Drug-coated balloon strategy following orbital atherectomy for calcified coronary artery compared with drug-eluting stent: One-year outcomes and optical coherence tomography assessment

BACKGROUND

Percutaneous coronary intervention (PCI) for calcified coronary artery remains challenging in the drug-eluting stent (DES) era. While recent studies reported the efficacy of orbital atherectomy (OA) combined with DES for calcified lesion, the effectiveness of drug-coated balloon (DCB) following OA has not been fully elucidated.

METHODS

Between June 2018 and June 2021, 135 patients who received PCI for calcified de novo coronary lesions with OA were enrolled and divided into two groups; OA followed by DCB (n = 43) if the target lesion achieved acceptable preparation, or second- or third-generation DESs (n = 92) if the target lesion showed suboptimal preparation between June 2018 and June 2021. All patients underwent PCI with optical coherence tomography (OCT) imaging. The primary endpoint was 1-year major adverse cardiac event (MACE), that was a composite of cardiac death, nonfatal myocardial infarction, or target lesion revascularization.

RESULTS

Mean age was 73 years and 82% was male. In OCT analysis, maximum calcium plaque was thicker (median: 1050 µm [interquartile range (IQR): 945-1175 µm] vs. 960 µm [808-1100 µm], p = 0.017), calcification arc tended to larger (median: 265° [IQR: 209-360°] vs. 222° [162-305°], p = 0.058) in patients with DCB than in DES, and the postprocedure minimum lumen area was smaller in DCB compared with minimum stent area in DES (median: 3.83 mm² [IQR: 3.30-4.52 mm² ] vs. 4.86 mm² [4.05-5.82 mm² ], p < 0.001). However, 1 year MACE free rate was not significantly different between 2 groups (90.3% in DCB vs. 96.6% in DES, log-rank p = 0.136). In the subgroup analysis of 14 patients who underwent follow-up OCT imaging, late lumen area loss was lower in patients with DCB than DES, despite lower lesion expansion rate in DCB than DES.

CONCLUSIONS

In calcified coronary artery disease, DCB alone strategy (if acceptable lesion preparation was performed with OA) was feasible compared with DES following OA with respect to 1-year clinical outcomes. Our finding indicated using DCB with OA might be reduce late lumen area loss for severe calcified lesion.

Predictors of coronary artery injury after orbital atherectomy as assessed by optical coherence tomography

PURPOSE

The association between the extent of the wire and device bias as assessed by optical coherence tomography (OCT) in the healthy portion of the vessel and the risk of coronary artery injury after orbital atherectomy (OA) has not been fully elucidated. Thus, purpose of this study is to investigate the association between pre-OA OCT findings and post-OA coronary artery injury by OCT.

METHODS

We enrolled 148 de novo lesions having calcified lesion required OA (max Ca angle > 90°) in 135 patients who underwent both pre- and post-OA OCT. In pre-OA OCT, OCT catheter contact angle and the presence or absences of guide-wire (GW) contact with the normal vessel intima were assessed. Also, in post-OA OCT, we assessed there was post-OA coronary artery injury (OA injury), defined as disappearance of both of intima and medial wall of normal vessel, or not.

RESULTS

OA injury was found in 19 lesions (13%). Pre-PCI OCT catheter contact angle with the normal coronary artery was significantly larger (median 137°; inter quartile range [IQR] 113-169 vs. median 0°; IQR 0-0, P < 0.001) and more GW contact with the normal vessel was found (63% vs. 8%, P < 0.001). Pre-PCI OCT catheter contact angle > 92° and GW contact with the normal vessel intima were associated with post-OA vascular injury (Both: 92% (11/12), Either: 32% (8/25), Neither: 0% (0/111), P < 0.001).

CONCLUSION

Pre-PCI OCT findings, such as catheter contact angle > 92° and guide-wire contact to the normal coronary artery, were associated with post-OA coronary artery injury.

Case Report: Importance of MRI Examination in the Diagnosis and Evaluation of COVID-19 mRNA Vaccination Induced Myocarditis: Our Experience and Literature Review

Acute myocarditis is a rare but serious complication associated with mRNA-based coronavirus disease 2019 (COVID-19) vaccination. In this article, four COVID-19 mRNA vaccination induced myocarditis cases managed at our tertiary Medical Center have been discussed. Three patients had typical myocarditis. One patient suffered from atrioventricular block and heart failure, which required more intensive treatment, but eventually improved. Additionally, a review of cardiac magnetic resonance imaging (MRI) features related to the diagnosis of myocarditis showed that COVID-19 mRNA vaccine-associated myocarditis tend to have more late-gadolinium enhancement (LGE) accumulation in the inferior lateral wall direction. According to a report by the U.S. Centers for Disease Control and Prevention (CDC), the diagnosis of COVID-19 mRNA vaccine-associated myocarditis is based on clinical symptoms, altered myocardial enzymes, cardiac MRI finding, or histopathology. Cardiac MRI is relatively less invasive than myocardial biopsy and plays an important role in the diagnosis of myocarditis. This review may aid in the diagnosis of COVID-19 mRNA vaccine-associated myocarditis.

Drug-coated balloon versus drug-eluting stent following orbital atherectomy for calcified coronary artery: one-year outcomes of a retrospective cohort study

Background

Percutaneous coronary intervention (PCI) for calcified coronary artery remains challenging in the drug-eluting stent (DES) era. The effectiveness of drug-coated balloons (DCBs) and orbital atherectomy system (OAS) is unknown.

Methods

In this retrospective, single-center study, we compared the use of DCBs with second- and third-generation DESs following orbital atherectomy (OA) for calcified de novo coronary lesions. All patients underwent PCI with intravascular imaging. The primary endpoint was major cardiac event, that was a composite of cardiac death, death for unknown cause, non-fatal myocardial infarction, or target lesion revascularization at 1 year.

Results

Between June 2018 and December 2019, 107 patients with coronary lesions were enrolled in this study and divided into two groups: 23 patients in DCB group and 84 patients in DES group. The post-procedure segment percentage diameter stenosis was 23.1% (interquartile range [IQR], 17.7 to 32.5) with DCB versus 14.4% (IQR, 10.0 to 21.2) with DES (P&lt;0.001). Overall adverse event rate for PCI procedure was low: one dissection with DES group, no persistent slow/no-flow, and no perforation with both group. The primary endpoint was not significantly different between 2 groups [DES: 6.0% (5/84), DCB: 0.0% (0/23), log-rank P=0.24].

Conclusions

In calcified coronary artery disease, using DCB following OA is as safe and effective as using DES following OA with respect to 1-year clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Multiple mycotic aneurysms with infective endocarditis: A case report

Mycotic aneurysms are sometimes seen in patients with infective endocarditis. We report a case of infective endocarditis with multiple mycotic aneurysms. Although antibiotics were effective, mycotic aneurysms appeared in the cerebral, hepatic, and gastroepiploic arteries. A 55-year-old man presented with mitral valve endocarditis due to Streptococcus oralis. Surgical treatment was deferred because of cerebral hemorrhage. After antibiotic initiation, his fever and C-reactive protein levels declined, and blood culture was negative. However, he experienced repeated cerebral hemorrhage and the number of cerebral mycotic aneurysms increased. Additionally, his spleen ruptured and the number of mycotic aneurysms in the hepatic and gastroepiploic arteries increased. After embolization for mycotic aneurysm and mitral valve replacement, no mycotic aneurysms appeared. Regardless of whether laboratory data improve or not, multiple mycotic aneurysms sometimes appear, and cardiac surgery for infection control should be considered in the early phase.

Dual phased array coils for high-resolution MRI of the shoulder

We connected two 3-inch coils to a dual phased array receiver system and sandwiched the shoulder between the two coils. To obtain a quantitative assessment of the improved SNR, we imaged a phantom with both the dual phased array coils and the standard shoulder coil. SNR as a function of distance from the coils was computed by the National Electrical Manufacturers Association (NEMA) standard. At the expected depth of the humeral head, the SNR of the phased array coils on single excitation was 1.42 times that of the standard shoulder coil on two excitations. The higher quality of the images on single excitation shortened the imaging procedure. The dual phased array coils realized the minimum FOV: 8 cm with a pixel of 0.31 x 0.41 mm. The dual phased array coils achieved high spatial resolution images of the shoulder with significantly shorter imaging times.

Phosphorylated and dephosphorylated types of non-activated glucocorticoid receptor

We purified glucocorticoid receptors quickly but very partially using DEAE-resin. [3H]-Triamcinolone acetonide-labeled and non-activated receptors in the quickly purified fraction were found to be separated into two fractions (P-2 and P-3) by hydroxyapatite column chromatography. The P-2 receptor was the main component, and the ratio of P-2/P-3 was around 2. The molecular weights of the two receptors were calculated to be the same, 242,000: Rs = 6.2 nm and s20,w = 9.0. Treatment of the receptor with catalytic subunits of phosphoprotein phosphatase 2A1 reduced the P-2/P-3 ratio from 2 to 0.5, while treatment with catalytic subunits of cAMP-dependent protein kinase and ATP increased it to 2.5. The isolated P-3 receptor could be converted into the P-2 type by the kinase treatment. Tungstate, a phosphatase inhibitor, stabilized the P-2 receptor, and the P-2/P-3 ratio was larger than 3 when the DEAE-fraction was prepared in the presence of tungstate. However, the tungstate effect was not very strong, and the P-2 type tended to change into the P-3. [3H]-Triamcinolone acetonide-labeled and non-activated receptors were purified very highly by using an affinity gel; the procedure required more than 10 h. Only the P-3 form was observed in the preparation of highly purified receptors. Hormone-free receptors were affected by neither the phosphatase nor the kinase. The results indicate that the hormone binding makes the receptor sensitive to phosphatase. The reversibly dephosphorylated receptor is more stable than the non-dephosphorylated one, and can be activated.

Identical properties of aldosterone and corticosterone binders and their presence in rat brain and kidney

The [3H]corticosterone binders from rat brain and kidney were characterized by binding affinity and chromatographies, and compared with the binders for [3H]aldosterone and [3H]triamicinolone acetonide. Corticosterone-binding globulin-like molecules at very high concentrations in crude extracts were completely eliminated by a DEAE-gel adsorption procedure. [3H]Aldosterone binder in the renal, DEAE-treated fraction was recovered in a single peak by gel-filtration chromatography and by ultracentrifugation in linear sucrose gradients, independent of hormone-binding and tungstate, a stabilizer of the binder. The Stokes' radius and sedimentation coefficient of the renal aldosterone binder were 6.6 nm and 9.3S, respectively, indicating an apparent molecular weight of 263,000. Corticosterone-preferring binder also existed in the DEAE-treated fraction. Both aldosterone and corticosterone binders were found in the brain and kidney preparations. Comparison among the binders showed identical values of Stokes' radius and elution pattern from DEAE-Toyopearl in a linear salt gradient regardless of the organ and the hormones. Scatchard analyses of [3H]aldosterone and [3H]corticosterone binding showed for each ligand only one group of high-affinity sites with the equivalent dissociation constants, 4-7 nM. The orders of steroids in competing for the two high-affinity sites were equivalent: corticosterone greater than or equal to aldosterone much greater than triamcinolone acetonide, and that for the triamcinolone acetonide binding was triamcinolone acetonide much greater than aldosterone greater than or equal to corticosterone. Hydroxyapatite column chromatography separated the aldosterone and corticosterone binders from the triamcinolone acetonide binder, but not the aldosterone binder from the corticosterone binder. It is concluded that aldosterone and corticosterone binders distinct from triamcinolone acetonide binder exist in rat brain and kidney.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of selenite on glucocorticoid receptor

Rat liver glucocorticoid receptor was partially purified and characterized for its hormone binding using selenite. Selenite at very low concentrations irreversibly inhibited the hormone binding. The concentration for half maximal inhibition was approximately 2.8 microM. The inhibition was restored by dithiothreitol. The receptor-hormone complex became considerably insensitive to the selenite inhibition. The receptor inhibited by selenite was eluted at the same position as the native receptor from DEAE ion exchange and gel filtration columns. The results suggest that at least four sulfhydryl groups are located in the hormone binding domain of the receptor making a cluster.

Effect of dobutamine on adenylate cyclase activity in rabbit renal pelvis and ureter

The adenylate cyclase activity in the rabbit renal pelvis and ureter was measured by the method of Salomon et al. (1974). The dobutamine-induced increase of adenylate cyclase activity is more prominent in the renal pelvis including the pacemaker region than in the ureter that is non-pacemaker region in the upper urinary tract. Therefore, it is thought that the pacemaker region is different from other regions in the upper urinary tract with regard to responses to dobutamine.

Sulfhydryl groups of aldosterone receptors from swine kidney

Specific [3H]aldosterone binding activity in swine kidney cytosol was inactivated by pretreatment of the cytosol with monoiodoacetamide (pH 8.5), N-ethylmaleimide (pH 7.0), or 5,5'-dithiobis(2-nitrobenzoate) (pH 7.5). Dithiothreitol restored the specific binding activity inactivated by the nitrobenzoate, but not that inactivated with ethylmaleimide. Incubation of the cytosol with aldosterone prior to pretreatment with ethylmaleimide protected the receptors from inactivation. The rank order of steroids for the protection was: aldosterone greater than hydrocortisone greater than or equal to dexamethazone = progesterone greater than triamcinolone greater than estradiol. The initial velocity of the specific hormone binding could be determined by the binding reaction for 60 sec at 30 degrees. Double reciprocal plots of the initial velocity versus the hormone concentration with or without the nitrobenzoate showed a typical pattern of competition between the hormone and the inactivator. The results indicated the presence of functional sulfhydryl groups on the hormone binding sites of aldosterone receptors.