BACKGROUND:Although physiological assessment has been used in decision-making for revascularization, its role in predicting the future risk of acute coronary syndrome (ACS) remains underexplored. OBJECTIVES:This study aims to investigate the independent and combined prognostic significance of hemodynamic disease severity and distribution in identifying ACS culprit vessels, in conjunction with lumen and plaque characteristics. METHODS:The EMERALD-II study is an international, multicenter, internal case-control study enrolling 351 patients with ACS who underwent coronary computed tomography angiography (CTA) 1 month to 3 years before the event. Culprit and nonculprit vessels were identified by matching invasive coronary angiography with coronary CTA findings. High-risk plaque (HRP) characteristics, including minimum lumen area <4 mm2, plaque burden ≥70%, low-attenuation plaque, positive remodeling, spotty calcification, and napkin-ring sign, were assessed by a core laboratory, with HRP defined as ≥3 HRP characteristics. From coronary CTA, the authors derived both the hemodynamic severity of the disease (fractional flow reserve derived from computed tomography [FFRCT]) and its spatial distribution (diffuse vs focal), as assessed by the pullback pressure gradient derived from coronary CTA (PPGCT). Vessels were categorized into 4 hemodynamic disease patterns: nonischemic (FFRCT >0.80), hemodynamic diffuse (FFRCT ≤0.80 and PPGCT ≤0.50), mixed (FFRCT ≤0.80 and 0.50 < PPGCT ≤0.60), and focal disease (FFRCT ≤0.80 and PPGCT >0.60). RESULTS:Among 873 vessels, the mean FFRCT was 0.74 ± 0.17 and the mean PPGCT was 0.54 ± 0.14. Both lower FFRCT and higher PPGCT were independently associated with higher ACS risk (OR per 0.1 increase in FFRCT: 0.71 [95% CI: 0.65-0.77]; P < 0.001; OR per 0.1 increase in PPG: 1.22 [95% CI: 1.09-1.37]; P < 0.001). Among the 4 subgroups of hemodynamic disease pattern, hemodynamic focal disease showed the highest risk of ACS (relative risk [RR]: 2.02 [95% CI: 1.74-2.36]; P < 0.001), myocardial infarction (RR: 1.75 [95% CI: 1.43-2.14]; P < 0.001), and unstable angina (RR: 2.54 [95% CI: 2.00-3.22]; P < 0.001). It remained a predictor for ACS in nonobstructive lesions (OR: 3.56 [95% CI: 1.43-8.84]), obstructive lesions (OR: 3.16 [95% CI: 1.96-5.07]), non-HRP (OR: 6.69 [95% CI: 3.59-12.5]), and HRP (OR: 2.98 [95% CI: 1.83-4.87]). Although the maximal lesion-level ΔFFRCT (differences in FFRCT across the lesion) demonstrated superior model performance compared with models incorporating FFRCT and PPGCT, higher PPGCT was additionally associated with increased ACS risk, particularly among vessels with maximal ΔFFRCT ≥0.10. CONCLUSIONS:Hemodynamic disease distribution, as measured by PPGCT, complements FFRCT in predicting ACS risk. The integration of hemodynamic disease patterns provides additional prognostic value beyond lumen and plaque characteristics, with hemodynamic focal disease emerging as an independent predictor and a potential therapeutic target for ACS prevention. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II [EMERALD II]; NCT03591328).

BackgroundChildren with a history of Kawasaki disease (KD) and severe coronary involvement are at risk for acute coronary syndrome later in adulthood even in the absence of severe luminal lesions. We therefore investigated whether the coronary vessel walls in such adults are accompanied by potential substrates for acute coronary syndrome using optical coherence tomography (OCT), a high-resolution imaging modality.MethodsOCT was performed in patients who were followed up by serial coronary angiogram (CAG) and cardiac multi-detector computed tomography (MDCT) for ≥ 15 years after the diagnosis of acute KD with coronary artery aneurysms (≥ 6 mm in diameter).ResultsEleven patients (6 males, 55%) with median age 25.3 years (IQR: 22.7-30.3) and median interval 22.6 years (19.9-25.8) after acute KD were recruited. We investigated 51 coronary segments, comprising 43 coronary artery lesions (CALs) (19 regressed aneurysms, 37.2%; 16 persistent aneurysms, 31.4%; and 8 localized stenoses, 15.7%) and 8 normal segments (15.7%). OCT findings revealed fibrocalcific plaque in 20 segments (39.2%), fibroatheroma in 16 (31.4%), superficial signal-rich regions with attenuation in 14 (27.5%), microvessels in 18 (35.3%), luminal thrombi in 13 (25.5%), and ruptured plaque in 4 (7.8%). Qualitatively, all but one normal segment showed no OCT-derived abnormalities, whereas CALs, including regressed aneurysms, exhibited fibrocalcific plaques, fibroatheroma, and microvessels, along with luminal thrombi and ruptured plaques. Quantitatively, CAG-derived advanced lesions (persistent aneurysms and localized stenoses) and MDCT-derived calcified plaques were associated with OCT-detected vessel wall abnormalities.ConclusionsThe present study showed that CALs in adults long after acute KD with severe coronary involvement are associated with OCT-derived vessel wall abnormalities, which are correlated with luminal lesions and MDCT-detected calcified plaques. Although these results do not demonstrate causality and may not be generalizable to milder cases, they warrant further studies to optimize screening and monitoring of adult KD-related coronary sequelae.

BACKGROUND:Risk assessment of coronary side branch (SB) lesions remains challenging because stenosis-based assessment alone often fails to identify clinically relevant lesions. OBJECTIVES:To characterize SB lesions associated with acute coronary syndrome (ACS), evaluate the performance of conventional main vessel (MV)-derived high-risk plaque criteria in SB lesions, and identify independent SB predictors of ACS. METHODS:We analyzed 2451 coronary lesions (2011 MV, 440 SB) from the EMERALD-II study, in which coronary CT angiography was performed 1-36 months before ACS using an AI-assisted quantitative analysis platform. Lesion characteristics included stenosis severity, plaque burden, adverse plaque characteristics (APCs), and the change in CT-derived fractional flow reserve across the lesion (ΔFFRCT). Diagnostic performance of conventional high-risk plaque criteria was compared between MV and SB lesions. RESULTS:Culprit lesions showed greater stenosis severity, plaque burden, APC count, and ΔFFRCT than non-culprit lesions in both vessels. However, these interrelationships were weaker in SB lesions. Among lesions meeting high-risk criteria, SB lesions were less often ACS culprits than MV lesions: ≥50% stenosis, 11.1% vs. 38.5%; plaque burden ≥70%, 8.6% vs. 23.8%; ≥2 APCs, 18.2% vs. 34.4%; and ΔFFRCT ≥0.10, 19.4% vs. 49.4%. Positive predictive values and F1-scores were consistently lower for SB lesions. APC count and ΔFFRCT were independent predictors of ACS in SB lesions. CONCLUSIONS:SB lesions had a substantially lower likelihood of subsequent ACS culprit status than equivalent MV lesions. These findings from AI-assisted CCTA analysis highlight the limitations of applying MV-derived thresholds to SB lesions and support the need for SB-specific risk assessment.

Background Acute coronary syndrome (ACS) arises from a complex interplay among luminal narrowing, plaque morphology, and hemodynamic environment. Objectives The authors aimed to compare the effectiveness of anatomy- and physiology-based ACS risk assessment. Methods In this international, multicenter, internal case-control study, 351 ACS patients who underwent coronary computed tomography angiography (CCTA) 1 month to 3 years before the event were analyzed. Lesions were classified as culprit or nonculprit based on invasive coronary angiography at the time of ACS. Core lab CCTA analyses assessed lesion-specific characteristics: stenosis severity, adverse plaque characteristics (APC) (low-attenuation plaque, positive remodeling, spotty calcification, napkin-ring sign), plaque burden at minimum lumen area, and changes in CCTA-derived fractional flow reserve (ΔFFRCT). Diagnostic performance in identifying culprit lesions was compared. Results Among 2,451 lesions, 363 (14.8%) became ACS culprits, with a median interval of 375 [95.0-644.5] days. All anatomical and simulated physiological characteristics were independently associated with culprit lesions (all P < 0.001). In identifying ACS culprit lesions, plaque burden ≥70% showed the highest sensitivity of 90.6% (87.2%-93.2%) and ΔFFRCT ≥0.10 had the highest specificity of 88.3% (86.9%-89.6%) %. Predictability was similar between ΔFFRCT and the combined degree of stenosis, the number of APCs, and plaque burden (area under the curve 0.805 [0.782-0.829] vs 0.802 [0.777-0.826]; P = 0.748), with additive discrimination towards each other. Conclusions Luminal narrowing, plaque quality and quantity, and local hemodynamics were independent predictors of ACS, offering specificity in physiology and sensitivity in anatomy. A comprehensive assessment of them further refined the risk prediction for future ACS. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II [EMERALD II]; NCT03591328)

BACKGROUND:Severely calcified femoropopliteal lesions remain challenging for endovascular therapy. The Aggressive Wire Recanalization in Calcified Atheroma and Dilatation (ARCADIA) technique enables intra-calcium wiring, potentially facilitating subsequent plaque modification. However, the clinical utility of combining ARCADIA with rotational atherectomy and drug-coated balloon (DCB) therapy requires further evaluation. AIMS:To investigate the clinical outcomes of combining intra-calcium wiring (ARCADIA technique) with Jetstream atherectomy followed by DCB in treating severely calcified femoropopliteal artery lesions. METHODS:This retrospective study included patients with symptomatic lower extremity artery disease (LEAD) and PACSS grade 3-4 femoropopliteal lesions treated between April 2020 and July 2024. Patients were divided into two groups: Jetstream (ARCADIA + Jetstream + DCB) and non-Jetstream (ARCADIA + DCB). Primary endpoints were 1-year primary patency and freedom from clinically driven target lesion revascularization (CD-TLR). RESULTS:Among 67 patients with 100 lesions, 27 (38 lesions) received Jetstream-based therapy and 40 (62 lesions) underwent ARCADIA with DCB alone. One-year primary patency was significantly higher in the Jetstream group (92.4% vs. 75.9%, p = 0.024), as was freedom from CD-TLR (96.6% vs. 83.1%, p = 0.031). No major complications, including perforation, embolization, or acute limb ischemia, occurred in either group. CONCLUSIONS:Combining ARCADIA with Jetstream atherectomy and DCB significantly improves patency and reduces CD-TLR in severely calcified femoropopliteal lesions. The ARCADIA technique plays a key role in safely enabling effective atherectomy in these complex cases.

BACKGROUND:The relevant time frame for predicting future acute coronary syndrome (ACS) based on coronary lesion characteristics remains uncertain. OBJECTIVES:The aim of this study was to investigate the association of lesion characteristics with test-to-event time and their prognostic impact on ACS. METHODS:The EMERALD II (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II) study analyzed 351 patients who underwent coronary computed tomography angiography (CTA) and experienced ACS between 1 month and 3 years of follow-up. Lesions identified on coronary CTA were classified as culprit (n = 363) or nonculprit (n = 2,088) on the basis of invasive coronary angiography findings at the time of ACS. Core laboratory coronary CTA analyses assessed 4 domains: degree of stenosis, plaque burden, number of adverse plaque characteristics (APC) (low-attenuation plaque, positive remodeling, spotty calcification, and napkin-ring sign), and changes in coronary CTA-derived fractional flow reserve across the lesion (ΔFFRCT). Patients were categorized into short (<1 year), mid (1-2 years), and long (2-3 years) test-to-event time groups. RESULTS:Patient characteristics, including cardiovascular risk factors, did not differ across short, mid, and long test-to-event groups (P > 0.05 for all), and the proportion of ACS culprit lesions was similar (P = 0.552). Among culprit lesions, shorter test-to-event time was associated with higher luminal stenosis, plaque burden, and ΔFFRCT (P for trend < 0.001 for all). The predictability for ACS culprit lesions based on the combined 4 characteristics tended to decrease over time and significantly reduced beyond 2 years (AUC: 0.851 vs 0.741; P = 0.006). In predicting ACS risk within test-to-event time <2 years using obstructive lesions (stenosis ≥ 50%), APC ≥2, plaque burden ≥70%, and ΔFFRCT ≥0.10, the risk was elevated compared to the average proportion of lesions becoming ACS culprit (12.1%) in the following subsets: lesions with 4 characteristics (proportion of lesions becoming ACS culprit: 49.3%; P < 0.001), lesions with 3 characteristics (obstructive lesions with plaque burden ≥70% and either ΔFFRCT ≥0.10 [proportion of lesions becoming ACS culprit: 33.0%; P < 0.001] or APC ≥2 [proportion of lesions becoming ACS culprit: 31.2%; P < 0.001]), and lesions with 2 characteristics (plaque burden ≥70% and ΔFFRCT ≥0.10; proportion of lesions becoming ACS culprit: 21.5%; P = 0.016). CONCLUSIONS:Increased luminal stenosis, plaque burden, and ΔFFRCT were associated with shorter test-to-ACS event time. The prognostic impact of lumen, plaque, and local hemodynamic characteristics was most relevant to ACS risk within a 2-year period, with higher risk observed when specific combinations of them were present. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary CT Angiography and Computational Fluid Dynamics II [EMERALD II] Study; NCT03591328).

HomeCirculation: Cardiovascular ImagingVol. 17, No. 3Unique Case of Coronary Artery Rupture and Acute Myocardial Infarction Triggered by a Karate Punch: Evaluation of the Hit Site by CT Imaging No AccessCase ReportRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialNo AccessCase ReportRequest AccessFull TextUnique Case of Coronary Artery Rupture and Acute Myocardial Infarction Triggered by a Karate Punch: Evaluation of the Hit Site by CT Imaging Yosuke Kirii, Tairo Kurita, Kae Morita, Yosuke Kasai, Kohei Unno, Akihiro Takasaki, Masaki Ishiyama, Mitsuyasu Terashima, Yoshiharu Emi and Kaoru Dohi Yosuke KiriiYosuke Kirii Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y. Kirii, T.K., Y. Kasai, A.T., M.I., K.D.). , Tairo KuritaTairo Kurita Correspondence to: Tairo Kurita, MD, PhD, Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie 514-8507, Japan. Email E-mail Address: [email protected] https://orcid.org/0000-0002-2882-6512 Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y. Kirii, T.K., Y. Kasai, A.T., M.I., K.D.). , Kae MoritaKae Morita Department of Cardiology, Ise Municipal General Hospital, Ise, Japan (K.M., K.U., Y.E.). , Yosuke KasaiYosuke Kasai Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y. Kirii, T.K., Y. Kasai, A.T., M.I., K.D.). , Kohei UnnoKohei Unno https://orcid.org/0009-0009-9644-7467 Department of Cardiology, Ise Municipal General Hospital, Ise, Japan (K.M., K.U., Y.E.). , Akihiro TakasakiAkihiro Takasaki https://orcid.org/0000-0003-0641-6464 Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y. Kirii, T.K., Y. Kasai, A.T., M.I., K.D.). , Masaki IshiyamaMasaki Ishiyama https://orcid.org/0000-0001-8051-8982 Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y. Kirii, T.K., Y. Kasai, A.T., M.I., K.D.). , Mitsuyasu TerashimaMitsuyasu Terashima Department of Cardiology, Toyohashi heart center, Toyohashi, Japan (M.T.). , Yoshiharu EmiYoshiharu Emi Department of Cardiology, Ise Municipal General Hospital, Ise, Japan (K.M., K.U., Y.E.). and Kaoru DohiKaoru Dohi https://orcid.org/0000-0002-5078-6326 Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan (Y. Kirii, T.K., Y. Kasai, A.T., M.I., K.D.). Originally published4 Mar 2024https://doi.org/10.1161/CIRCIMAGING.123.016343Circulation: Cardiovascular Imaging. 2024;17FootnotesFor Sources of Funding and Disclosures, see page 251.Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.123.016343.Correspondence to: Tairo Kurita, MD, PhD, Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie 514-8507, Japan. Email k_siho_yuu@hotmail.comREFERENCES1. Yousef R, Carr JA. Blunt cardiac trauma: a review of the current knowledge and management.Ann Thorac Surg. 2014; 98:1134–1140. doi: 10.1016/j.athoracsur.2014.04.043CrossrefMedlineGoogle Scholar2. Seven E, Henningsen K, Abildgaard U. Coronary artery dissection following blunt chest trauma.Ugeskr Laeger. 2015; 177:V10140572–V10140572.MedlineGoogle Scholar3. Clancy K, Velopulos C, Bilaniuk J, Collier B, Crowley W, Kurek S, Lui F, Nayduch D, Sangosanya A, Tucker B, et al. Screening for blunt cardiac injury: an eastern association for the surgery of trauma practice management guideline.J Trauma Acute Care Surg. 2012; 73:301–306. doi: 10.1097/TA.0b013e318270193aCrossrefMedlineGoogle Scholar4. Inokuchi G, Makino Y, Motomura A, Chiba F, Torimitsu S, Hoshioka Y, Iwase H. Fatal right coronary artery rupture following blunt chest trauma: detection by postmortem selective coronary angiography.Int J Legal Med. 2016; 130:759–763. doi: 10.1007/s00414-015-1215-1CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 2024Vol 17, Issue 3 Advertisement Article InformationMetrics © 2024 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.123.016343PMID: 38436111 Originally publishedMarch 4, 2024 Keywordscoronary vesselsdiagnostic imagingmartial artsrupturetraumaPDF download Advertisement SubjectsComputerized Tomography (CT)ImagingUltrasound

BACKGROUND:A lesion-level risk prediction for acute coronary syndrome (ACS) needs better characterization. OBJECTIVES:This study sought to investigate the additive value of artificial intelligence-enabled quantitative coronary plaque and hemodynamic analysis (AI-QCPHA). METHODS:Among ACS patients who underwent coronary computed tomography angiography (CTA) from 1 month to 3 years before the ACS event, culprit and nonculprit lesions on coronary CTA were adjudicated based on invasive coronary angiography. The primary endpoint was the predictability of the risk models for ACS culprit lesions. The reference model included the Coronary Artery Disease Reporting and Data System, a standardized classification for stenosis severity, and high-risk plaque, defined as lesions with ≥2 adverse plaque characteristics. The new prediction model was the reference model plus AI-QCPHA features, selected by hierarchical clustering and information gain in the derivation cohort. The model performance was assessed in the validation cohort. RESULTS:Among 351 patients (age: 65.9 ± 11.7 years) with 2,088 nonculprit and 363 culprit lesions, the median interval from coronary CTA to ACS event was 375 days (Q1-Q3: 95-645 days), and 223 patients (63.5%) presented with myocardial infarction. In the derivation cohort (n = 243), the best AI-QCPHA features were fractional flow reserve across the lesion, plaque burden, total plaque volume, low-attenuation plaque volume, and averaged percent total myocardial blood flow. The addition of AI-QCPHA features showed higher predictability than the reference model in the validation cohort (n = 108) (AUC: 0.84 vs 0.78; P < 0.001). The additive value of AI-QCPHA features was consistent across different timepoints from coronary CTA. CONCLUSIONS:AI-enabled plaque and hemodynamic quantification enhanced the predictability for ACS culprit lesions over the conventional coronary CTA analysis. (Exploring the Mechanism of Plaque Rupture in Acute Coronary Syndrome Using Coronary Computed Tomography Angiography and Computational Fluid Dynamics II [EMERALD-II]; NCT03591328).

Abstract Background/Introduction Injury to the sinus node artery (SNA) leading to SN dysfunction during radiofrequency catheter ablation (RFCA) of atrial Fibrillation (AF) and atrial tachycardia (AT) has been reported. Purpose The purpose of this study was to elucidate the prevalence and clinical course of SNA injuries during RFCA of AF/AT and examine the efficacy of the percutaneous coronary intervention (PCI) to restore SN function. Methods We retrospectively analyzed data from 6,906 consecutive patients (pts) who underwent RFCA of AF/AT (6,379 pts with AF ablation and 527 pts with AT ablation) in two institutions between January 2013 and December 2022. Results Among 6,906 pts, 9 (0.13%) pts developed SN dysfunction due to SNA injury during RFCA (8 with AF, 1 with AT). Acute SNA injury (total occlusion or severe narrowing of the SNA) was confirmed by coronary angiography (CAG) during the RFCA session in 8/9 pts. In the remaining patient, SNA injury was suspected based on the CT angiography. The culprit sites of the SNA injury were located at the septal site of the superior vena cava-right atrium junction in 4 pts (44%), on the left atrial appendage ridge in 3 (33%), on the roof of the left atrium adjacent to the right superior pulmonary vein in 1 (11%), and in the persistent left superior vena cava in 1 (11%). PCI to the occluded SNA was performed in 8 of the 9 pts: 1) coronary blood flow of the SNA was restored by a 0.014" guidewire advancement into the occluded artery using a micro-catheter followed by direct nitroprusside injection in 4 pts; 2) the direct balloon angioplasty using 0.75-1.5 mm diameter balloons was required to maintain the blood flow of SNA in 3 pts; and 3) CAG revealed spontaneous recovery of the blood flow of SNA in one pt. The remaining patient did not receive the CAG/PCI. All 8 pts who underwent the PCI resulted in restoration of normal sinus rhythm. During a median of 44 months follow-up, all 8 pts who received the PCI maintained normal sinus rhythm, while one patient without PCI demonstrated persistent SN dysfunction. Conclusions SNA injury during RFCA is a rare but critical complication. Prompt recognition by CAG and subsequent PCI effectively restores SN function in pts with unexpected SN dysfunction during RFCA procedures.

• Diagnosis of MINOCA (e.g. coronary spasm) is important to avoid unnecessary PCI. • Sufficient coronary dilatation is crucial, but accurate diagnosis may be still challenging. • Intravascular imaging such as IVUS or OCT can help determine the exact cause of Acute Myocardial Infarction .

Recurrent in-stent restenosis of the coronary artery is a rare but intractable problem. In this situation, coronary arteritis should be considered as an etiology. This case highlights the use of immunosuppressive drugs, including tocilizumab, and follow-up F-18-fluorodeoxyglucose positron emission tomography/computed tomography to break the vicious circle of recurrent stenosis caused by isolated coronary arteritis of unknown cause.

Currently, IVUS is essential for PCI. IVUS provides information on the distribution, morphology, and characteristics of the plaque, which can be used to select an optimal device for PCI. In addition, operators can recognize high-risk lesions that may cause serious complications such as coronary perforation, and prevent them based on IVUS findings.

Purpose: The endovascular approach for eccentric calcified lesions of the no-stenting zone is challenging. This study aimed to investigate the effect of a novel technique for these lesions. Methods: We performed EVT for severe and eccentric calcified lesions using the technique, which is presented previously and named aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA). In brief, a guidewire is passed to the residual lumen firstly. Next, another guidewire is advanced into and cross through the calcified plaque and returned to the distal original lumen with intravascular ultrasound (IVUS) guided. The calcified plaque is dilated by using a scoring-balloon or non-compliant balloon. Results: Consecutive 14 peripheral artery disease patients with isolated and eccentric calcification in a no-stenting zone were treated using ARCADIA technique between January 2018 and March 2020. In IVUS data, lumen cross-section area was significantly increased from 5.2 ± 2.0 mm2 to 18.1 ± 6.9 mm2 (p < 0.01), lumen area was expanded roundly evaluating as symmetry index from 0.45 ± 0.09 to 0.81 ± 0.12 (p < 0.01). There were no distal embolization and perforation after ARCADIA technique. One-year target lesion revascularization occurred in only 2 cases. The primary patency of 1 year was 85.7%. Conclusion: ARCADIA technique is safe and appropriate, and can be 1 option to treat for eccentric calcified lesions of the no-stenting zone as an optimal wire crossing method.

Background: Drug eluting stent (DES) remain several problems, including stent thrombosis, stent fracture and neoatherosclerosis. Stent-less Percutaneous coronary intervention (PCI) using a drug coated balloon (DCB) is a stent-less strategy, and several trials have supported the efficacy of DCB. However, the optimal preparation before using DCB was uncertain. The aim of this study was to investigate the optimal preparation for plaque oppression/debulking before DCB dilatation for de novo coronary artery lesion. Methods: A total 936 patients were treated using DCB from 2014 to 2017 at our institution. Among them, we analyzed 247 patients who underwent PCI using DCB alone for de novo lesion. The primary end point of this study was target lesion failure (TLF). Results: The area under the receiver operating characteristic (ROC) curve (AUC) was used to determine the optimal cutoff value of % plaque area to predict TLF. ROC curve analysis revealed plaque area >= 58.5% (AUC, 0.81) were associated with TLF. Eligible 188 patients were divided into 2 groups (plaque area >= 58.5% [n = 38] and <58.5% [n = 150]) according to IVUS data before using DCB. TLF was significantly higher in plaque area >= 58.5% group than in <58.5% group (P < 0.01). Multivariable analysis selected plaque area >= 58.5% as an independent predictor of TLF (hazard ratio 7.59, P < 0.01). Conclusions: Lesion preparation achieving plaque area < 58.5% was important in stent-less PCI using DCB. (C) 2021 Elsevier Inc. All rights reserved.

•Limitations of single use of intravascular ultrasound (IVUS) or optical coherence tomography (OCT) for evaluation of coronary artery disease.•Usefulness and limitations of sequential use of IVUS or OCT.•Advances in hybrid IVUS-OCT imaging devices.•Clinical application and usefulness of hybrid IVUS-OCT imaging devices.

Background: Coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) is an established tool for identifying lesion-specific ischemia that is now approved for use by the Japanese insurance system. However, current clinical reimbursement is strictly limited to institutions with designated appropriate use criteria (AUC). This study assessed differences in physicians' behavior (e.g., use and interpretation of FFRCT, final management) according to Japanese AUC and non-AUC site designation. Methods and Results: Of 5,083 patients in the ADVANCE Registry, 1,829 from Japan were enrolled in this study. Physicians' behavior after interrogating CCTA and FFRCT was analyzed separately according to AUC and non-AUC site designation. Compared with AUC sites, patients referred for FFRCT from non-AUC sites had a higher rate of negative FFRCT, less severe anatomic stenosis, and a slightly lower rate of management plan reclassification (51.2% vs. 61.3%), with near-identical utility in both groups. Actual care corresponded equally well to post-FFRCT plans in both groups. The likelihood of revascularization for positive or negative FFRCT was similar between the 2 groups. Importantly, AUC and non-AUC sites were equally unlikely to revascularize patients with negative FFRCT and stenosis >50% or patients with positive FFRCT and stenosis <50%. Conclusions: Compared with AUC sites, non-AUC sites had lower disease burden and reclassification of management plans, but nearly identical clinical integration. Actual care corresponded equally well to post-FFRCT recommendations at both sites.

OBJECTIVES The aim of this study was to investigate the accuracy of pre-percutaneous coronary intervention (PCI) predicted nonhyperemic pressure ratios (NHPRs) with actual post-PCI NHPRs and to assess the efficacy of PCI strategy using pre-PCI NHPR pullback. BACKGROUND Predicting the functional results of PCI is feasible using pre-PCI longitudinal vessel interrogation with the instantaneous wave-free ratio (iFR), a pressure-based, adenosine-free NHPR. However, the reliability of novel NHPRs (resting full-cycle ratio [RFR] and diastolic pressure ratio [dPR]) for this purpose remains uncertain. METHODS In this prospective, multicenter, randomized controlled trial, vessels were randomly assigned to receive pre-PCI iFR, RFR, or dPR pullback (50 vessels each). The pre-PCI predicted NHPRs were compared with actual NHPRs after contemporary PCI using intravascular imaging. The number and the total length of treated lesions were compared between NHPR pullback-guided and angiography-guided strategies. RESULTS The predicted NHPRs were strongly correlated with actual NHPRs: iFR, r = 0.83 (95% confidence interval: 0.72 to 0.90; p < 0.001); RFR, r = 0.84 (95% confidence interval: 0.73 to 0.91; p < 0.001), and dPR, r = 0.84 (95% confidence interval: 0.73 to 0.91; p < 0.001). The number and the total length of treated lesions were lower with the NHPR pullback strategy than with the angiography-guided strategy, leading to physiological improvement. CONCLUSIONS Predicting functional PCI results on the basis of pre-procedural RFR and dPR pullbacks yields similar results to iFR. Compared with an angiography-guided strategy, a pullback-guided PCI strategy with any of the 3 NHPRs reduced the number and the total length of treated lesions. (Study to Examine Correlation Between Predictive Value and Post PCI Value of iFR, RFR and dPR; UMIN000033534) (C) 2020 Published by Elsevier on behalf of the American College of Cardiology Foundation.

The aim of this study was to investigate the accuracy of pre–percutaneous coronary intervention (PCI) predicted nonhyperemic pressure ratios (NHPRs) with actual post-PCI NHPRs and to assess the efficacy of PCI strategy using pre-PCI NHPR pullback. Predicting the functional results of PCI is feasible using pre-PCI longitudinal vessel interrogation with the instantaneous wave-free ratio (iFR), a pressure-based, adenosine-free NHPR. However, the reliability of novel NHPRs (resting full-cycle ratio [RFR] and diastolic pressure ratio [dPR]) for this purpose remains uncertain. In this prospective, multicenter, randomized controlled trial, vessels were randomly assigned to receive pre-PCI iFR, RFR, or dPR pullback (50 vessels each). The pre-PCI predicted NHPRs were compared with actual NHPRs after contemporary PCI using intravascular imaging. The number and the total length of treated lesions were compared between NHPR pullback–guided and angiography-guided strategies. The predicted NHPRs were strongly correlated with actual NHPRs: iFR, r = 0.83 (95% confidence interval: 0.72 to 0.90; p < 0.001); RFR, r = 0.84 (95% confidence interval: 0.73 to 0.91; p < 0.001), and dPR, r = 0.84 (95% confidence interval: 0.73 to 0.91; p < 0.001). The number and the total length of treated lesions were lower with the NHPR pullback strategy than with the angiography-guided strategy, leading to physiological improvement. Predicting functional PCI results on the basis of pre-procedural RFR and dPR pullbacks yields similar results to iFR. Compared with an angiography-guided strategy, a pullback–guided PCI strategy with any of the 3 NHPRs reduced the number and the total length of treated lesions. (Study to Examine Correlation Between Predictive Value and Post PCI Value of iFR, RFR and dPR; UMIN000033534)

BACKGROUND:Chronic vessel enlargement (CVE) of the coronary artery is observed in patients who undergo percutaneous coronary intervention (PCI) for severely stenotic or occluded lesions. Recently, the presence of a peri-medial high-echoic band (PHB) identified by intravascular ultrasound (IVUS) has been reported to correlate with this phenomenon. We sought to assess the incidence, predictive factors of CVE, and association between CVE and PHB. METHODS:From January 2017 to December 2018, 97 patients, with 101 severely stenotic and occluded lesions, who underwent IVUS-guided PCI and a 9-month follow-up angiography were enrolled. CVE was defined as more than a 10% increase of distal lumen gain at follow-up angiography. All lesions were stratified into 2 groups: CVE group and non-CVE group. Clinical outcomes were compared and predictive factors for CVE were assessed. Relationships between PHB angle and CVE were also assessed. RESULTS:At follow-up angiography, CVE was observed in 27 lesions (26.7%, 27/101). PHBs were frequently observed in the CVE group (88.9%), which was significantly higher than that in the non-CVE group (40.5%). The multivariate logistic regression analysis revealed that the presence of PHB was the only predictive factor for CVE (odds ratio, 11.3; 95% confidence interval, 2.95-43.0; p < 0.001). In addition, a linear relationship was observed between the incidence of CVE and PHB angle. The number of patients with CVE significantly increased in cases with a PHB angle more than 180 degrees. CONCLUSIONS:The presence of PHB strongly predicts CVE after PCI for severely stenotic or occluded lesions.