SummaryA J-shaped or U-shaped curve phenomenon might exist between systolic blood pressure (SBP) or pulse pressure (PP) at admission and in-hospital mortality in Japanese patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). However, data regarding a relationship between mean blood pressure (MBP) at admission and in-hospital outcome in AMI patients undergoing primary PCI are still lacking in Japan.A total of 1,413 primary PCI-treated AMI patients were classified into quintiles based on admission MBP (< 79 n = 283, 79-91 n = 285, 92-103 n = 285, 104-115 n = 279, and ≥ 116 mmHg n = 281). Patients with MBP < 79 mmHg had a significantly higher in-hospital mortality, while mortality was not significantly different among the other quintiles: 16.6% (< 79), 4.9% (79-91), 3.9% (92-103), 3.2% (104-115), and 5.0% (≥ 116 mmHg). On multivariate analysis, Killip class ≥ 3 at admission, LMT or multivessels as culprit lesions, admission MBP < 79 mmHg, and age were independent positive predictors of in-hospital mortality, whereas hypercholesterolemia and TIMI 3 flow before/after PCI were negative predictors, while the other MBP categories were not.These results suggest that admission MBP < 79 mmHg might be associated with in-hospital death, and the in-hospital prognostic effects of MBP, the steady component of blood pressure, at admission might be different from those of SBP or PP, the pulsatile component of blood pressure, at admission in Japanese AMI patients undergoing primary PCI. (Int Heart J 2016; 57: 547-552) Key words: Systolic blood pressure, Pulse pressure, Prognosis, J-curve phenomenon B ased on numerous reports from Western countries, an inverse relationship between systolic blood pressure (SBP) at admission and in-hospital mortality in acute myocardial infarction (AMI) patients has largely been established, [1][2][3][4] and indeed admission SBP is involved in several riskscoring methods for AMI patients.5-7) In addition to major blood pressure indexes, such as SBP and diastolic blood pressure (DBP), blood pressure is characterized by its pulsatile and steady components, which correspond to pulse pressure (PP) and mean blood pressure (MBP), respectively. We have already shown that admission SBP or PP in a certain interval between an extremely low subset and extremely high subset might be associated with a lower in-hospital mortality in Japanese AMI patients undergoing primary percutaneous coronary intervention (PCI), which followed a J-or U-shaped curve pattern. 8,9) However, sufficient data regarding the effects of the steady component of blood pressure, MBP, at admission on the prognosis in AMI patients are still lacking.
SummaryRotational atherectomy with/without low-pressure balloon dilation has been a mainstay of interventional treatment for stenosis due to the coronary sequelae of Kawasaki disease (KD). Here, we report a restenosis case of probable coronary sequelae of KD treated with rotational atherectomy with low-pressure 2.5-mm balloon dilation 6 months previously. Under the guidance of optical frequency domain imaging, we performed rotational atherectomy followed by 2.5-mm drug-coated balloon (DCB) dilation for an atherosclerotic restenosis at the inlet of a calcified aneurysm in the proximal left anterior descending coronary artery. Coronary angiography 6 months later showed no apparent progression of vessel narrowing, and we could defer repeat intervention. The present case suggests that rotational atherectomy followed by DCB dilation could be an alternative revascularization therapy of choice in coronary KD sequelae complicated with atherosclerosis. (Int Heart J 2016; 57: 367-371) Key words: Optical frequency domain imaging, Fractional flow reserve, Atherosclerosis, Dyslipidemia C oronary sequelae of Kawasaki disease (KD) has a variety of morphological manifestations, such as aneurysm, stenosis, and total occlusion concomitant with nonatherosclerotic intimal thickening and frequent severe calcification, while a few reports have demonstrated early atherosclerosis progression in young adults with prior KD.1-3) Since these stiff calcified lesions have risk of stent underexpansion and neo-aneurysmal formation ascribed to high-pressure balloon inflation, rotational atherectomy with/without additional low-pressure balloon dilation alone has been a mainstay of interventional treatment for stenosis due to the coronary sequelae of KD. [4][5][6] In contrast, drug-coated balloons (DCB) now play a central role in the treatment of in-stent restenosis through their inhibition of neointimal hyperplasia, despite the lack of evidence for de novo coronary artery disease. 7,8) We describe here our experience with an atherosclerotic-restenosis case of probable coronary sequelae of KD previously treated with rotational atherectomy with additional low-pressure balloon dilation 6 months before, 3) in which rotational atherectomy followed by DCB dilation could defer any subsequent repeat intervention. Case ReportAn asymptomatic 47 year-old male was admitted to our hospital to undergo 6-month follow-up coronary angiography (CAG). Six months previously, based on a diagnosis of silent myocardial ischemia due to possible sequelae of KD, we had performed rotational atherectomy with 1.5/2.0 mm burrs followed by low-pressure dilation using a balloon catheter 2.5/15 mm at 4 atm for a stenosis at the inlet of a calcified aneurysm in the proximal segment of the left anterior descending coronary artery (LAD) ( Figure 1A, 1B). Although he had no apparent history of KD, he was hospitalized for 40 days due to fever of unknown cause with systemic eruption at the age of 6 months. His coronary risk factor was dyslipidemia, and under medication consisting ...
SummaryAn 83-year-old man presented with recurrent acute coronary syndrome (ACS) at the left main coronary artery (LMCA) complicated with ostial chronic total occlusion (CTO) in the right coronary artery (RCA) (RCA-CTO). At the first LMCA-ACS approximately 1 year earlier, he had undergone LMCA-crossover stenting with a biolimus-eluting stent in the presence of RCA-CTO. At the second LMCA-ACS, we angiographically confirmed severe in-stent restenosis in the distal LMCA, in addition to angled severe stenosis in the just proximal LCx, and performed primary PCI for the LMCA bifurcation lesion under intra-aortic balloon pumping support. Because of difficulty in crossing a guidewire through the just proximal LCx lesion, we first performed rotational atherectomy against the LMCA in-stent eccentric lesion. After successfully crossing the guidewire into the LCx, we added balloon dilation with kissing balloon inflation followed by alternate drug-coated balloon dilation. An eight-month follow-up coronary angiography revealed no further vessel narrowing in the LMCA bifurcation lesion.(Int Heart J 2017; 58: 806-811) Key words: Acute myocardial infarction, Intravascular Ultrasound, Percutaneous coronary intervention S ignificant unprotected left main coronary artery (LMCA) disease in the presence of chronic total occlusion (CTO) in the right coronary artery (RCA) (RCA-CTO) is a deteriorated condition with high morbidity and mortality, 1) and generally remains an absolute candidate for coronary artery bypass grafting (CABG) surgery even during new-generation drug-eluting stent (DES) era. Drug-coated balloon (DCB) has now played a central role in the treatment for in-stent restenosis (ISR) through inhibiting neointimal hyperplasia, 2,3) despite its little evidence for ISR in DES implanted in LMCA. [4][5][6] We describe our experience with an unusual critical case of recurrent acute coronary syndrome (ACS) due to ISR in LMCA complicated with ostial RCA-CTO, in which rotational atherectomy followed by DCB dilation against the LMCA bifurcation lesion could defer a further repeat intervention. Case ReportAn 83-year-old man with repeat ACS was admitted to our hospital due to general fatigue and chest discomfort for 24 hours. His coronary risk factors included hypertension and diabetes mellitus. He had experienced inferior myocardial infarction (MI) 35 years earlier, and undergone percutaneous coronary intervention (PCI) using a bare metal stent (BMS) (Multi-link Penta 2.5/18) for a posterolateral branch of the left circumflex coronary artery (LCx) 12 years before. He had suffered from LMCA-culprit ACS complicated with ostial RCA-CTO ( Figure 1A-C) and undergone LMCA-left anterior descending coronary artery (LAD) crossover stenting with a biolimus-eluting stent (Nobori 3.5/18) under intra-aortic balloon pumping (IABP) support 11 months earlier ( Figure 1D-F). Preprocedural intravascular ultrasound imaging (IVUS) depicted much concentric plaque with partial superficial calcification (Figure 2A), and final IVUS after the stent implantat...
A 76-year-old woman was referred to our hospital with dyspnea on effort and palpebral edema. She had been treated with methotrexate (MTX) for rheumatoid arthritis until that time. Blood laboratory examination showed leukopenia, anemia, and elevated values of brain natriuretic peptide (237.4 pg/ml) and soluble Interleukin-2 receptor (3730 U/ml). Echocardiography revealed multiple nodules in the thickened left ventricular wall with diffuse mild hypokinesis and moderate amount of pericardial effusion ( Fig. 1a, b). Contrast-enhanced computed tomography (CT) showed small abdominal subcutaneous nodules, mediastinal lymph nodes swelling, and an abnormal mass near her left kidney. Based on the clinical history and the pathological findings from subcutaneous tissue biopsy, she was diagnosed as diffuse large B cell lymphoma (DLBCL) subtype of MTX-associated lymphoproliferative disorder complicated with heart failure. We started a conventional chemotherapy (R-THP-COP; rituximab plus pirarubicin, cyclophosphamide, vincristine, and prednisolone) and confirmed disappearance of the intra-left-ventricular-wall nodules without pericardial effusion, improvement of motion of left ventricular wall, and thinning of thickened left ventricular wall to normal range by follow-up echocardiography (Fig. 1c, d). After the first course of the chemotherapy we also confirmed volume reduction of the abdominal-mass by CT. Finally, we performed the total 6 courses of the chemotherapy for 5 months, and then she has been kept free of DLBCL relapse and heart failure without specific medications.The two most frequently involved sites of cardiac malignant lymphoma are the right atrium and right ventricle [1,2]. Although intra-left ventricular-wall nodules are rare, they might be also one of echocardiographic manifestations in malignant lymphoma-associated cardiac disorder. In cardiac malignant lymphoma, complications of arrhythmia such as atrioventricular block due to involvement into the conduction pathway have also been reported [1], however, in this case, these complications were not confirmed. It was thought that heart failure occurred mainly due to the left ventricular wall motion decline. This case was diagnosed with heart failure symptoms, and good progress was obtained by starting chemotherapy. On the other hand, cardiac malignant lymphoma is often delayed in diagnosis due to the lack of specific symptoms, some cases which were not confirmed until necropsy after death and were thought to have died suddenly by fatal arrhythmia were also reported [3] [4]. Reports, reporting intra-left ventricular-wall nodules confirmed by echocardiography early in the onset, and the improvement over time of echocardiographic manifestations along with the reduction of nodules by chemotherapy as this case, are rare.
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