Cutting balloons (CBs) are valuable tools for modifying calcified coronary lesions. However, few comparative studies have assessed the efficacy of different CBs in real-world practice. Therefore, we evaluated the dilatation efficacy and safety of a novel non-compliant CB (NCB) in a head-to-head comparison with a conventional semi-compliant CB (CCB). This single-center, prospective observational study included 50 consecutive calcified lesions treated with the NCB as the initial interventional device. Another 50 consecutive lesions treated with the CCB were retrospectively analyzed as a historical control. All lesions underwent intravascular ultrasound (IVUS) evaluation before and after dilatation with CB. The primary endpoints were post-modification minimum lumen area (post-CB MLA), change in MLA (ΔMLA), and crack formation at the MLA site. Secondary endpoints included the incidence of coronary dissection, perforation, and slow/no-reflow. Baseline patient and lesion characteristics were generally comparable between groups. Post-CB MLA was significantly larger in the NCB group than in the CCB group (4.26 ± 1.62 mm² vs. 3.45 ± 1.26 mm²; p = 0.007). ΔMLA was also greater in the NCB group (1.49 ± 0.97 mm² vs. 0.94 ± 0.65 mm²; p = 0.001). The NCB achieved more cracks per MLA cross-Sect. (2 [IQR 1–2] vs. 1 [IQR 1–1]; p = 0.014) and a lower incidence of malignant dissection (12

The use of debulking devices in saphenous vein graft (SVG) interventions is generally contraindicated due to the risk of vascular injury, making the treatment of heavily calcified lesions challenging. We report the case of a 73-year-old man who developed unstable angina 26 years after coronary artery bypass grafting. Urgent coronary angiography revealed severe calcification and critical stenosis at the SVG-to-left anterior descending artery (LAD) anastomosis. Intravascular ultrasound demonstrated a calcified nodule at the anastomosis and circumferential calcification in the mid-LAD. Balloon angioplasty was attempted but failed due to inadequate lesion dilation. To facilitate lesion modification, an orbital atherectomy system (OAS) was delivered using a guide extension catheter (GEC). Multiple ablations were performed, followed by successful balloon angioplasty and application of a drug-coated balloon. The patient was discharged 3 days later without complications. This case suggests that GEC-supported OAS may be a safe and effective option for treating heavily calcified SVG lesions.

Aims Delayed diagnosis of pulmonary hypertension (PH) is a known cause of poor patient prognosis. We aimed to develop an artificial intelligence (AI) model, using ensemble learning method to detect PH using electrocardiography (ECG), chest X-ray (CXR), and brain natriuretic peptide (BNP), facilitating accurate detection and prompting further examinations. Methods and results We developed a convolutional neural network model using ECG data to predict PH, labelled by ECG from seven institutions. Logistic regression was used for the BNP prediction model. We referenced a CXR deep learning model using ResNet18. Outputs from each of the three models were integrated into a three-layer fully connected multimodal model. Ten cardiologists participated in an interpretation test, detecting PH from patients' ECG, CXR, and BNP data both with and without the ensemble learning model. The area under the receiver operating characteristic curves of the ECG, CXR, BNP, and ensemble learning model were 0.818 [95% confidence interval (CI), 0.808-0.828], 0.823 (95% CI, 0.780-0.866), 0.724 (95% CI, 0.668-0.780), and 0.872 (95% CI, 0.829-0.915). Cardiologists' average accuracy rates were 65.0 +/- 4.7% for test without AI model and 74.0 +/- 2.7% for test with AI model, a statistically significant improvement (P < 0.01). Conclusion Our ensemble learning model improved doctors' accuracy in detecting PH from ECG, CXR, and BNP examinations. This suggests that earlier and more accurate PH diagnosis is possible, potentially improving patient prognosis.

Although the impact of the presence of large circumferential pericardial effusion (LCPE) on the intracoronary pressure assessment of coronary artery disease (CAD) has been reported, the changes in comprehensive coronary physiology including coronary microcirculatory system according to the presence or absence of LCPE remain unclear. This paper depicts the serial changes in comprehensive coronary physiological assessment immediately after pericardial drainage in a patient with LCPE and CAD. It is important to recognize that the presence of LCPE may influence coronary circulation, requiring careful assessment of CAD.

Artificial intelligence models reportedly detect a low ejection fraction (EF) with chest radiography (CXR) examinations, which traditionally require a transthoracic echocardiogram (TTE) for evaluation. However, whether coupling a CXR model with an electrocardiogram (ECG) model improves the detection performance remains unclear. This study aimed to evaluate various models and fusion strategies for their detection performance.This study included 7,246 patients who underwent CXR, ECG, and TTE at the University of Tokyo Hospital. Two ECG models were used-a convolutional neural network and masked autoencoder. Two methods for combining CXR and ECG models were tested, early and late fusion. In the early fusion method, the CXR and ECG models were trained simultaneously, whereas in the late fusion method, three ensemble techniques were implemented. The CXR single model achieved an area under the curve (AUC) of 0.798. Both fusion models significantly outperformed the CXR single model. The early fusion model achieved an AUC of 0.937 (P = 0.015), while the late fusion model had an AUC of 0.928 (P = 0.010).Combining the CXR and ECG models significantly improved detection performance. This approach enables more accurate identification of patients with low EF, a condition typically requiring TTE for diagnosis.

BACKGROUND:Treating ostial left circumflex artery (LCx) lesions in percutaneous coronary intervention (PCI) for left main disease (LMD) remains a challenge. Despite recent recommendations for the use of drug-coated balloon (DCB) in this lesion, there are concerns about crossover-stenting from the left main trunk (LMT) to the left anterior descending artery (LAD). Specifically, isolated DCB treatment for the ostial LCx lesion may induce carina shift, while conventional kissing balloon technique (C-KBT) with a standard balloon and a DCB may prolong LMT occlusion, leading to hemodynamic instability. OBJECTIVES:This study aimed to evaluate the safety and feasibility of a novel double-effect KBT (W-KBT) using a perfusion balloon (PB) for the LMT-LAD and a DCB for the LMT-LCx, allowing prolonged inflation while maintaining coronary perfusion. METHODS:This single-center prospective study enrolled consecutive patients with de-novo LMD and ostial LCx lesions, requiring crossover-stenting from the LMT to the LAD followed by proximal optimization technique and C-KBT. After confirming optimal PCI, W-KBT was performed. RESULTS:Among 12 enrolled patients (mean age 73.8 ± 7.2, 91.7% men), procedural success, defined as device delivery and W-KBT time ≥ 30 s, was achieved in all cases via the transradial approach. W-KBT inflation-time was consistently 60 s; ST changes occurred in 50% (no ST-elevation); mean ST-change time was 41.2 ± 7.1 s; mean delta-blood pressure was -13.7 ± 11.4 mmHg; mean delta-heart rate was -3.4 ± 5.9 bpm; and no inotropes or mechanical cardiac support were needed. CONCLUSION:Within the limited sample size of this pilot study, the safety and feasibility of the first-in-man W-KBT were suggested. SUMMARY:This pilot study evaluated the safety and feasibility of a novel double-effect kissing balloon technique (W-KBT) in percutaneous coronary intervention for left main coronary artery disease, realized by the combined use of a perfusion balloon and a drug-coated balloon. Among 12 patients, device delivery was successful via a transradial approach using a 7 Fr guiding catheter. The W-KBT was maintained for 60 s without hemodynamic instability, providing adequate drug application to the ostial left circumflex artery lesion. Furthermore, no ST-elevation or periprocedural myocardial infarction was observed, highlighting the safety and feasibility of this technique.

BACKGROUND:Owing to the advent of new generation drug-eluting stents, percutaneous coronary intervention (PCI) outcomes are improving. However, the polymers, which have been the most common type of coatings used in drug-eluting stents, have some issues. The study aim was to evaluate the clinical outcomes of patients undergoing PCI with polymer-free sirolimus- and probucol-eluting stents (NP023). METHODS:This clinical trial was a prospective multicenter single-blind noninferiority randomized study performed at 22 hospitals in Japan. We randomly assigned patients in a 2:1 ratio to undergo PCI with either NP023 or durable polymer-based everolimus-eluting stents (control stents) with a 5-year follow-up. The primary outcome was freedom from target lesion failure (TLF) at 9 months, defined as patient-oriented composite of cardiac death, ischemia-driven target vessel-related myocardial infarction, or ischemia-driven target lesion revascularization. The secondary outcome included adverse outcomes at 5 years following the index procedure. RESULTS:Overall, 432 patients (463 lesions) were treated at 22 sites in Japan [mean age, 68 years; males, 345 (80 %); chronic coronary artery diseases, 322 (74.5 %)]. Of the participants, 91 % completed the 5-year follow-up. The Kaplan-Meier estimates of the percentages of patients who were free from TLF were 95.8 % and 97.3 % with NP023 and control stents, respectively (hazard ratio, 0.98; 95 % confidential interval, 0.80-1.21; p < 0.01 for noninferiority). At the 5-year follow-up, the secondary endpoint for safety was not different between the two groups. CONCLUSIONS:The results of this study showed similar outcomes for polymer-free sirolimus- and probucol-eluting stents and durable polymer-based everolimus-eluting stents regarding freedom from TLF at 9 months and other outcomes at 5 years among patients undergoing PCI.

Simultaneous subacute occlusion of the latest drug-eluting stents in 2 coronary arteries was documented in an immune thrombocytopenia patient receiving eltrombopag while undergoing potent dual antiplatelet therapy. Careful consideration is needed for the interruption of eltrombopag and the timing of staged percutaneous coronary intervention after the initial coronary event.

BackgroundBelt electrode skeletal muscle electrical stimulation (B-SES) is an emerging therapy anticipated to yield more favorable outcomes than conventional neuromuscular electrical stimulation (NMES), owing to its larger stimulation area. However, information on its efficacy and safety in patients with heart failure remains limited.Case presentationA 43-year-old man with a body mass index of 41 kg/m2 was admitted to our hospital for acute heart failure due to dilated cardiomyopathy. The patient required prolonged catecholamine support owing to poor cardiac function, and heart transplantation was considered. We initiated a mobilization program, but the patient's mobility was highly limited due to severe obesity and symptomatic orthostatic hypotension. B-SES was introduced to accomplish weight loss and early ambulation. We applied an intensive monitoring program for safe use and modulated the intensity of B-SES according to physical function. During the B-SES program, the patient's body weight decreased from 89.6 kg to 78.6 kg. Sequential evaluations of body composition and skeletal muscle ultrasonography revealed improved muscle mass, quality, and physical function. Furthermore, we explored the workload of B-SES using expiratory gas analysis. No adverse events were observed during B-SES.DiscussionWe successfully used B-SES to improve muscle function and morbidity in the treatment of acute heart failure. B-SES could be an option for patients with heart failure who have limited mobility and obesity.

Despite previous reports indicating that in-stent tissue protrusion is not associated with worse clinical outcome, its natural history remains unclear. This is the first to describe the natural history of in-stent thrombus associated with tissue protrusion post-stenting, using multimodal imaging.

The automatic pacing threshold measurement and output adjustment function, ie, ventricular capture management (VCM; Medtronic, Minneapolis, MN), is found in almost all permanent pacemakers, as it ensures patient safety during unexpected increases in threshold as well as reduces battery consumption and frequency of generator replacement.1–4 As surgeries for pacemaker generator replacement may result in complications such as lead fracture or infection, the automatic adjustment system benefits patients with a pacemaker; however, this system may also fail.

Background Heart failure should be diagnosed as early as possible. Although deep learning models can predict one or more echocardiographic findings from electrocardiograms (ECGs), such analyses are not comprehensive. Objectives This study aimed to develop a deep learning model for comprehensive prediction of echocardiographic findings from ECGs. Methods We obtained 229,439 paired ECG and echocardiography data sets from 8 centers. Six centers contributed to model development and 2 to external validation. We identified 12 echocardiographic findings related to left-sided cardiac abnormalities, valvular heart diseases, and right-sided cardiac abnormalities. These findings were predicted using convolutional neural networks, and a composite label was analyzed using logistic regression. A positive composite label indicated positivity in any of the 12 findings. Results For the composite findings label, the area under the receiver-operating characteristic curve was 0.80 (95% CI: 0.80-0.81) on hold-out validation and 0.78 (95% CI: 0.78-0.79) on external validation. The composite findings label applying logistic regression had an area under the receiver-operating characteristic curve of 0.80 (95% CI: 0.80-0.81) with accuracy of 73.8% (95% CI: 73.2-74.4), sensitivity of 81.1% (95% CI: 80.5-81.8), and specificity of 60.7% (95% CI: 59.6-61.8). Conclusions We have developed convolutional neural network models that predict a wide range of echocardiographic findings, including left-sided cardiac abnormalities, valvular heart diseases, and right-sided cardiac abnormalities from ECGs and created a model to predict a composite findings label by logistic regression analysis. This model has potential to serve as an adjunct for early diagnosis and treatment of previously undetected cardiac disease.

BackgroundFractional flow reserve (FFR) is the current gold standard for identifying myocardial ischemia in individuals with coronary artery stenosis. However, FFR is not penetrated as much worldwide due to time consumption, costs associated with adenosine, FFR-related discomfort, and complications. Resting physiological indexes may be widely accepted alternatives to FFR, while the discrepancies with FFR were found in up to 20% of lesions. The saline-induced Pd/Pa ratio (SPR) is a new simplified option for evaluating coronary stenosis. However, the clinical implication of SPR remains unclear.ObjectivesIn the present study, we aimed to compare the accuracies of SPR and resting full-cycle ratio (RFR) and to investigate the incremental value of SPR in clinical practice.MethodsIn this multicenter prospective study, 112 coronary lesions (105 patients) were evaluated by SPR, RFR, and FFR.ResultsThe overall median age was 71 years, and 84.8% were men. SPR was correlated more strongly with FFR than with RFR (r = 0.874 vs. 0.713, respectively; p < 0.001). Using FFR < 0.80 as the reference standard variable, the area under the receiver-operating characteristic (ROC) curve for SPR was superior to that of RFR (0.932 vs. 0.840, respectively; p = 0.009).ConclusionSaline-induced Pd/Pa ratio predicted FFR more accurately than RFR. SPR could be an alternative method for evaluating coronary artery stenosis and further investigation including elucidation of the mechanism of SPR is needed (225 words).

We describe a 69-year-old man with subacute inferior myocardial infarction who had surgical repair for a left ventricular (LV) pseudoaneurysm incidentally detected by routine 6-month follow-up echocardiography. Although LV pseudoaneurysm is a rare complication after myocardial infarction, the delayed diagnosis and management can cause adverse patient outcomes. The present case suggests that patients with multiple risk factors for LV pseudoaneurysms, including advanced age, late presentation, and delayed revascularization, should receive intensive blood pressure control and closer examination using a multimodal imaging approach for early detection of aneurysmal formation and complications.