estimated as 48 cases in each group with 5% type I error and 90% statistical power.

Results

Since June-2014 and August-2016, we prospectively enrolled 109 patients (mean age 70 years, male 78%) with 126 lesions. Baseline patient and lesion characteristics were well balanced and average nominal size and length of stent used did not differ between OFDI-guided and IVUS-guided PCI (3.0 and 19.1mm vs. 3.1 and 19.3mm, respectively). Post-procedural minimum stent area was 6.24mm2 in OFDI group and 6.72mm2 in IVUS group (p=0.20). At 8-month follow-up, in-segment MLA was 4.56mm2 in OFDI group and 4.13mm2 in IVUS group (P for non-inferiority <0.001). During the follow-up (median 4.5 years [1654 days]), incidence rates of major adverse cardiac event were comparable between the two groups (7.4% in OFDI group and 7.3% in IVUS group, hazard ratio 0.96, 95% CI 0.24–3.83, p=0.95). No definite or probable stent thrombosis were documented in both groups.

Conclusion

OFDI-guided PCI demonstrated comparable results in achieving satisfactory imaging surrogates as well as long-term clinical outcomes after newer generation DES implantation as compared to IVUS-guided PCI.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Suzuken Memorial Foundation

Five-year major adverse cardiac and cerebrovascular events of patients with lipid core abutting lumen (LCAL) on integrated-backscatter intravascular ultrasound undergoing PCI with current DES

Background

Percutaneous Coronary Intervention (PCI) using the new generation drug-eluting stent (DES) has been extremely reduced target lesion revascularization (TLR) in recent years. However, a high incidence of non-target lesion-related cardiovascular events in patients undergoing PCI is an important problem to be solved. According to the previous findings, patients with vulnerable plaques particularly have a high recurrence of cardiovascular events. Little studies, however, has been done to examine the relationship between plaque characteristics on intravascular imaging in a target lesion and non-target lesion-related cardiovascular events.

Purpose

The main objective of this study is to investigate the five-year major adverse cardiac and cerebrovascular events (MACCE) of patients with lipid core abutting lumen (LCAL) on integrated backscatter intravascular ultrasound (IB-IVUS) in a target lesion undergoing PCI with current DES.

Methods and results

Between February 2010 and September 2013, in total 780 patients with ischemic heart disease undergoing PCI, 166 target lesions in 166 consecutive patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) and stable angina pectoris (SAP) undergoing IVUS-guided PCI were studied.

Plaque characteristics in all target lesions were analyzed by three-dimensional IB-IVUS system using the mechanical IVUS catheter. Our previous study has found that LCAL which is defined as a lipid pool directly in contact with the lumen visualizes the thin fibrous cap of less than 75μm on optical coherence tomography (OCT). On the basis of this data, LCAL at minimal lumen area (MLA) site was identified.

In total, 39 patients had lesions with LCAL at MLA site (LCAL(+)), and 127 patients had those without LCAL (LCAL(−)).

The primary endpoint was defined as MACCE, including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke and non-TLR for the new lesion during a median follow up of five years. The MACCE occurred significantly higher in the LCAL(+) than in the LCAL(−) (38.5% vs. 17.3%; p<0.005). And the Kaplan-Meier estimates have shown that the cumulative incidence of MACCE was significantly higher in the LCAL(+) than in the LCAL(−) (log rank test, p=0.041). Additionally, after adjustment for confounders, gender, prior PCI and LCAL was the independent predictors for the MACCE of patients undergoing PCI with current DES.

Furthermore, after adding LCAL to a baseline model with established factors consisting of age, gender, diabetes mellitus, prior PCI and percentage lipid volume on IB-IVUS, the net reclassification (p<0.002) and integrated discrimination improvement (p<0.004) significantly improved compared to baseline model alone.

Conclusions

In this study, it has become clear that LCAL on IB-IVUS is likely to be a surrogate marker of MACCE in patients undergoing PCI with current DES.

Funding Acknowledgement

Type of funding source: None

The role of B cells and IgG in aortic dissection

Background

Aortic dissection (AD) is one of the destructive and fatal aortic diseases, for which molecular pathogenesis is largely unknown. Recent studies have highlighted the importance of inflammatory response in AD. We and others reported that B cells and immunoglobulins participate in pathogenesis of abdominal aortic aneurysm, another form of aortic destructive disease, by promoting inflammatory response. It is not known whether and how B cells participate in AD pathogenesis.

Methods and results

Immunohistochemical staining of human AD tissue revealed that B cells were clustered together with T cells, macrophages and neutrophils at the entry site of AD with medial disruption. B cell cluster was also observed at the site of medial disruption in mouse model of AD that was induced by continuous infusion of beta-aminopropionitrile and angiotensin II (BAPN+AngII). In muMT mouse, which is deficient for B cells and immunoglobulins due to genetic deletion of immunoglobulin heavy chain, BAPN+AngII induced significantly less severe AD compared to that in wild type. Depositions of IgG and fibrinogen, one of the endogenous antigen for natural IgG, were observed after BAPN+AngII infusion before and after AD development in wild type mice. Deposition of fibrinogen was also observed in mMT mice after BAPN+AngII infusion. The rate of aortic rupture and sudden death was approximately 42% in wild type mice, while that in muMT mouse was 12% (P<0.05). Administration of mouse normal polyclonal IgG to muMT mice resulted in dramatic increase in aortic rupture and sudden death, starting at day 7 of BAPN+AngII infusion, and reaching 69% of rupture rate, indicating the critical role of IgG in AD.

Conclusion

These findings demonstrated B cells and IgG are critically involved in the destructive inflammation of AD pathogenesis. Further, the deposition of fibrinogen, one of the targets of natural IgG, precedes the development of AD. Our findings may provide the conceptual foundation of the diagnostic strategy for on-going tissue destruction and for the therapeutic opportunities to intervene the progressive tissue destruction in AD.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Japan Society for the Promotion of Science

Kimura's disease: effects of age on clinical presentation

BACKGROUND

Kimura's disease (KD) is known to be dominant among young Asian men, but it can also occur in middle- and advanced-aged people. The clinical characteristics of KD, especially by age, are not well known.

AIM

This study was performed to investigate the effects of age on the clinical characteristics of KD.

DESIGN

We conducted a case series study.

METHODS

All case studies of patients diagnosed with KD were collected via a PubMed search of studies published until August 2018. The data were analyzed by age group.

RESULTS

In total, 215 studies were reviewed (238 patients; mean age of 36 years). The male:female ratio was 4:1 overall, 17:1 in patients aged <20 years, 4:1 in patients aged 20-39 years and 2:1 in patients aged ≥40 years (P = 0.01). The percentage of patients with pruritus was 15.4% overall, 3.8% in patients aged <20 years, 15.5% in patients aged 20-39 years and 21.7% in patients aged ≥40 years (P = 0.02). The time to diagnosis was 5.3 years overall, 3.2 years in patients aged <20 years, 4.7 years in patients aged 20-39 years and 7.1 years in patients aged ≥40 years (P < 0.01).

CONCLUSIONS

The proportion of female patients affected the incidence of pruritus, and the time to diagnosis increased as the patients' age increased. There were no significant age-related differences in region/race, complications, multiplicity, laterality, anatomical distribution, maximum size, eosinophil count, immunoglobulin E level, initial treatment, recurrence or outcomes. This may be useful information for the diagnosis of KD.

P175 Prognostic value of 99mTc-ECD brain perfusion SPECT in patients with atrial fibrillation and dementia

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and those afflicted have reduced quality of life, functional status, and cardiac performance. The patients with AF have a high risk of coronary heart disease and cardiovascular disease. Although the prevalence of AF is increasing, cognitive disorders are also on the rise in tandem with the aging of the population. The patients with dementia have also experienced lower the quality of life and have increased mortality. Technetium 99m ECD brain perfusion single photon emission computed tomography (99mTc-ECD brain perfusion SPECT) is a useful modality for diagnosing dementia and identifying high risk patients with mild cognitive impairment. However, there are few reports about the relationship between the value of Z score calculated by 99mTc-ECD brain perfusion SPECT and prognosis of patients with AF and dementia.

Purpose

The aim of this study was to evaluate the prognostic values of brain perfusion using 99mTc-ECD SPECT in patients with AF and dementia.

Methods

Among 405 consecutive patients who were diagnosed as AF in cardiac outpatients and subsequently diagnosed as dementia using Mini-Mental State Examination by neurologists or psychiatrists, we identified 170 patients (81 ± 10 years) who underwent 99mTc-ECD brain perfusion SPECT for the current study. Of those, 73, 73, and 24 were diagnosed as Alzheimer’s dementia (AD), vascular dementia (VD), and non-specified dementia respectively. Multivariate Cox model was used to assess if higher Z score by 99mTc-ECD brain perfusion SPECT and clinical parameters were associated with major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, hospitalization for heart failure, and stroke. Sub-analyses of multivariate Cox models by AD or VD were also assessed. The cut-off values of Z score were determined using area under the curve by a receiver operating characteristic analysis based on MACE occurrences.

Results

During a mean follow-up of 1258 ± 1044 days, 62 MACE occurred. There was not significant difference of MACE between AD and VD (33%, vs. 44%, p = 0.153). By multivariable Cox model, the higher Z score of temporal-occipital-pariental lobe was associated with increased MACE compared to the lower group (HR 2.521, 95% CI 1.465–4.337, p &lt; 0.001). In a sub-analysis of patients with AD, Z score was the most significant prognostic factor for MACE (HR 3.969, 95% CI 1.374–11.468, p = 0.011). The similar trend was observed in those with VD (HR 2.247, 95% CI 1.028–4.913, p = 0.043). Conclusion: This study demonstrated that the Z score of temporal-occipital-pariental lobe by 99mTc-ECD brain perfusion SPECT could be a potential prognostic value among patients with AF and dementia, regardless of type of dementia.

Room temperature and low-field resonant enhancement of spin Seebeck effect in partially compensated magnets

Resonant enhancement of spin Seebeck effect (SSE) due to phonons was recently discovered in Y[Formula: see text]Fe[Formula: see text]O[Formula: see text] (YIG). This effect is explained by hybridization between the magnon and phonon dispersions. However, this effect was observed at low temperatures and high magnetic fields, limiting the scope for applications. Here we report observation of phonon-resonant enhancement of SSE at room temperature and low magnetic field. We observe in Lu[Formula: see text]BiFe[Formula: see text]GaO[Formula: see text] an enhancement 700% greater than that in a YIG film and at very low magnetic fields around 10[Formula: see text] T, almost one order of magnitude lower than that of YIG. The result can be explained by the change in the magnon dispersion induced by magnetic compensation due to the presence of non-magnetic ion substitutions. Our study provides a way to tune the magnon response in a crystal by chemical doping, with potential applications for spintronic devices.

P4760New minimally invasive and tailor-made strategy for cryoballoon ablation in patients with paroxysmal atrial fibrillation

Background

Currently, cryoballoon ablation (CBA) has proven to be highly effective in achieving free from atrial fibrillation (AF), especially paroxysmal AF. However, the optimal freezing protocol for each patient to achieve successful pulmonary vein isolation by only CBA is still uncertain. The aim of this study was to evaluate the clinical implications of a reduction in the freezing duration (<180s) during CBA guided by the time to target temperature.

Methods

From November 2015 to August 2018, 286 consecutive paroxysmal AF patients undergoing CBA were enrolled. We compared 107 patients undergoing a tailor-made CBA procedure (Group A; August 2017-August 2018) to 179 patients with a standard CBA procedure (Group B; November 2015–July 2017). In Group A, the freezing duration was reduced to 150s when the temperature reached ≤−40°C within 40s. Furthermore, we reduced it to 120s when it reached ≤−50°C within 60s. In the other patients, the freezing time was 180s except for excessive freezing over −60°C and/or emergent situations while monitoring the esophageal temperature and for phrenic nerve injury as in Group B.

Results

The baseline clinical characteristics were similar between two groups. In Group A, 89 patients (83%) underwent CBA with a reduction in the freezing time. The rate of having reduction time in left inferior PV (LIPV) and right inferior PV (RIPV) was lower compared with left superior PV (LSPV) and right superior PV (RSPV) (respectively 17%, 29%, 56%, and 63.5%). However, for right inferior PV, in 31 patients having the reduced freezing time, none of them required touch-up ablation. Although the procedure time and frequency of touch-up ablation did not differ between the 2 groups, total freezing time for each PV was significantly shorter in Group A than Group B as shown in figure (LSPV: 164±28s vs. 216±67s; p<0.001, LIPV: 187±44s vs. 218±69s; p<0.001, RSPV: 147±31s vs. 192±51s; p<0.001, RIPV: 180±50 vs. 218±73s; p<0.001). The AF free survival rate during the follow-up period (356±167 days) was similar between the 2 groups (log-rank test, p=0.38). Furthermore, the complication rate was similar 2 groups.

The freezing time for each PV

Conclusion

The safety and efficacy of the new tailor-made CBA strategy were non-inferior to the standard procedure. This study showed that the unnecessary freezing time could be reduced in most of paroxysmal AF patients.

P6494Activation of focal adhesion kinase is involved in pathogenesis of aortic dissection in mice

Background

Aortic dissection (AD) is a fatal disease where the media of the aorta suddenly fail. Currently, Molecular pathogenesis of AD is unknown. Recently, we discovered that the activity of MRTF-A, a mechanosensitive transcriptional regulator, promotes AD development. The activity of MRTF-A is regulated by mechanical stress to cells, which is transduced through focal adhesion and actin dynamics. However, it is currently unknown whether the mechanotransduction mechanism is involved in AD pathogenesis.

Purpose

We investigated the role of focal adhesion kinase (FAK), a signaling molecule that transduces mechanostress from focal adhesion to actin dynamics, in AD pathogenesis.

Methods

We created a mouse model of AD with a continuous infusion of beta-aminopropionitrile (150 mg/kg/day), a collagen crosslink inhibitor, and angiotensin II (1,000 ng/kg/min) (BAPN + AngII) by an osmotic pump. This model caused about 60% death in all mice due to AD rupture within 2 weeks. In this model, we examined the severity and mortality rate of aortic dissection after 2 weeks in mice administered with PND-1186, an orally available FAK inhibitor, and in those treated with vehicle (n=20 for each group). We performed immunochemical staining, immunofluorescence staining and Western blot for activated (phosphorylated) FAK (pFAK) to evaluate the activation status of FAK in the aortic tissue. We also performed transcriptome analysis of the aortic tissue in with and without PND-1186 with BAPN + AngII stimulation before AD development.

Results

Immunochemical staining revealed that FAK was inactive in normal mouse aorta, but was strongly activated in the aortic walls after AD development. Immunofluorescence staining showed that FAK was activated mainly in smooth muscle cells after AD development. Western blot analysis also revealed that FAK was activated in 3 days after BAPN + AngII infusion before AD development, followed by transient reduction at day 7, and re-activation after AD at day 14. Significantly, administration of PND-1186 resulted in a significant reduction in the severity of AD in the aortic arch (1.96±0.41 mm in vehicle group, 0.66±0.29 mm in PND group, P<0.05). In addition, survival rate improved from 36.4% to 80.0% by administration of PND-1186 (P<0.01). In immunofluorescence staining, the PND-1186 treated group showed weaker staining of pFAK. Transcriptome analysis showed that genes for hematopoiesis and immune system were suppressed in PND-1186 treated group.

Conclusions

These findings proved that FAK plays a central role in the pathogenesis of AD probably by transmitting pathological stress to the aortic wall to cause tissue destruction. We propose that FAK is a potential therapeutic target for limiting the fatal destruction of the aortic wall of AD.

P5626The clinical impact of the angle of OCT detected irregular protrusion after primary PCI at the STEMI culprit lesions

Background and introduction

The percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) shows worse clinical outcomes than that for stable angina. As the one of the reasons, a recent optical coherence tomography (OCT) registry showed that the presence of irregular protrusion (IP)after coronary stenting was the worse predictor of 1-year device-oriented clinical end points. However, the impact of the quantitative findings on IP has not been well investigated in ACS patients.

Aim

To investigate the clinical impact of the post stent OCT findings, especially IP, detected by OCT after coronary stenting in ACS patients.

Methods

Consecutive 256 ACS lesions treated with OCT-guided PCI in our Medical University Hospital from January 2013 to November 2016 was retrospectively analyzed. In 256 lesions, 173 lesions were enrolled which had ST-elevation acute myocardial infarction (STEMI) with the onset to recanalization time within 720 minutes. In 170 lesions, the OCT images were available. In OCT image, IP was detected in 140 lesions (82.3%). Quantitative analysis of IP in post-procedure OCT imaging was observed to identify the OCT predictors for clinical endpoint including cardiac death, target vessel revascularization ant stent thrombosis in 1 year after index PCI.

Result

In post-procedure OCT findings, stent edge dissection was detected in 32.4% of lesions. Incomplete stent apposition was detected in 74.1%. Maximum angle of irregular protrusion was 194±86 degree and the incidence of maximum IP angle >180 degree was 52.9%. Maximum height of IP was 0.26±0.11mm. Small minimal stent area, defined as a lesion with minimal stent area <5.0 mm2 in a drug-eluting stent or <5.6 mm2 in a bare metal stent, was observed in 32.4% of lesions. Maximum IP angle and that of >180degree was significantly associated with the clinical endpoint (p=0.0259 and 0.0429, respectively).

Conclusion

In STEMI patients, IP was frequently observed in post-procedure OCT imaging during primary PCI. The maximum angle of IP was significantly associated with the clinical end points. The prognostic impact of maximum IP angle in STEMI patient needs further investigations.

P6493Syk activation is a defense mechanism in murine model of aortic dissection

Background

Aortic dissection (AD) is a serious clinical condition with unknown etiology that frequently results in fatal outcome. Recent studies showed essential role of inflammatory response both in promoting AD and aortic aneurysm (AA). However, the difference of the molecular pathogenesis between AD and AA is unclear. Previously, we reported that Syk, a tyrosine kinase that regulates differentiation and activation of inflammatory cells, promotes AA formation in a mouse model.

Objective

In the current study, we investigated the role of Syk in AD.

Methods and results

A mouse AD model was created by continuous infusion of beta-aminopropionitrile (125 mg/kg/day) and angiotensin II (1,000 ng/min/kg) (BAPN+AngII), which caused AD in approximately 80% of mice within 14 days. Immunohistochemical staining for activated (phosphorylated) Syk (pSyk) revealed that Syk was inactive in normal mouse aorta, but was activated in the aortic walls after AD development. Double immunofluorescence staining for pSyk and smooth muscle alpha actin showed that Syk was active not only in the infiltrating inflammatory cells, but also in smooth muscle cells in AD tissue. Western blot analysis revealed that BAPN+AngII treatment caused Syk activation at 3 days before AD development, followed by transient suppression, and reactivation at 14 days after AD development. We examined the significance of Syk activation in AD by treating mice with fostamatinib, a specific Syk inhibitor, before and during BAPN+AngII infusion. Notably, fostamatinib-treated group developed more severe AD compared to the vehicle-treated group. The AD lesion length was 3.80±0.86 mm for vehicle group and 8.87±1.69 mm for fostamatinib group (P<0.05, n=12 for each group). In addition, fostamatinib significantly worsened the mortality of mice due to the rupture of the aorta from 0% to 42% (P<0.05, n=12 for each group). Transcriptome analysis revealed that fostamatinib suppressed both positive and negative regulators of immune response, defense response and inflammatory response.

Conclusions

These findings uncovered the previously unrecognized role of Syk for protecting the aortic tissue in AD pathogenesis, and suggested fundamentally different disease mechanisms of AD and AA.

P3388Five year outcomes of patients with lipid rich plaque detected three-dimensional Integrated-Backscatter intravascular ultrasound (IB-IVUS) in target lesion after second generation DES implantation

Background

Elective percutaneous coronary intervention (PCI) using second generation drug-eluting stent (DES) has been dramatically reduced restenosis rate. Recently, it has been reported that plaque characterization in nontarget lesion is associated with cardio-vascular events in ischemic heart disease patients undergoing elective PCI. However, it is unclear whether plaque characterization in target lesion is predictor of MACEs (major adverse cardiac events) after elective PCI.

Purposes

The aim of this study is whether plaque characterization detected integrated-backscatter intravascular ultrasound (IB-IVUS) in the target lesion is associated with MACEs in patients with PCI after second generation DES implantation.

Methods and results

Of 700 patients with ischemic heart disease, 552 patients were excluded for chronic totally occlusion, severe calcification hindering precise intracoronary imaging, tortuous lesions, ostial or left main stem lesions and ST-elevated myocardial infarction patients. Finally, 148 consecutive patients who consented to repeated IB-IVUS prior to undergoing elective PCI were recruited in the study.Plaque characterization in target lesion was identified for three-dimensional IB-IVUS technology using the mechanical IVUS catheter (ViewIT, 40 MHz, 2.5 Fr; Terumo, Tokyo, Japan). The median of percentage lipid volume in all target lesions was 47.6%. Furthermore, lipid rich plaque (LRP) group was defined as the lesions consisting of percentage lipid volume greater than the median. And, non-lipid rich plaque (non-LRP) group was defined as the lesions consisting of percentage lipid volume less than the median. MACEs were defined as cardiovascular death, target vessel myocardial infarction, target lesion revascularization and stent thrombosis. The median of follow up period was 60 months. Of the 148 patients, 106 patients had stable angina pectoris. The remaining 42 patients are acute coronary syndrome (NSTE-ACS). 74 patients were classified LRP groups and 74 patients were non-LRP groups. No significant differences were observed between the two groups with respect to age, sex and coronary risk factors. While plaque and vessel volume were greater in the LRP group (216.9±116.3mm3, p<0.001) than non-LRP group (322.5±144.0mm3, p p<0.001). Remodeling index was greater in LRP group (1.02±0.18) than non-LRP group (0.93±0.18, p<0.003). Although MACEs were no significant differences between the two groups, the number of MACEs tend to be more in patients with LRP group (8.1±27.4%) than small lipid group (2.7±16.3, p<0.147). Especially, cardiac death tend to be more in LRP group (6.7±25.2% than non-LRP group (1.3±11.6, p<0.096).

Conclusions

In conclusion, lipid rich plaque detected by three dimensional IB-IVUS system in target lesion with patients undergoing elective PCI may be associated with clinical outcomes for five years after second generation DES implantation.

Acknowledgement/Funding

None

P2694Early and late restenosis after excimer laser coronary angioplasty and paclitaxel-coated balloon combination therapy for drug-eluting stent restenosis

Background

Drug-eluting stent restenosis (DES-ISR) is associated with poorer outcomes than those of bare-metal stent restenosis after treatment with paclitaxel-coated balloon (PCB), and late restenosis after PCB angioplasty for DES-ISR is a residual problem. Excimer laser coronary angioplasty (ELCA) is thought to be advantageous for ISR treatment by removing neointima. However, whether the combination of ELCA and PCB angioplasty is more effective than the use of PCB only angioplasty in DES-ISR has not been studied so far.

Purpose

We evaluated the efficacy of ELCA and PCB combination therapy for DES-ISR at mid-and late-term after revascularization.

Methods

From January 2014 to March 2016, 166 DES-ISR lesions were treated with ELCA and no-ELCA prior to PCB. Two serial angiographic follow-ups were planned for the patients (at 6–12 and 18–24 months after procedure). Acute procedural and follow-up angiographic results were assessed by quantitative coronary angiography. ELCA and no-ELCA group included 74 lesions and 92 lesions, respectively.

Results

There was no significant difference between the two groups in the clinical characteristics except the prevalence of hemodialysis, the rate of first-generation DES (37.9% vs 36.8%, p=0.897), previous stent size (2.90±0.39 mm vs 2.77±0.39 mm, p=0.063), and reference vessel diameter (2.65±0.46 mm vs 2.60±0.65 mm, p=0.593). Early follow-up angiography was performed in 66 lesions (89.1%) of ELCA group, and was done in 76 lesions (82.6%) of no-ELCA group. In the ELCA group, percentage diameter stenosis (%DS) just after procedure and at 6–12 months later were significantly smaller than those of no-ELCA group. Besides, target lesion revascularization (TLR) rate at 6–12 months after procedure was tended to be lower in the ELCA group. Late follow-up angiography was performed for 93 lesions (81.6%) of the remaining 114 lesions (excluding TLR lesion), late restenosis was found 9 lesions (18.6%) in the ELCA group and 11 lesions (24.4%) in the no-ELCA group (p=0.504). Late luminal loss was similar in both groups (0.37±0.71 mm vs 0.24±0.82 mm, p=0.438), and %DS at 12–18 months after revascularization was not different between the two groups.

Changes of %DS and TLR rate

Conclusions

%DS in the ELCA group was smaller at just after procedure and the advantage was kept even after 1-year. However, late restenosis and TLR at 2-year after revascularization for DES-ISR could not be reduced by ELCA and PCB combination therapy.

Cortical bone mineral density is increased by the cathepsin K inhibitor ONO-5334, which leads to a robust increase in bone strength: results from a 16-month study in ovariectomised cynomolgus monkeys

This study evaluated the long-term effects of the cathepsin K inhibitor ONO-5334 on bone mass and strength in ovariectomised (OVX) cynomolgus monkeys. Animals were assigned to one of the following six groups: Sham (non-OVX), OVX control treated with vehicle, ONO-5334 1.2, 6 or 30 mg/kg/day, p.o., or alendronate (ALN) 0.05 mg/kg/2 weeks, i.v. for 16 months. Peripheral quantitative computed tomography (pQCT) analysis revealed that ONO-5334 increased not only trabecular bone mineral density (BMD) but also cortical BMD in the distal radius and the lumbar vertebra. ONO-5334 and ALN suppressed the deterioration of trabecular architecture by micro-CT analysis in the distal radius. Assessments of bone strength showed that ONO-5334 increased maximum load at the distal and midshaft radius. The linear regression lines between bone mass and strength in the lumbar vertebra were tended to be shifted towards increasing bone strength in the ONO-5334 6 and 30 mg/kg groups compared with the ALN groups. This indicated that bone strength was higher in the ONO-5334 groups than the ALN group, even though bone mineral content (BMC) and BMD were comparable. Subpopulation analysis revealed that, at similar integral BMC or BMD level, cortical bone mass for ONO-5334 was higher than for ALN; the opposite effects were observed for trabecular bone. In conclusion, ONO-5334 preferentially increased cortical bone, which may provide a greater contribution to bone strength. Since these results support a different mode of action for ONO-5334 compared with that of ALN, ONO-5334 may offer new therapeutic options to patients with osteoporosis.

A case of generalized pustular psoriasis caused by hydroxychloroquine in a patient with systemic lupus erythematosus

Hydroxychloroquine (HCQ) has been used to treat systemic lupus erythematosus (SLE) in Japan since 2015. We herein report a case of SLE that developed generalized pustular psoriasis (GPP) following the administration of HCQ. Twenty-one days after the HCQ treatment, a pustular rash with itching appeared on the auricle, scalp, and forearm, and spread rapidly to the face and body trunk with a high fever and arthralgia. Skin biopsy showed pustule formation under the cornified layer, neutrophil infiltration, the destruction of keratinocytes, and spongiform pustules of Kogoj. The patient was diagnosed with GPP. HCQ was immediately discontinued, the dose of prednisolone (PSL) was increased, and granulocyte and monocyte adsorption apheresis was performed. Her symptoms subsequently disappeared. Since arthralgia relapsed after the tapering of PSL, cyclosporine was added. Although single nucleotide polymorphisms (c.28C>T and c.115+6T>C) in the interleukin (IL)-36RN gene, which encodes the IL-36 receptor antagonist, have frequently been reported in GPP, these mutations were not observed in the present case. The potential development of GPP needs to be considered when administering HCQ to patients with SLE.

Impact of different timing of consuming sweet snack on postprandial glucose excursions in healthy women

AIMS

Our aim was to evaluate the acute effect of eating sweet snacks at different times of day on glycaemic parameters in young women without diabetes.

METHODS

In this randomized controlled three-treatment crossover study, 17 women [(means ± SD) age: 21.2 ± 0.8 years, BMI: 20.7 ± 2.5 kg/m2, HbA_1c: 36 ± 2 mmol/mol (5.1 ± 0.2%)] wore flash (continuous) glucose monitoring systems for 7 days. Each participant consumed identical test meals on days 4, 5 and 6, but consumed sweet snacks (baked cake: 498 kcal; 53.6 g of carbohydrate, 8.0 g of protein, 28.0 g of fat) at 12:30 (post-lunch), 15:30 (mid-afternoon) and 19:30 (post-dinner), respectively, on each of those days. Daily glycaemic parameters on those 3 days of snacking at different times of day were compared within-participant.

RESULTS

The mean amplitude of glycaemic excursions (3.54 ± 0.32 vs. 2.73 ± 0.20 mmol/L; P < 0.05), standard deviation of glucose (1.20 ± 0.11 vs. 0.92 ± 0.07 mmol/L; P < 0.05), incremental area under the curve (IAUC) for glucose at 12:00-07:00 (986 ± 89 vs. 716 ± 88 mmol/L × min; P < 0.05) and IAUC at 07:00-10:00 the next day (141 ± 17 vs. 104 ± 12 mmol/L × min; P < 0.05) when the snack was eaten post-dinner were all significantly higher than with mid-afternoon snacking.

CONCLUSION

Eating sweet snacks post-dinner should be avoided because it worsens glucose excursions as well as postprandial glucose levels after both dinner and the following day's breakfast in young healthy (non-diabetic) women.