Optimal Timing of Coronary Intervention in Non-Culprit Lesion in ST Elevation Myocardial Infarction with Multi-Vessel Disease

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Automated Accurate Lumen Segmentation Using L-mode Interpolation for Three-Dimensional Intravascular Optical Coherence Tomography

Intravascular optical coherence tomography (IVOCT) lumen-based computational flow dynamics (CFD) enables physiologic evaluations such as of the fractional flow reserve (FFR) and wall sheer stress. In this study, we developed an accurate, time-efficient method for extracting lumen contours of the coronary artery. The contours of cross-sectional images containing wide intimal discontinuities due to guide wire shadowing and large bifurcations were delineated by utilizing the natural longitudinal lumen continuity of the arteries. Our algorithm was applied to 5931 pre-intervention OCT images acquired from 40 patients. For a quantitative comparison, the images were also processed through manual segmentation (the reference standard) and automated ones utilizing cross-sectional and longitudinal continuities. The results showed that the proposed algorithm outperforms other schemes, exhibiting a strong correlation (R = 0.988) and overlapping and non-overlapping area ratios of 0.931 and 0.101, respectively. To examine the accuracy of the OCT-derived FFR calculated using the proposed scheme, a CFD simulation of a three-dimensional coronary geometry was performed. The strong correlation with a manual lumen-derived FFR (R = 0.978) further demonstrated the reliability and accuracy of our algorithm with potential applications in clinical settings.ope

Post-PCI management with DES for minor and major non-cardiac surgery

In-stent restenosis has been reduced significantly after introduction of drug eluting stent (DES). But concern of long-term safety has emerged because of inappropriate neointimal coverage over stent related with cytotoxic drug and polymer. Recently, non-cardiac surgery after DES implantation is increasing and use of anti-platelet agent during operation might be problematic. Non-cardiac surgery might increase the risk of stent thrombosis, which was related with myocardial infarction and death, particularly in DES. Preoperative discontinuation of dual-antiplatelet therapy (DAT) and early surgery after stent implantation have been well known factors of perioperative stent thrmbosis. Thus, current guideline for anti-platelet therapy in non-cardiac surgery was established in patients after balloon angioplasty and bare metal stent based on duration of DAT according to the period of complete endothelization and neointimal growth after stent implantation. But, there are controversies and little evidence in DES for timing and use of DAT to reduce the stent thrombosis in non-cardiac surgery. Therefore, I reviewed the existing data about stent thrombosis after noncardiac surgery, the impact of delay from surgery and discontinuation of DAT. Based on these published data, I suggested recommendations for patients who require noncardiac surgery after DES.ope

Left Atrial Appendage Occlusion Device Embolization (The LAAODE Study): Understanding the Timing and Clinical Consequences from a Worldwide Experience

Background: Left atrial appendage occlusion device embolization (LAAODE) is rare but can have substantial implications on patient morbidity and mortality. Hence, we sought to perform an analysis to understand the timing and clinical consequences of LAAODE. Methods: A comprehensive search of PubMed and Web of Science databases for LAAODE cases was performed from October 2nd, 2014 to November 1st, 2017. Prior to that, we included published LAAODE cases until October 1st, 2014 reported in the systematic review by Aminian et al. Results: 103 LAAODE cases including Amplatzer cardiac plug (N=59), Watchman (N=31), Amulet (N=11), LAmbre (N=1) and Watchman FLX (N=1) were included. The estimated incidence of device embolization was 2% (103/5,000). LAAODE occurred more commonly in the postoperative period compared with intraoperative (61% vs. 39%). The most common location for embolization was the descending aorta 30% (31/103) and left atrium 24% (25/103) followed by left ventricle 20% (21/103). Majority of cases 75% (77/103) were retrieved percutaneously. Surgical retrieval occurred most commonly for devices embolized to the left ventricle, mitral apparatus and descending aorta. Major complications were significantly higher with postoperative LAAODE compared with intraoperative (44.4% vs. 22.5%, p=0.03). Conclusions: LAAODE is common with a reported incidence of 2% in our study. Post-operative device embolization occurred more frequently and was associated with a higher rate of complications than intraoperative device embolizations. Understanding the timings and clinical sequelae of DE can aid physicians with post procedural follow-up and also in the selection of patients for these procedures.ope

Asian Pacific Society of Cardiology Consensus Recommendations on the Use of MitraClip for Mitral Regurgitation

Transcatheter mitral valve repair with the MitraClip, a catheter-based percutaneous edge-to-edge repair technique to correct mitral regurgitation (MR), has been demonstrated in Western studies to be an effective and safe MR treatment strategy. However, randomised clinical trial data on its use in Asian-Pacific patients is limited. Hence, the Asian Pacific Society of Cardiology convened an expert panel to review the available literature on MitraClip and to develop consensus recommendations to guide clinicians in the region. The panel developed statements on the use of MitraClip for the management of degenerative MR, functional MR, and other less common indications, such as acute MR, dynamic MR, hypertrophic obstructive cardiomyopathy, and MR after failed surgical repair. Each statement was voted on by each panel member and consensus was reached when 80% of experts voted 'agree' or 'neutral'. This consensus-building process resulted in 10 consensus recommendations to guide general cardiologists in the evaluation and management of patients in whom MitraClip treatment is being contemplated.ope

Linear Micro-patterned Drug Eluting Balloon (LMDEB) for Enhanced Endovascular Drug Delivery

In-stent restenosis (ISR) often occurs after applying drug eluting stents to the blood vessels suffering from atherosclerosis or thrombosis. For treatment of ISR, drug eluting balloons (DEB) have been developed to deliver anti-proliferative drugs to the lesions with ISR. However, there are still limitations of DEB such as low drug delivery efficiency and drug loss to blood flow. Although most researches have focused on alteration of drug formulation for more efficient drug delivery, there are few studies that have attempted to understand and utilize the contact modality of DEB drug delivery. Here, we developed a linear micro-patterned DEB (LMDEB) that applied higher contact pressure to enhance drug stamping to vascular tissue. Ex vivo and in vivo studies confirmed that higher contact pressure from micro-patterns increased the amount of drug delivered to the deeper regions of vessel. Finite element method simulation also showed significant increase of contact pressure between endothelium and micro-patterns. Quantitative analysis by high performance liquid chromatography indicated that LMDEBs delivered 2.3 times higher amount of drug to vascular tissue in vivo than conventional DEBs. Finally, efficacy studies using both atherosclerotic and ISR models demonstrated superior patency of diseased vessels treated with LMDEB compared to those treated with DEB.ope

Effects of Fixed-dose Combination of Low-intensity Rosuvastatin and Ezetimibe Versus Moderate-intensity Rosuvastatin Monotherapy on Lipid Profiles in Patients With Hypercholesterolemia: A Randomized, Double-blind, Multicenter, Phase III Study

Purpose: We investigated whether the combination therapy of low-intensity rosuvastatin and ezetimibe is an useful alternative to moderate-intensity rosuvastatin monotherapy in patients requiring cholesterol-lowering therapy. Methods: This was a multicenter randomized, double-blind study to investigate the safety and efficacy of a fixed-dose combination of rosuvastatin 2.5 mg and ezetimibe 10 mg (R2.5+E10) compared to those of ezetimibe 10 mg monotherapy (E10), rosuvastatin 2.5 mg (R2.5), and rosuvastatin 5 mg monotherapy (R5) in patients with hypercholesterolemia. A total of 348 patients at 15 centers in Korea were screened, and 279 patients were randomized to different groups in the study. Clinical and laboratory examinations were performed at baseline and 4 and 8 weeks after intervention. The primary endpoint was the percentage change of low-density lipoprotein (LDL) cholesterol levels at the 8-week follow-up. Findings: Baseline characteristics were similar among the four groups. There were significant changes in lipid profiles at the 8-week follow-up. A greater decrease in the LDL cholesterol levels (primary endpoint) were found in the R2.5+E10 group (-45.7±18.6%) than in the E10 group (-16.7±14.7%, p<0.0001), R2.5 group (-32.6±15.1%, p<0.0001), and R5 group (-38.9±13.9%, p=0.0003). Similar outcomes were observed regarding the decrease in total cholesterol, non-high-density lipoprotein (HDL) cholesterol, and apolipoprotein B protein. In addition, changes in the triglyceride and HDL levels in the R2.5+E10 group were significantly different compared with those in the E10 group; however, the changes were similar to those in the other treatment groups. In patients with low and moderate risk, all patients achieved the target LDL cholesterol levels in the R2.5+E10 group (100%) compared to 13.0% in the E10 group, 47.6% in the R2.5 group, and 65.2% in the R5 group. Adverse effects were rare and similar in the four groups. Implications: Fixed-dose combination of low-intensity rosuvastatin and ezetimibe was more effective in lowering LDL cholesterol and achieving LDL cholesterol goals than moderate-intensity rosuvastatin monotherapy. These findings suggest that the combination therapy of low-intensity rosuvastatin and ezetimibe is an useful alternative to moderate-intensity rosuvastatin monotherapy for cholesterol management, particularly in patients with low and moderate risk. ClinicalTrials.gov identifier: NCT04652349.ope

Achievement of LDL-C Targets Defined by ESC/EAS (2011) Guidelines in Risk-Stratified Korean Patients with Dyslipidemia Receiving Lipid-Modifying Treatments

Background: This study assessed the proportion of risk-stratified Korean patients with dyslipidemia achieving their low-density lipoprotein cholesterol (LDL-C) targets as defined by the European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) (2011) guidelines while receiving lipid-modifying treatments (LMTs). Methods: In this multicenter, cross-sectional, observational study, we evaluated data from Korean patients aged ≥19 years who were receiving LMTs for ≥3 months and had an LDL-C value within the previous 12 months on the same LMT. Data were collected for demographics, cardiovascular (CV) risk factors, medical history, and healthcare consumption. Patients were risk-stratified according to the ESC Systematic COronary Risk Evaluation (SCORE) chart and LDL-C target achievement rate was assessed. Results: Guideline-based risk-stratification of the 1,034 patients showed the majority (72.2%) to be in the very high-risk category. Investigators' assessment of risk was underestimated in 71.6% compared to ESC/EAS guidelines. Overall LDL-C target achievement rate was 44.3%; target achievement was the highest (66.0%) in moderate-risk patients and the lowest (39.0%) in very high-risk patients. Overall 97.1% patients were receiving statin therapy, mostly as a single-agent (89.2%). High-intensity statins and the highest permissible dose of high-intensity statins had been prescribed to only 9.1% and 7.3% patients in the very high-risk group, respectively. Physician satisfaction with patients' LDL-C levels was the primary reason for non-intensification of statin therapy. Conclusion: Achievement of target LDL-C level is suboptimal in Korean patients with dyslipidemia, especially in those at very high-risk of CV events. Current practices in LMTs need to be improved based on precise CV risk evaluation posed by dyslipidemia.ope

Comparison of nebivolol versus diltiazem in improving coronary artery spasm and quality of life in patients with hypertension and vasospastic angina: A prospective, randomized, double-blind pilot study

Background: Beta-blockers are often not the preferred treatment for patients with vasospastic angina. However, nebivolol, beta-blocker with nitric oxide-releasing effect, could theoretically improve coronary vasospasm. We compared nebivolol versus diltiazem in improving coronary vasospasm and quality of life in patients with hypertensive vasospastic angina during a 12-week follow-up. Methods: Fifty-one hypertensive patients with documented coronary vasospasm were randomly allocated into 3 treatment groups: (1) Nebivolol Group (5mg for 2 weeks/10mg for 10 weeks); (2) Diltiazem Group (90mg for 2 weeks/180mg for 10 weeks); (3) Low-dose Combination Group (2.5mg + 45mg for 2 weeks/5mg + 90mg for 10 weeks). The primary endpoint was to compare the percent changes in coronary vasospasm at 12 weeks from baseline among the 3 groups. The secondary endpoints included changes in quality of life based on the Seattle Angina Questionnaire and changes in blood pressure at 12 weeks from baseline. Results: Significant improvements in coronary vasospasm were found in all groups; however, the improvement in percent changes in coronary artery spasm was greatest in the Diltiazem Group (50.4±8.8% vs. 67.8±12.8% vs. 46.8±12.3%, Nebivolol Group vs. Diltiazem Group p = 0.008; Nebivolol Group vs. Low-dose Combination Group p = 0.999; Diltiazem Group vs. Low-dose Combination Group p = 0.017). The overall Seattle Angina Questionnaire scores were significantly elevated at 12 weeks compared to the baseline in entire study population. There were no significant differences between the three groups in the overall Seattle Angina Questionnaire score changes and blood pressure changes. Conclusions: Both nebivolol and diltiazem showed significant coronary vasospasm reduction effect, but the effect was greater for diltiazem.ope

심장 내 이물질로 인한 반복적인 뇌경색 발생에 관한 증례

We present a case of recurrent ischemic stroke in a 68-year-old man with a linear foreign body in the right atrium and ventricle and a patent foramen ovale (PFO). The patient developed atrial fibrillation despite taking warfarin at a therapeutic dose and had a third acute stroke. We planned left atrial appendage (LAA) occlusion via the PFO, followed by PFO closure and foreign body removal. The percutaneous LAA occlusion and PFO closure were successful. However, it was difficult to remove the radiolucent foreign body. We inserted an Omni™ catheter via the right jugular vein to contact the foreign body in the right atrium directly, grasped its distal end with a snare, and successfully extracted it. The patient was followed-up in the outpatient clinic and had no recurrent stroke.ope