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Comparison of serial optical coherence tomography imaging following aggressive stent expansion technique: insight from the MECHANISM study.
Sasaki, W, Ishida, M, Itoh, T, Uchimura, Y, Oda, H, Taguchi, Y, Kaneko, K, Sakamoto, T, Goto, I, Sakuma, M, et al
The international journal of cardiovascular imaging. 2021;(2):419-428
Abstract
To compare early vascular healing following cobalt-chromium everolimus-eluting stent (CoCr-EES) implantation between groups with or without aggressive stent expansion in patients treated by CoCr-EES for stable coronary artery disease (CAD). Seventy-one stable CAD lesions underwent CoCr-EES implantation and analysis of serial optical coherence tomography (OCT) images obtained post-procedure and at early-term (1- or 3-month) follow-up. The endpoints of this study were neointimal thickness at the time of 1- or 3-month OCT and presence and healing of stent edge dissection. Aggressive stent expansion was defined as a lesion complying with ILUMIEN III sizing protocol; that is, external elastic lamina (EEL) diameter minus maximum balloon diameter ≤ 0.25 mm. Comparing groups with and without aggressive stent expansion, median neointimal thickness at 1 and 3 months after CoCr-EES implantation was similar (1 month: 0.031 mm vs. 0.041 mm, respectively, p = 0.27; 3 months: 0.036 mm vs. 0.040 mm, respectively, p = 0.84). Regarding stent edge findings, the presence of any stent edge dissection immediately after percutaneous coronary intervention was also similar between the groups (25% vs. 15%, respectively; p = 0.30) and most stent edge dissections resolved completely within 3 months, regardless of location or dissection severity. After 1 year, no clinically driven target lesion revascularization or stent thrombosis was observed in either cohort. Even after aggressive stent expansion, early neointimal proliferation appeared modest with CoCr-EES implantation, and most stent edge dissections had resolved by 3 months. These findings may support the feasibility of EEL-based sizing by pre-stenting OCT.
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The frequency and clinical characteristics of in-stent restenosis due to calcified nodule development after coronary stent implantation.
Isodono, K, Fujii, K, Fujimoto, T, Kasahara, T, Ariyoshi, M, Irie, D, Tsubakimoto, Y, Sakatani, T, Matsuo, A, Inoue, K, et al
The international journal of cardiovascular imaging. 2021;(1):15-23
Abstract
The purpose of this study was to evaluated the clinical characteristics of calcified nodule-like in-stent restenosis (ISR) lesions using optical coherence tomography (OCT) in vivo. A total of 124 ISR lesions that were treated with a repeat coronary intervention under OCT guidance were included in this analysis. ISR neointimal morphology was classified as "calcified nodule-like ISR", that appeared as a high-backscattering protruding mass with an irregular surface covered by signal-rich bands, or "non-calcified nodule-like ISR". The maximum arc and thickness of calcium behind the stent struts was also measured. Of the 124 ISR lesions, calcified nodule-like ISR was observed in 11 lesions (9%). OCT analysis data showed that the maximum arc of calcium and the maximum calcium thickness behind the stent were significantly larger in the calcified nodule-like ISR lesions than in the non-calcified nodule-like ISR lesions (269 ± 51 vs. 179 ± 92°, p < 0.01 and 989 ± 174 vs. 684 ± 241 μm, p < 0.01, respectively). The enlargement of the stent area was significantly larger in the calcified nodule-like ISR lesions than in the non-calcified nodule-like ISR lesions (1.6 ± 2.3 vs. 0.7 ± 1.3 mm2, p = 0.02). As a result, the enlargement of the lumen area tended to be larger in the calcified group (2.8 ± 1.7 vs. 2.4 ± 1.3 mm2, p = 0.3). Calcified nodule-like neointima within the stent could develop in approximately 10% of all ISR lesions, especially within stents deployed in severely calcified lesions.
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Feasibility of morphological assessment of coronary artery calcification with electrocardiography-gated non-contrast computed tomography: a comparative study with optical coherence tomography.
Takahashi, Y, Toba, T, Otake, H, Fukuyama, Y, Nakano, S, Matsuoka, Y, Tanimura, K, Izawa, Y, Kawamori, H, Kono, AK, et al
The international journal of cardiovascular imaging. 2021;(4):1445-1453
Abstract
To investigate the feasibility of pre-procedural morphological assessment of coronary artery calcification in severely calcified lesions with electrocardiography (ECG)-gated non-contrast computed tomography (CT). Severely calcified coronary arteries in patients who underwent ECG-gated non-contrast CT prior to optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) were studied retrospectively. CT and OCT data were co-registered by marking landmark structures such as side branches and reviewed side by side with cross-sectional images. The maximum calcium angle (MCA) and presence of nodular calcification (NC) were evaluated. A total of 496 cross-sections in 16 lesions were included in this analysis. The Pearson correlation coefficient between CT- and OCT-derived MCA was 0.92 (p < 0.001). Bland-Altman plots of OCT-derived MCA in relation to CT-derived MCA showed a mean bias of 4.8 degrees with 95% limits of agreement of - 69.7 to 79.4 degrees. Sensitivity, specificity, and positive and negative predictive values of CT in identifying MCA > 270 degrees were 90.3%, 79.7%, 92.1%, and 97.4%, respectively. Sensitivity, specificity, and positive and negative predictive values of CT in identifying NC were 73.3%, 97.5%, 47.8%, and 99.2%, respectively. ECG-gated non-contrast coronary CT might be helpful to obtain detailed information of severe coronary artery calcification before PCI.
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Association between debulking area of rotational atherectomy and platform revolution speed-Frequency domain optical coherence tomography analysis.
Mizutani, K, Hara, M, Nakao, K, Yamaguchi, T, Okai, T, Nomoto, Y, Kajio, K, Kaneno, Y, Yamazaki, T, Ehara, S, et al
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions. 2020;(1):E1-E7
Abstract
OBJECTIVES In this study, we sought to investigate the association between revolution speed of rotational atherectomy (RA) and debulking area assessed by frequency domain-optical coherence tomography (FD-OCT). BACKGROUND The number of patients with severe calcified coronary artery disease requiring treatment with calcium ablation, such as RA, is increasing. However, there is little evidence available regarding the association between debulking area and revolution speed during RA. METHODS We retrospectively investigated 30 consecutive severely calcified coronary lesions in 29 patients who underwent RA under FD-OCT guidance. The association between preset revolution speed of RA and burr size-corrected debulking area of the calcified lesion was evaluated using a multivariable regression model with nonlinear restricted-cubic-spline, which can help assess nonlinear associations between variables. RESULTS The median age of study participants was 73 years (quartile 65-78); 82.8% were male. The median burr size was 1.5 mm (1.5-1.75); median total duration of ablation was 120 s (100-180). FD-OCT revealed that the post-procedural minimum lumen area increased significantly from 1.64 mm2 (1.40-2.09) to 2.45 mm2 (2.11-2.98) (p < .001). In addition, the burr size-corrected debulking area increased significantly as the preset revolution speed decreased (p = .018), especially when the revolution speed was less than 150,000 rpm. This result implies that additional lumen gain will be obtained by decreasing rpm when the burr speed is set at <150,000 rpm. CONCLUSIONS FD-OCT demonstrated that RA with lower revolution speed, below 150,000 rpm, has the potential to achieve greater calcium debulking effect in patients with severe calcified coronary lesions.
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Quantification of calcium burden by coronary CT angiography compared to optical coherence tomography.
Monizzi, G, Sonck, J, Nagumo, S, Buytaert, D, Van Hoe, L, Grancini, L, Bartorelli, AL, Vanhoenacker, P, Simons, P, Bladt, O, et al
The international journal of cardiovascular imaging. 2020;(12):2393-2402
Abstract
Coronary artery calcifications (CAC) are frequently observed in patients referred for coronary CT angiography (CTA). Calcification volume (in mm3) can accurately be assessed during catheterization by optical coherence tomography (OCT). The aim of the present study was to investigate the accuracy of CTA-derived assessment of calcification volume as compared with OCT. 66 calcified plaques (32 vessels) from 31 patients undergoing OCT-guided PCI with coronary CT acquired as a standard of care were included. Coronary CT and OCT images were matched using fiduciary points. Calcified plaques were reconstructed in three dimensions to calculate calcium volume. A Passing-Bablok regression analysis and the Bland-Altman method were used to assess the agreement between imaging modalities. Twenty-seven left anterior descending arteries and 5 right coronary arteries were analyzed. Median calcium volume by CTA and OCT were 18.23 mm3 [IQR 8.09, 36.48] and 10.03 mm3 [IQR 3.6, 22.88] respectively; the Passing-Bablok analysis showed a proportional without a systematic difference (Coefficient A 0.08, 95% CI - 1.37 to 1.21, Coefficient B 1.61, 95% CI 1.45 to 1.84) and the mean difference was 9.69 mm3 (LOA - 10.2 to 29.6 mm3). No differences were observed for minimal lumen area (Coefficient A 0.07, 95% CI - 0.46 to 0.15, Coefficient B 0.85, 95% CI 0.64 to 1.2). CTA volumetric calcium evaluation overestimates calcium volume by 60% compared to OCT. This may allow for an appropriate interpretation of calcific burden in the non-invasive setting. Even in presence of calcific plaques, a good agreement in the MLA assessment was found. Coronary CT may emerge as a tool to quantify calcium burden for invasive procedural planning.
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Machine learning of clinical variables and coronary artery calcium scoring for the prediction of obstructive coronary artery disease on coronary computed tomography angiography: analysis from the CONFIRM registry.
Al'Aref, SJ, Maliakal, G, Singh, G, van Rosendael, AR, Ma, X, Xu, Z, Alawamlh, OAH, Lee, B, Pandey, M, Achenbach, S, et al
European heart journal. 2020;(3):359-367
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Abstract
AIMS: Symptom-based pretest probability scores that estimate the likelihood of obstructive coronary artery disease (CAD) in stable chest pain have moderate accuracy. We sought to develop a machine learning (ML) model, utilizing clinical factors and the coronary artery calcium score (CACS), to predict the presence of obstructive CAD on coronary computed tomography angiography (CCTA). METHODS AND RESULTS The study screened 35 281 participants enrolled in the CONFIRM registry, who underwent ≥64 detector row CCTA evaluation because of either suspected or previously established CAD. A boosted ensemble algorithm (XGBoost) was used, with data split into a training set (80%) on which 10-fold cross-validation was done and a test set (20%). Performance was assessed of the (1) ML model (using 25 clinical and demographic features), (2) ML + CACS, (3) CAD consortium clinical score, (4) CAD consortium clinical score + CACS, and (5) updated Diamond-Forrester (UDF) score. The study population comprised of 13 054 patients, of whom 2380 (18.2%) had obstructive CAD (≥50% stenosis). Machine learning with CACS produced the best performance [area under the curve (AUC) of 0.881] compared with ML alone (AUC of 0.773), CAD consortium clinical score (AUC of 0.734), and with CACS (AUC of 0.866) and UDF (AUC of 0.682), P < 0.05 for all comparisons. CACS, age, and gender were the highest ranking features. CONCLUSION A ML model incorporating clinical features in addition to CACS can accurately estimate the pretest likelihood of obstructive CAD on CCTA. In clinical practice, the utilization of such an approach could improve risk stratification and help guide downstream management.
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Nonculprit Lesion Plaque Morphology in Patients With ST-Segment-Elevation Myocardial Infarction: Results From the COMPLETE Trial Optical Coherence Tomography Substudys.
Pinilla-Echeverri, N, Mehta, SR, Wang, J, Lavi, S, Schampaert, E, Cantor, WJ, Bainey, KR, Welsh, RC, Kassam, S, Mehran, R, et al
Circulation. Cardiovascular interventions. 2020;(7):e008768
Abstract
BACKGROUND Complete revascularization with routine percutaneous coronary intervention of nonculprit lesions after primary percutaneous coronary intervention improves outcomes in ST-segment-elevation myocardial infarction. Whether this benefit is associated with nonculprit lesion vulnerability is unknown. METHODS In a prospective substudy of the COMPLETEs trial (Complete vs Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI), we performed optical coherence tomography of at least 2 coronary arteries before nonculprit lesion percutaneous coronary intervention in 93 patients with ST-segment-elevation myocardial infarction and multivessel disease; and the ST-segment-elevation myocardial infarction culprit vessel if there was unstented segment amenable to imaging. Nonculprit lesions were categorized as obstructive (≥70% stenosis by visual angiographic assessment) or nonobstructive, and as thin-cap fibroatheroma (TCFA) or non-TCFA by optical coherence tomography criteria. TCFA was defined as a lesion with mean fibrous cap thickness <65 μm overlying a lipid arc >90°. RESULTS On a patient level, at least one obstructive TCFA was observed in 44/93 (47%) of patients. On a lesion level, there were 58 TCFAs among 150 obstructive nonculprit lesions compared with 74 TCFAs among 275 nonculprit lesions (adjusted TCFA prevalence: 35.4% versus 23.2%, P=0.022). Compared with obstructive non-TCFAs, obstructive TCFAs had similar lesion length (23.1 versus 20.8 mm, P=0.16) but higher lipid quadrants (55.2 versus 19.2, P<0.001), greater mean lipid arc (203.8° versus 84.5°, P<0.001), and more macrophages (97.1% versus 54.4%, P<0.001) and cholesterol crystals (85.8% versus 44.3%, P<0.001). For nonobstructive lesions, TCFA lesions had similar lesion length (16.7 versus 14.6 mm, P=0.11), but more lipid quadrants (36.4 versus 13.5, P<0.001), and greater mean lipid arc (191.8° versus 84.2°, P<0.001) compared with non-TCFA. CONCLUSIONS Among patients who underwent optical coherence tomography imaging in the COMPLETE trial, nearly 50% had at least one obstructive nonculprit lesion containing complex vulnerable plaque. Obstructive lesions more commonly harbored vulnerable plaque morphology than nonobstructive lesions. This may help explain the benefit of routine percutaneous coronary intervention of obstructive nonculprit lesions in patients with ST-segment-elevation myocardial infarction and multivessel disease. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01740479s.
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Chronic stent recoil in severely calcified coronary artery lesions. A serial optical coherence tomography study.
Amemiya, K, Maehara, A, Yamamoto, MH, Oyama, Y, Igawa, W, Ono, M, Kido, T, Ebara, S, Okabe, T, Yamashita, K, et al
The international journal of cardiovascular imaging. 2020;(9):1617-1626
Abstract
Chronic second-generation drug-eluting stent recoil in severely calcified coronary lesions has not been studied. We aimed to evaluate chronic stent recoil by optical coherence tomography (OCT) in severely calcified lesions treated with thin strut stents after rotational atherectomy. In 28 lesions (26 patients with 23% on hemodialysis) treated with everolimus-eluting stents after rotational atherectomy, baseline and 8-month follow-up OCT were compared. Stent recoil was defined as >10% decrease in stent area from baseline to follow-up. Overall, there was no change in minimal stent area (6.0 mm2 [5.0, 8.1] to 6.0 mm2 [4.8, 8.6], p = 0.51) from baseline to follow-up, although neointimal hyperplasia measured 16.3 ± 15.8%. Thirty-six percent of lesions showed stent recoil associated with 6 non-nodular calcifications, 1 calcified nodule, and 3 stent deformations. The overall mean calcium angle with attenuation decreased (54° [29-76] to 31° [19-48], p < 0.0001), and calcium without attenuation increased (28° [21-67] to 64° [34-93], p < 0.0001), but primarily at the location of stent recoil. Furthermore, in the stent recoil segments in 10 recoil lesions, the stent circumference decreased primarily at non-calcium segments rather than at calcium with or without attenuation. One lesion with stent recoil and 2 lesions without stent recoil required repeat revascularization. Thin strut stents can chronically recoil in severely calcified lesions, but this rarely causes restenosis.
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Comparison of the vessel healing process after everolimus-eluting stent and bare metal stent implantations in patients with ST-elevation myocardial infarction.
Yano, H, Horinaka, S, Watahik, M, Watanabe, T, Ishimitsu, T
Heart and vessels. 2019;(4):572-582
Abstract
Cobalt-chromium everolimus-eluting stent (CoCr EES) is associated with a lower rate of stent thrombosis even in patients with ST-elevation myocardial infarction (STEMI). However, the time-serial changes of endothelial coverage of the stent struts in the extremely early period have never been reported, especially in patients with STEMI. The aim of this study was to compare the vessel healing process between CoCr EES and cobalt-chromium bare metal stent (CoCr BMS) implantations using optical coherence tomography (OCT) in patients with STEMI. Sixty-three patients who had primary emergent percutaneous coronary intervention (PCI) with CoCr EES (42 patients) or CoCr BMS (21 patients) were enrolled in this study for 3 years. OCT was performed just after, 2 and 12 weeks after EES or BMS implantations. Time-serial changes in the neointimal coverage (NIC), the neointimal thickness, and malapposition of stent struts were evaluated. NIC of stent struts did not differ between CoCr EES (23.2%, 99.4%) and CoCr BMS (24.0%, 97.8%) at 2 weeks and 12 weeks after PCI, respectively. Thicknesses of the neointima on the stent strut was significantly thinner in CoCr EES (34.0 ± 13.8, 107.0 ± 32.4 µm) than in CoCr BMS (40.0 ± 14.6, 115.7 ± 33.8 µm) at 2 weeks and 12 weeks after PCI (p = 0.011, p = 0.008), respectively. The malapposition did not differ just after PCI, and was completely resolved at 12 weeks after PCI in both groups. Thrombus was significantly less in CoCr EES than in CoCr BMS at 2 weeks (19.0% vs 42.9%, p < 0.01), and decreased over time in both groups, but at 12 weeks, disappeared only in CoCr EES (CoCr EES: 0% vs. CoCr BMS: 4.8%, p = 0.56). This study demonstrated that NIC and apposition of the stent struts almost completed at 12 weeks after EES and BMS implantations, while the neointimal thickness on the stent struts were thinner in EES than in BMS. Moreover, thrombus was significantly less in EES than in BMS implantations 2 weeks after PCI, which may explain the lower rate of acute and subacute stent thrombosis of EES compared with BMS.
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Low short-term and long-term cardiovascular and all-cause mortality in absence of coronary artery calcium: A 22-year follow-up observational study from large cohort.
Shaikh, K, Li, D, Nakanishi, R, Kinninger, A, Almeida, S, Cherukuri, L, Shekar, C, Roy, SK, Birudaraju, D, Rai, K, et al
Journal of diabetes and its complications. 2019;(9):616-622
Abstract
OBJECTIVES We sought to evaluate the gender-specific predictive value of coronary artery calcium (CAC) score on all-cause mortality and cardiovascular disease (CVD) mortality in individuals with and without diabetes mellitus (DM). BACKGROUND CAC score is a robust predictor of CVD and all-cause mortality during long-term follow-up in large cohorts in adults with DM. However, less is known about its sex-specific impact on all-cause mortality in DM. METHODS We evaluated 25,563 asymptomatic participants with no known history of coronary artery disease (CAD) who underwent clinically indicated CAC. 1999 (7.8%) individuals had diabetes. CAC was characterized as an Agatston score of 0, 1-99, 100-300, and ≫300. We evaluated the association between CAC and all-cause mortality and CVD mortality. RESULTS Overall, 1345 individuals died (5.3%) from all causes during a mean follow-up of 14.7 ± 3.8 years. CAC score was 0 in 57.5% females and 34.4% of males without DM, while 36.6% females and 20.3% males with DM had CAC-0. The frequency of CAC ≫ 300 was 18% and 36% in females and males with DM, respectively. CAC score of zero was associated with low all-cause mortality event rate in females and males with diabetes (1.7 and 2.5 events per 1000 person-years, respectively). Cardiovascular mortality per 1000 person years was ≪1 in females and males with CAC score of 0 irrespective of their diabetes. Adjusted multivariable analysis, compared to CAC-0, HR for all-cause mortality associated with CAC 1-99, 100-299 and ≫300 were 1.74(95% CI 0.65, 4.63, P-0.20), 5.54(95% CI 2.16, 14.22, P ≪ 0.001) and 5.75(95% CI 2.30, 14.37, P ≪ 0.001) in females with DM respectively; in males with DM HR associated with CAC 1-99, 100-299 and ≫300 were 1.87(95% CI 0.95, 3.66, P-0.06), 2.15(95% CI 1.05, 4.38, P-0.035) and 2.60(95% CI 1.34, 5.0, P-0.004), respectively. CONCLUSION Presence of subclinical atherosclerosis varies among individuals with DM. The absence of CAC was associated with very low cardiovascular as well as all-cause mortality events in all subgroups during long term follow-up.