Fractional flow reserve (FFR) is considered the standard for assessment of the physiological significance of coronary artery stenosis. Intracoronary papaverine (PAP) is the most potent vasodilator used for the achievement of maximal hyperemia. However, its use can provoke ventricular tachycardia (VT) due to excessive QT prolongation. We evaluated the clinical efficacy and safety of the administration of PAP after nicorandil (NIC), a potassium channel opener that prevents VT, for optimal FFR measurement.A total of 127 patients with 178 stenoses were enrolled. The FFR values were measured using NIC (NIC-FFR) and PAP (PAP-FFR). We administered PAP following NIC (NIC-PAP). Changes in the FFR and electrogram parameters (baseline versus NIC versus PAP) were assessed and the incidence of arrhythmias after PAP was evaluated. In addition, we analyzed another 41 patients with 51 stenoses by assessing the FFR using PAP before NIC (PAP-NIC). After propensity score matching, the electrogram parameters between 2 groups were compared.The mean PAP-FFR was significantly lower than the mean NIC-FFR (0.82 ± 0.11 versus 0.81 ± 0.11, P < 0.05). The mean baseline-QTc, NIC-QTc, and PAP-QTc values were 425 ± 37 ms1/2, 424 ± 41 ms1/2, and 483 ± 54 ms1/2, respectively. VT occurred in only 1 patient (0.6%). Although PAP induced QTc prolongation (P < 0.05), the PAP-QTc duration was significantly shorter in NIC-PAP compared to PAP-NIC (P < 0.05).The administration of PAP with NIC may induce sufficient hyperemia and prevent fatal arrhythmia through reductions in the PAP-induced QTc prolongation during FFR measurement.
To clarify the viability of myocardium in acute myocardial infarction, we examined 18 patients scintigraphically. They underwent rest or stress imaging and delayed imaging of thallium-201 during acute, convalescent and chronic periods. During acute period, a scintigraphic finding of the delayed filling in was observed in 9 cases (50%; Redistribution group). Worsening of the delayed image was observed in 6 cases (33%; Reverse redistribution group). No scintigraphic change of the perfusion defect was observed in 3 cases (17%; No change group). In reverse redistribution group, a remarkable improvement of the delayed image was observed through acute, convalescent and chronic periods. In redistribution group and no change group, no significant improvement was observed. We conclude that the myocardium of the reverse redistribution region during acute period may be viable. In the reverse redistribution region, recanalization of the coronary artery possibly protects myocardial damage from necrosis.
ABSTRACT Background The efficacy of balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary disease (CTEPD) with or mild pulmonary hypertension (PH) or without PH remains unknown. Exercise pulmonary hypertension (Ex-PH) is associated with impaired exercise capacity and ventilatory efficiency, even under normalized pulmonary hemodynamics at rest. We hypothesized that patients with Ex-PH and/or hypoxemia would be candidates for BPA. We aimed to verify the prevalence and clinical profiles of Ex-PH and the effect of BPA on oxygenation and Ex-PH in patients with CTEPD with mean pulmonary arterial pressure (mPAP) < 25 mmHg. Methods We retrospectively reviewed 29 patients with CTEPD and mPAP < 25 mmHg at rest, who had undergone a cardiopulmonary exercise test with right heart catheterization (median age, 65 years; 38% male). Patients were divided into two groups: Ex-PH, defined as a cardiac output slope (mPAP/CO slope) > 3.0, and non-Ex-PH. Results Overall, six patients had mild PH (mPAP: 21–24 mmHg), and 16 and 13 were assigned to the Ex-PH and Non-Ex-PH groups, respectively. There were no significant differences in the clinical parameters, including hemodynamics at rest, blood gas analysis, and 6-minute walk distance, between the Ex-PH and Non-Ex-PH groups. Among the 16 patients with Ex-PH and/or long-term oxygen therapy (LTOT), BPA improved the World Health Organization-functional class (WHO-FC) and PaO 2 in association with a decrease in the mPAP/CO slope. All nine patients discontinued LTOT after BPA. No significant complications were observed during each BPA session. Conclusions Ex-PH was common among patients with CTEPD and mPAP < 25 mmHg. BPA can improve symptoms, oxygenation, and exercise hemodynamics in patients with CTEPD and Ex-PH and/or hypoxemia. What is Known? BPA has been recommended for patients with non-operable CTEPH. Although there is still a small body of evidence, BPA for patients with CTEPD with mild PH (mPAP < 25 mmHg) or without PH can safely improve symptoms. The prevalence of Ex-PH in CTEPD patients with or without PH is unknown. What the Study Adds? Approximately 50% of CTEPD patients with mild PH or without PH had Ex-PH. In patients with CTEPD with mPAP < 25 mmHg, BPA improves exercising hemodynamics, such as the mPAP/CO slope, which could be a parameter to determine the indication for BPA. Graphical Abstract. The distribution of exercise pulmonary hypertension (Ex-PH) in patients with chronic thromboembolic pulmonary disease (CTEPD) with mild pulmonary hypertension (PH) or without PH, and efficacy of balloon pulmonary angioplasty (BPA) for CTEPD with Ex-PH and/or hypoxemia. Blue person symbols mean Ex-PH, and white person symbols mean non-Ex-PH.
A 46-year-old man complained of chest pain at rest for the past three months. His symptoms gradually exacerbated and were suspected of being due to unstable angina. A coronary angiogram revealed focal tight stenosis at the proximal left anterior descending coronary artery with gross spastic coronary findings. Optical coherence tomography (OCT) revealed layered low-intensity structures with microvessels and the accumulation of macrophages, which indicated progressive stenosis with multiple-layered organized thrombus caused by coronary erosion. We treated the stenosis using a drug-coated balloon instead of drug-eluting stents. There was no restenosis, and OCT revealed good plaque healing at follow-up. This case suggests that the pre-interventional OCT plaque morphology can have a positive impact on the revascularization strategy.
BACKGROUND: Limited large-scale, real-world data exist on the prevalence and clinical impact of discordance between fractional flow reserve (FFR) and nonhyperemic pressure ratios (NHPRs). METHODS: The J-PRIDE registry (Clinical Outcomes of Japanese Patients With Coronary Artery Disease Assessed by Resting Indices and Fractional Flow Reserve: A Prospective Multicenter Registry) prospectively enrolled 4304 lesions in 3200 patients from 20 Japanese centers. The lesions were classified into FFR+/NHPR−, FFR−/NHPR+, FFR+/NHPR+, or FFR−/NHPR groups according to cutoff values of 0.89 for NHPRs and 0.80 for FFR. The primary study end point was the cumulative 1-year incidence of target vessel failure (a composite of cardiac death, target vessel–related myocardial infarction, and clinically driven target vessel revascularization) on a lesion basis. RESULTS: An NHPR cutoff value of 0.89, determined using online software, predicted an FFR of 0.80 across various NHPR types. Discordance between FFR and NHPRs was observed in 20% of lesions (FFR+/NHPR−, 11.2%; FFR−/NHPRs+, 8.8%). Revascularization was deferred in 42.9% and 88.4% of the FFR+/NHPR− and FFR−/NHPR+ groups, respectively. In deferred vessels, the FFR+/NHPR− and FFR−/NHPR+ groups showed a higher 1-year incidence of target vessel failure compared with the FFR−/NHPR− group (7.9% versus 5.5% versus 1.7%; for FFR+/NHPR−, adjusted hazard ratio [aHR], 4.89 [95% CI, 2.68–8.91]; P <0.001; for FFR−/NHPR+, aHR, 2.64 [95% CI, 1.49–4.69]; P <0.001). In revascularized vessels, the 1-year target vessel failure rate was numerically higher in the FFR−/NHPR+ group than in the FFR+/NHPR+ group (9.6% versus 3.4%; aHR, 2.27 [95% CI, 0.70–7.34]; P =0.17), although with similar outcomes between the FFR+/NHPR− and FFR+/NHPR+ groups (2.3% versus 3.4%; aHR, 0.96 [95% CI, 0.37–2.38]; P =0.93). The FFR+/NHPR− group benefited from revascularization compared with medical treatment (aHR, 0.26 [95% CI, 0.08–0.86]; P =0.027); the FFR−/NHPR+ group did not (aHR, 2.39 [95% CI, 0.62–9.21]; P =0.20). CONCLUSIONS: Discordance between FFR and NHPRs was noted in 20% of lesions, and discordant deferred lesions resulted in worse outcomes than concordant negative lesions. Although the outcomes after deferring revascularization were comparable between the FFR+/NHPR− and FFR−/NHPR+ lesions, only FFR+/NHPR− lesions showed a benefit from revascularization compared with medical treatment, suggesting that an FFR-guided strategy is superior to an NHPR-guided strategy in discordant lesions. REGISTRATION: URL: https://www.umin.ac.jp ; Unique identifier: UMIN000038403.
