Takayuki Okamura

Due to the substantial discrepancy in vessel diameter between the proximal and distal segments, appropriate stent size selection is important in percutaneous coronary intervention (PCI) of the left main bifurcation (LMB). Inadequate stent expansion in both the main trunk and daughter branches after kissing balloon inflation (KBI) may contribute to adverse clinical outcomes. We investigated the relationship between stent size selection and vessel dilation in the distal main vessel (DMV) and side branch (SB). We analyzed 80 cases of single stenting with KBI under optical coherence tomography (OCT) guidance for LMB at the Yamaguchi University Hospital and in the 3D-OCT bifurcation registry. Cases were divided into large and small size stent groups based on whether the stent size exceeded or fell below the average of the distal and proximal reference diameters (AvRD). The percentages of ostial stenosis (%OS) in the DMV and SB, along with incomplete stent apposition (ISA) at the bifurcation segment derived by OCT, were compared between the groups. The large size stent group exhibited better dilation in both the DMV and SB compared to the small size stent group (DMV%OS: 4.8 ± 9.3% vs. 9.7 ± 7.8%, P = 0.03; SB%OS: 14.4 ± 10.1% vs. 22.1 ± 12.3%, P = 0.004). There was no significant difference in the incidence of ISA at the bifurcation segment between the two groups (large size stent group:11.4 ± 9.2% vs. small size stent group:14.4 ± 15.7%, P = 0.29). Selecting a stent size larger than the AvRD may be associated with optimal ostium dilatation in both the DMV and SB of the LMB. Graphical abstract

Background: Periprocedural myocardial injury (PMI) is a common complication of percutaneous coronary intervention (PCI). Elevated post-PCI index of microcirculatory resistance (IMR) has been linked to PMI. The angiography-derived IMR (angio-IMR) serves as a pressure-wire-free method to assess coronary microvascular function. This study aimed to establish the association between post-PCI angio-IMR and PMI.Methods and Results: We retrospectively analyzed 101 consecutive elective PCI cases where PMI diagnosis and post-PCI angio-IMR calculation were feasible. Angio-IMR was computed using computational flow and pressure simulations. Patients were categorized into 2 groups based on PMI status: PMI (n=33), and non-PMI (n=68). The PMI group had significantly higher post-PCI angio-IMR values than the non-PMI group (31.8±5.9 vs. 23.8±6.0; P<0.001). Both univariate and multivariate logistic regression analyses revealed an association between post-PCI angio-IMR and PMI. Patients with post-PCI angio-IMR ≥29 had a significantly higher incidence of PMI (67.6% vs. 12.5%; P<0.001).Conclusions: Increased post-PCI angio-IMR values were strongly associated with PMI. Post-PCI angio-IMR might serve as a useful non-invasive predictive of PMI following elective PCI.

Objective: Severe aortic stenosis (AS) is a life-threatening valvular disease with an in-hospital mortality rate exceeding 50% when complicated by cardiogenic shock. In this critical setting, emergency balloon aortic valvuloplasty (BAV) is sometimes performed as an initial therapy. However, reports on emergency BAV followed by Impella (Abiomed, Danvers, MA, USA) support, referred to as the BAV-PELLA strategy, remain limited.Case Presentation: We report 4 patients who were treated using this strategy. This staged management markedly reduced the surgical risk scores in all 4 cases. Three of the 4 patients underwent elective definitive valve replacement after a preoperative window that provided sufficient time for hemodynamic stabilization and a comprehensive assessment of surgical candidacy. One patient required urgent surgical aortic valve replacement (SAVR) with coronary artery bypass grafting under continued combined venoarterial extracorporeal membrane oxygenation and Impella (ECPELLA) support. Among the remaining 3 patients, 1 underwent isolated SAVR, 1 underwent SAVR with mitral valve repair, and 1 underwent transcatheter aortic valve replacement (TAVR) after stabilization. Following emergent BAV, Impella placement was successfully performed in all patients, despite the persistence of severe AS. No procedure-related complications associated with BAV or Impella implantation were observed.Conclusion: The BAV-PELLA strategy not only supports circulatory recovery in the acute phase but also provides a valuable preoperative window, enabling individualized definitive therapy based on the patient’s condition.

Background: A 55-year-old woman was admitted with recurrent early-morning chest tightness approximately twice per month. Coronary computed tomography showed no significant stenosis. Case summary: During acetylcholine provocation testing, the patient developed extensive left main coronary artery (LMCA) dissection extending into the left anterior descending artery and left circumflex artery, resulting in thrombolysis in myocardial infarction (TIMI) Grade 1 flow and cardiogenic shock. A microaxial flow pump (Impella CP) was immediately inserted via the femoral artery, leading to rapid haemodynamic stabilization and improvement of ST-segment depression. Intravascular ultrasound demonstrated dynamic reduction of the false lumen and expansion of the true lumen after initiation of Impella support. Percutaneous coronary intervention was subsequently performed under the Impella support, with stent deployment from the LMCA to the left anterior descending artery (LAD), followed by kissing-balloon inflation into the left circumflex artery (LCx). Final angiography confirmed restoration of TIMI Grade 3 flow. Discussion: The patient experienced a favourable clinical course and was discharged after completing cardiac rehabilitation. This case highlights the potential role of early Impella support in stabilizing haemodynamics and preserving true lumen integrity during bailout percutaneous coronary intervention for iatrogenic LMCA dissection. Intravascular ultrasound provided valuable insights into haemodynamic improvements following Impella support.

Background/Objectives: Transcatheter aortic valve implantation (TAVI) is a standard treatment for severe aortic stenosis, especially in older adults and high-risk patients. However, many TAVI candidates have osteopenia or osteoporosis, indicated by low bone mineral density (BMD), which is linked to frailty and adverse outcomes. Although prior research suggests an association with poor clinical outcomes, data remain limited. We investigated the impact of osteopenia on TAVI outcomes, hypothesizing that a lower BMD is associated with poor perioperative outcomes and decreased long-term survival. Methods: In this single-center retrospective study, we analyzed data from 411 patients who underwent TAVI at Yamaguchi University Hospital from 2014 to 2024. Clinical and survival data were collected, and Cox regression analysis was used to identify independent predictors of mortality. Preoperative BMD was measured using computed tomography, defining osteopenia as p = 0.04) and higher late cardiac mortality (p < 0.001). Six-year survival was 36.2% and 88.1% in patients with and without osteopenia, respectively (p < 0.0001). Cox regression analysis revealed osteopenia as a mortality risk factor (hazard ratio: 6.75, 95% confidence interval: 2.96–15.38, p < 0.0001). Severe osteopenia was associated with the poorest outcomes. Conclusions: Osteopenia is an independent predictor of poor long-term survival after TAVI. These findings underscore the importance of comprehensive risk assessment, suggesting that targeted interventions may improve outcomes.

Background: Implantable central venous catheters are routinely used to maintain venous access. While generally safe, they can lead to unique complications such as pinch-off syndrome, where the catheter fractures due to mechanical stress. Typically, detached fragments migrate to the right atrium or pulmonary artery, but migration into the coronary sinus is extremely rare and challenging to manage. Case summary: A 50-year-old woman with a history of breast cancer and an implanted central venous catheter presented with chest discomfort. Imaging of fluoroscopy and cardiac computed tomography revealed a fractured catheter with a fragment migrating into the coronary sinus, extending straightly through the tricuspid valve to the right ventricular free wall. Initial retrieval attempts were unsuccessful due to the misalignment with the snare’s direction of advancement and the fragment’s vigorous movement. A second procedure using advanced techniques, including the wire-loop and double snare methods, successfully retrieved the entire fragment. Discussion: Percutaneous retrieval of catheter fragments that have migrated into the coronary sinus can be particularly challenging, especially when the fragment has limited capturable portions. In our case, the fragment’s minimal exposure outside the sinus, its linear orientation towards the right ventricular free wall, and its vigorous synchronous movement with the wall made retrieval difficult, requiring advanced techniques. This report highlights a challenging case of fragment retrieval from the coronary sinus following pinch-off syndrome and underscores that preprocedural computed tomography can provide crucial information for predicting and planning for such complex interventions.

OBJECTIVES: Stratifying patients with aortic stenosis is crucial for improving their lifetime management. Several studies analysed computed tomography (CT)-defined sarcopenia in patients undergoing transcatheter aortic valve implantation (TAVI). However, the criteria for CT-defined sarcopenia are heterogeneous among these studies. Mostly, they primarily evaluated short-term outcomes; research focusing on long-term outcomes, related to lifetime management in patients with aortic stenosis, is rare. We assessed the effects of CT-defined sarcopenia on the short- and long-term outcomes in patients undergoing TAVI using three different sarcopenia criteria, including two traditional criteria and a novel criterion. METHODS: In this retrospective study, we enrolled 360 patients. Three different sarcopenia criteria (skeletal muscle index [SMI], psoas muscle area [PMA] and psoas muscle volume index [PVI]) were applied to assess safety and early and long-term clinical outcomes. RESULTS: SMI-, PMA- and PVI-sarcopenia were diagnosed in 244 (67.7%), 246 (68.3%) and 161 (44.7%) patients, respectively. However, PMA-sarcopenia was associated with poor long-term survival after TAVI. Furthermore, PVI-sarcopenia was associated with lower safety at 30 days and poor long-term survival. Using Cox regression hazard models, PVI-sarcopenia tended to be a risk factor for overall survival (hazards ratio: 1.49, P = 0.052). CONCLUSIONS: In patients undergoing TAVI, CT-defined sarcopenia using PVI-based criteria was a reliable predictor of poor outcomes. This finding might facilitate stratification of patients undergoing TAVI.

Background: Side branch (SB) occlusion during bifurcation stenting is a serious complication. This study aimed to predict SB compromise (SBC) using optical coherence tomography (OCT).Methods and Results: Among the 168 patients who enrolled in the 3D-OCT Bifurcation Registry, 111 bifurcation lesions were analyzed to develop an OCT risk score for predicting SBC. SBC was defined as worsening of angiographic SB ostial stenosis (≥90%) immediately after stenting. On the basis of OCT before stenting, geometric parameters (SB diameter [SBd], length from proximal branching point to carina tip [BP-CT length], and distance of the polygon of confluence [dPOC]) and 3-dimensional bifurcation types (parallel or perpendicular) were evaluated. SBC occurred in 36 (32%) lesions. The parallel-type bifurcation was significantly more frequent in lesions with SBC. The receiver operating characteristic curve indicated SBd ≤1.77 mm (area under the curve [AUC]=0.73, sensitivity 64%, specificity 75%), BP-CT length ≤1.8 mm (AUC=0.83, sensitivity 86%, specificity 68%), and dPOC ≤3.96 mm (AUC=0.68, sensitivity 63%, specificity 69%) as the best cut-off values for predicting SBC. To create the OCT risk score, we assigned 1 point to each of these factors. As the score increased, the frequency of SBC increased significantly (Score 0, 0%; Score 1, 8.7%; Score 2, 28%; Score 3, 58%; Score 4, 85%; P<0.0001).Conclusions: Prediction of SBC using OCT is feasible with high probability.