Heart and Vessels最新文献

The international guidelines recommend a target low-density lipoprotein cholesterol (LDL-c) level of < 55 mg/dL in very-high-risk patients with dyslipidemia, which were defined as those with history of acute coronary syndrome (ACS), chronic coronary syndrome with multivessel disease, diabetes mellitus, chronic kidney disease, familiar hypercholesterolemia, recurrent coronary artery disease, or polyvascular disease. In addition, an early reduction in LDL-c levels is recommended especially for ACS. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been reported to be very effective for an early reduction in the LDL-c level, but some patients showed non-early reduction. We investigated the factors correlating with non-early lowering LDL-c levels using PSCK9 inhibitors in very-high-risk patients. We enrolled consecutive patients with dyslipidemia who received evolocumab due to very-high-risk. We divided them into the early achievement of the target LDL-c level (EAC) group whose LDL-c level decreased to < 55 mg/dL 1 month later and the non-EAC group. We investigated the various factors possibly correlated with non-EAC. The non-EAC group comprised 25 patients (35.2%). A univariable analysis revealed that a body mass index (BMI) > 23.9 kg/m², history of ACS, LDL-c > 144 mg/dL, and high-intensity statins were related to the non-EAC group. A multivariable analysis showed that a history of ACS was negatively and LDL cholesterol level > 144 mg/dL positively correlated with non-EAC. In conclusion, we induced PSCK9 inhibitors more aggressively in ACS, and we should pay attention to the patients with higher baseline LDL-c levels during the follow-up.

The association between high-density lipoprotein cholesterol (HDL-C) levels and prognosis in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) remains unclear. This study aimed to investigate the relationship between HDL-C levels and all-cause mortality in this population. This multicenter prospective cohort study included 17,180 ACS patients who underwent PCI from the Multicenter Prospective Cohort Study on Acute Coronary Syndrome (MPCS-ACS). HDL-C levels were categorized into four groups: < 30, 30-60, 60-90 (reference), and ≥ 90 mg/dL. The primary endpoint was all-cause mortality. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), with multivariable adjustments. During a median follow-up of 49 months, 1200 all-cause mortality events occurred. U-shaped associations were observed between HDL-C levels and risks of all-cause mortality. After multivariable adjustment, compared to patients with HDL-C levels of 60-90 mg/dL, ACS patients with HDL-C < 30 mg/dL or ≥ 90 mg/dL had a significantly increased risk of all-cause mortality, with HRs [95% CI] of 3.52 (2.66-4.64) and 2.71 (2.10-3.50), respectively. Both extremely low and high HDL-C levels were associated with increased risk of all-cause mortality in ACS patients undergoing PCI. Maintaining HDL-C levels within the 60-90 mg/dL range may be associated with better long-term outcomes.

Coronary microcirculatory dysfunction (CMD) is a known predictor of adverse outcomes after percutaneous coronary intervention (PCI). However, the prognostic significance of CMD in patients with severely calcified lesions treated with rotational atherectomy (RA) remains unclear. We retrospectively studied consecutive chronic coronary syndrome patients who underwent PCI with RA followed by second-generation drug-eluting stent (DES) implantation. CMD was evaluated by angiography-derived index of microcirculatory resistance (IMR_angio), calculated from the quantitative flow ratio (QFR) obtained immediately after PCI without hyperemia. The primary outcome was the occurrence of major adverse cardiovascular events (MACE) within 2 years, including cardiovascular death, spontaneous myocardial infarction, and target vessel revascularization. Among the 128 enrolled patients, 22 (17.2%) experienced MACE. Post-IMR_angio was significantly higher in patients who experienced MACE than in those who did not (39.3 ± 12.5 vs. 30.4 ± 9.8, p < 0.001). Increased post-IMR_angio was independently associated with MACE (hazard ratio, 1.05; 95% confidence interval [CI]: 1.02-1.09, p = 0.004). Receiver operating characteristic curve analysis identified optimal cutoff values of 40.6 for post-IMR_angio to predict MACE (area under the curve 0.72, 95% CI: 0.58-0.86). Including high post-IMR_angio (> 40U), along with clinical risk factors and QFR findings, significantly improved the discriminatory and reclassification ability to identify the risk of MACE after RA. IMR_angio measured immediately after the PCI with RA followed by second-generation DES implantation is a valuable tool for risk stratification in patients with severely calcified lesions.

During cryoballon pulmonary vein isolation (PVI) complete occlusion of the pulmonary vein ostia during the freeze cycles is mandatory. Typically, PV occlusion is assessed by contrast injection under fluoroscopy. Using an update for the Cryo Console it is possible to directly visualize occlusion pressure as an indicator of complete PV occlusion during cryoballoon procedures. In this study, we compared PV pressure monitoring during cryoballoon PVI to a conventional approach regarding procedural outcomes. We retrospectively analysed the procedural data of 50 patients (25 patients with pressure-guided PVI and 25 patients with contrast-guided PVI) treated with cryoballoon PVI in our centre. Complete PV occlusion in the pressure-guided group was defined as an abrupt change in the pressure waveform with a loss of the a-wave after advancing the cryoballoon to the PV ostium. We observed comparable results regarding procedural time, left atrial dwell time or fluoroscopy time when comparing the pressure guided to our conventional approach. Moreover, there were no differences regarding acute procedural effectivity or freeze cycle characteristics. As expected, a significant reduction of contrast use was achieved in the pressure measurement group (10.4 vs. 25.5 ml, p < 0.0001). Monitoring complete PV occlusion by visualizing the occlusion pressure is feasible. Acute procedural outcome was comparable to our standard approach using contrast injection to verify complete PV occlusion. Most importantly, a significant reduction in contrast use could be achieved which has to be confirmed in larger patient cohorts.

An extracorporeal membrane oxygenation (ECMO) system consisting of a heparin-coated membrane oxygenator with polymethylpentene hollow fiber membranes and a heparin-coated hydrodynamically levitated centrifugal pump was developed. The effect of heparin anticoagulation on the antithrombogenicity of the ECMO system under veno-arterial bypass was evaluated in an animal model. Veno-arterial bypass with the ECMO system was induced in goats. Ten goats were evaluated which were divided into heparin anticoagulation-free (HPF; n = 5) and heparin anticoagulation (HP; n = 5) groups. Evaluation of the ECMO system focused on thrombus formation and changes in blood test data. Veno-arterial bypass with the ECMO system was maintained for 2 weeks in both groups. The extent of thrombus formation in the oxygenators was suppressed in the HP group. The centrifugal pumps were free of major thrombus formation in both groups. From baseline to postoperative day (POD) 1, both groups showed significant decreases in platelet counts, with a significant reduction in von Willebrand factor (vWF) activity levels in the HPF group. Between PODs 1 and 14, POD differences were observed in platelet counts without group or interaction differences. The levels of vWF activity showed significant group differences, with the HPF group demonstrating lower values than the HP group, but no significant POD or interaction differences. Veno-arterial bypass with the ECMO system was sustained for 2 weeks regardless of heparin anticoagulation. Heparin anticoagulation suppressed the extent of thrombus formation in the oxygenators. The centrifugal pumps were free of major thrombus formation regardless of heparin anticoagulation.

The HELT-E₂S₂ score, replacing diabetes mellitus and heart failure and adding extreme elderly (≥ 85 years), type of atrial fibrillation (AF), and low body mass index (BMI), has been proposed as a new measure for stratifying the risk of stroke in Japanese patients with AF. However, the association of the HELT-E₂S₂ score with left atrial appendage (LAA) dysfunction in patients with ischemic stroke remains unclear. We performed transthoracic and transesophageal echocardiography and evaluated the HELT-E₂S₂ scores in 593 patients with acute ischemic stroke and 296 patients without acute ischemic stroke as the control group. LAA dysfunction, defined as the presence of an LAA thrombus and/or severe spontaneous echo contrast, was identified in 182 patients. In a receiver operating characteristic curve analysis, the area under the curve of the HELT-E₂S₂ score for predicting LAA dysfunction was significantly higher than those of the CHADS₂ score (0.74 vs. 0.67, P < 0.001) and the CHA₂DS₂-VA score (0.74 vs. 0.67, P < 0.001). Multivariate logistic regression analysis showed that the HELT-E₂S₂ score was an independent predictor of LAA dysfunction after adjusting for conventional risk factors. The HELT-E₂S₂ score is a promising marker for predicting LAA dysfunction in patients with ischemic stroke.