It is well known that graft patency determines prognosis in coronary artery bypass grafting. Numerous reports over the past 20 years have documented superior patency and prognosis when multiple arterial grafts are used. The use of the left internal thoracic artery to graft the left anterior descending artery has been widely accepted as the gold standard for surgical treatment of coronary disease for over 40 years. A considerable body of evidence suggests that the right internal thoracic artery behaves in the same way. Radial artery grafts are being studied in several randomized trials, but observational studies suggest a performance comparing favorably with the saphenous vein. The right gastroepiploic artery has been recognized as a suitable and reliable conduit for coronary bypass surgery. However, the use of multiple other arterial grafts is performed in less than 10% of surgical procedures, probably because of perceptions of technical complexity, prolonged time for conduit harvesting, and increased perioperative complications. As a result, most patients with multivessel coronary artery disease do not benefit from extensive revascularization with arterial conduits. The aim of this review is to summarize the current evidence for the extensive use of arterial conduits in the revascularization of multivessel coronary artery disease.

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Glucose spikes after meals induce endothelial dysfunction, which may lead to progression of atherosclerosis and cardiovascular events. Controlling postprandial hyperglycemia should be the potential target for preventing cardiovascular events. In clinical settings, the α-glucosidase inhibitors (α-GIs) glinides are often prescribed to prevent postprandial hyperglycemia. Recent studies have showed that α-GIs may have incretin-like effects and other pleiotropic effects. This review will describe the endothelial function associated with postprandial hyperglycemia, and will discuss the effects of α-GIs on preventing cardiovascular disease.

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Periprocedural myocardial infarction (PMI) is one of the major complications of percutaneous coronary intervention (PCI). We investigated the influence of coronary plaque burden and characteristics on PMI using intravascular ultrasound (IVUS) with radiofrequency-based tissue characterization technology (iMAP). The study population consisted of 33 consecutive patients with stable angina pectoris who underwent PCI. IVUS images were recorded before and after PCI for offline analysis, and coronary flow reserve (CFR) was measured after PCI. PMI was defined as a post-PCI cardiac troponin T elevation > 5 × 99^th percentile of the upper reference limit (0.014 ng/mL). Plaque volume in patients with PMI (n = 12) was significantly greater than that in patients without PMI (n = 21) (240.4 ± 106.0 mm³ versus 152.1 ± 76.9 mm³, P = 0.0096). The iMAP-IVUS analysis demonstrated that the fibrotic, lipidic, and necrotic tissue volume within culprit lesions were also greater in patients with PMI than in patients without PMI (129.4 ± 52.2 mm³ versus 94.6 ± 40.8 mm³, P = 0.041; 26.8 ± 10.5 mm³ versus 15.8 ± 11.5 mm³, P = 0.011; and 81.3 ± 48.4 mm³ versus 40.2 ± 33.6 mm³, P = 0.0071, respectively). Multivariate logistic analysis demonstrated that necrotic tissue volume was the only independent predictor of PMI. Multiple regression analysis demonstrated that the post-PCI CFR values signifi cantly correlated with percent plaque burden, and there were no correlations with the percent tissue burden of each plaque component. In conclusion, the iMAP-IVUS analyses demonstrate that necrotic tissue volume is a potent predictor of PMI. Microcirculatory disturbance after PCI is significantly influenced by percent plaque burden, regardless of plaque compositions.

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The purpose of this study was to clarify the effect of standing balance training on walking speed (short-term outcome) and cardiac events (long-term outcome) in elderly ischemic heart disease (IHD) patients. This was a retrospective cohort study. Ninety-two elderly (≥ 65 years) IHD patients who underwent an inpatient cardiac rehabilitation program were assigned to two groups: a balance group that received standing balance training in addition to conventional (aerobic and resistance) training and a conventional group. Standing balance was assessed by one-leg standing time and a postural stability index reflecting dynamic balance, and normal walking speed was measured at baseline and hospital discharge. Patients were followed for up to 3 years or until a cardiac event occurred. There were no significant differences in clinical characteristics between the groups. Both groups showed a significant change in normal walking speed from baseline to hospital discharge (P < 0.001, respectively), and normal walking speed was significantly higher in the balance group compared to the conventional group (P = 0.001). The postural stability index improved significantly only in the balance group (P = 0.005). Multivariable analyses using Cox proportional hazards model confirmed that standing balance training (hazard ratio [HR]: 0.408; 95% confidence interval [CI]: 0.162-1.029; P = 0.058) and fast walking speed (HR: 0.362; 95% CI: 0.137-0.957; P = 0.041) were associated with cardiac events. These findings show that standing balance training improves walking speed and reduces cardiac events, and suggests that such training can be an effective intervention for elderly IHD patients.

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This study evaluated the clinical impact of Q-wave presence on ECG at presentation of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).
From April 2005 to September 2009, 184 consecutive STEMI patients who underwent primary PCI within 12 hours of chest pain onset were retrospectively evaluated. Patients were grouped according to the presence (Q positive, n = 109) or absence (Q negative, n = 75) of Q waves on initial ECG at emergency room presentation. Major adverse cardiac events (MACE) and stent thrombosis (ST) were evaluated for 2 years. Risk factors for MACE and left ventricular (LV) remodeling by echocardiography were also evaluated.
Baseline characteristics, including reperfusion time and infarct location, were similar between the groups. The MACE rate at 2 years was higher in the Q-positive group (32.1%) than in the Q-negative group (13.3%, P = 0.005). Independent risk factors for MACE were the presence of Q-wave (P = 0.008, Odds ratio 3.139) and no-reflow phenomenon (P = 0.016, Odds ratio, 2.819). LV remodeling was more frequent in the Q-positive group (47.9%) than in the Q-negative (24.5%, P = 0.009) group. Initial Q-wave presence (P = 0.048, Odds ratio 2.380) and anterior wall MI (P = 0.009, Odds ratio, 3.425) were independent risk factors for LV remodeling.
The presence of Q waves in ECG of patients presenting with STEMI undergoing primary PCI provides an independent prognostic marker of clinical outcomes and left ventricular remodeling.

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The association between the urinary albumin-to-creatinine ratio (UACR) and target lesion revascularization (TLR) is unknown in patients who are implanted with drug-eluting stents (DESs) or bare metal stents (BMSs) for the treatment of coronary artery disease. Of 231 Japanese patients who were implanted with DESs and/or BMSs during percutaneous coronary intervention (PCI) between July 2009 and January 2011, 118 underwent follow-up coronary angiography at 6 to 9 months after PCI; 103 were negative for qualitative tests for urine protein: 32 (31.0%)/103 patients underwent TLR for severe in-stent restenosis (ISR) and 71 did not. On the next day after admission to the hospital, first-morning-void spot urine samples were collected to calculate UACR based on urinalysis results. Pearson’s product-moment correlation coefficients indicated positive associations of UACR with late loss as assessed by quantitative coronary analysis in the overall cohort, (r = +0.515, P < 0.0001), the DES subgroup (r = +0.443, P < 0.0001), and the BMS subgroup (r = +0.652, P < 0.0001). The incidence of multivessel lesions was significantly higher (P < 0.05) in the TLR group. UACR was significantly higher (P < 0.01) in the TLR group (23.88 ± 31.8 mg/gCr) than in the control group (6.29 ± 7.46 mg/gCr). Multivariate logistic regression analysis revealed UACR (odds ratio: 1.07; 95% confidence interval: 1.02-1.12; P < 0.01) to be associated with TLR. UACR was suggested to be a potential predictor of TLR required for severe ISR after PCI with coronary stents.

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Whether additional intracoronary acetylcholine (ACH) injections are required for severe coronary spasm without limited coronary flow in the ACH provocation test remains unclear. We used ¹²³I-β-methyl-iodophenyl pentadecanoic acid (¹²³I-BMIPP) to identify myocardial ischemic memory to compare the severity of myocardial fatty acid dysmetabolism among Thrombolysis in Myocardial Infarction (TIMI) grade flow.
Thirteen hypertensive volunteers (mean age, 69.5 years) and 37 patients with VSA (mean age, 62.8 years) were enrolled. The patients with VSA were stratified according to TIMI flow grades of 3 (90% luminal narrowing; n = 12) or TIMI 0-2 (≥ 99% or total occlusion; n = 25) during ACH provocation tests. Two weeks after cardiac catheterization, ¹²³I-BMIPP myocardial scintigraphic images were obtained at 15 minutes (early) and at 4 hours (delayed) after tracer injection. The heart-to-mediastinum (H/M) ratio and washout rates (WR) were calculated from planar images.
The TIMI 3 and TIMI 0-2 groups had significantly lower early and delayed H/M ratios than controls but the difference did not reach significance between the two groups (Early: 2.7 ± 0.5 versus 2.3 ± 0.4 and 2.2 ± 0.3, P = 0.024; Delayed: 2.4 ± 0.4 versus 1.8 ± 0.3 and 1.8 ± 0.3, P = 0.001). The washout rate was greater for TIMI 0-2 than the controls.
The severity of myocardial fatty acid dysmetabolism did not differ between TIMI 3 and TIMI 0-2 coronary spasms. Additional ACH might not be required considering safety and the severity of coronary spams with TIMI 3 grade flow.

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It is unknown whether 12-lead ECG can predict new-onset AF. In the present study, we identified patients with new onset AF from our digitally stored ECG database, and the P wave morphologies were analyzed in their preceding sinus rhythm recordings as the precursor state for AF. The P wave was analyzed in the most recent ECG recording of sinus rhythm preceding new onset AF within 12 months. The duration and amplitude of P waves were analyzed in 12 leads and compared between the 2 groups with the other clinical parameters. The study population consisted of 68 patients with new-onset AF and 68 age and sex-matched controls. Multivariate analysis revealed that the P wave amplitude in leads II and V₁ (0.157 ± 0.056 versus 0.115 ± 0.057 mV, P = 0.032, and 0.146 ± 0.089 versus 0.095 ± 0.036 mV, P = 0.002) and P wave dispersion (56.9 ± 14.8 versus 33.5 ± 12.9 ms, P = 0.001) were significant independent factors for the prediction of new-onset AF. By using these factors, new-onset AF could be predicted with a sensitivity of 69.1% and specificity of 88.2%. P wave analysis is useful for predicting new onset AF.

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The aim of this study was to evaluate temporal changes in brain natriuretic petide (BNP) levels during exercise stress-echocardiography in patients with dilated cardiomyopathy with respect to the left ventricular contractile reserve. We studied 55 consecutive patients with dilated cardiomyopathy (mean age, 55 ± 10 years, 49 (89.1%) male). All patients underwent exercise stress-echocardiography on a treadmill using the modified Bruce protocol. Contractile reserve was assessed by measuring changes in the wall motion score index (ΔWMSI) at rest and and at peak exercise. Levels of BNP were measured at rest, in the first minute, and after 20 minutes following termination of the stress test. Thirty-six patients had preserved left ventricular contractile reserve and 19 patients did not. Patients with preserved left ventricular contractile reserve showed a continuous rise in BNP levels from baseline to peak exercise and to 20 minutes following exertion (83.95 ± 108.51 versus 105.89 ± 116.00 versus 110.95 ± 119.70 ng/L, P < 0.001, respectively). On the other hand, patients without preserved left ventricular contractile reserve showed a decline in BNP levels at peak exercise as compared to baseline (335.49 ± 693.11 versus 320.08 ± 562.60 P = 0.031). ΔBNP was positively correlated with preserved contractile reserve (r = 0.46, P = 0.03) and lower NYHA class (r = -0.65, P = 0.001) in patients in whom baseline LVEF was lower than 20%. Multivariate analysis identified only WMSI at rest (beta -3.365, P = 0.008, 95 CI 0.03 to 0.411) as an independent predictor of left ventricular contractile reserve.
The increase in BNP levels during exercise stress-echocardiography is associated with preserved left ventricular contractile reserve in patients with dilated cardiomyopathy.

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Adjunctive and non-pharmacological therapies, such as heat, for the treatment of heart failure patients have been proposed. Positive results have been obtained in clinically stable patients, but no studies of the use of thermal therapy in patients with decompensated heart failure (DHF) have been reported. An open randomized clinical trial was designed in patients with DHF and controls. We studied 38 patients with a mean age of 56.9 years. A total of 86.8% were men, and 71% had nonischemic myocardiopathy. All participants were using dobutamine, and the median brain natriuretic peptide (BNP) level was 1396 pg/mL. An infrared thermal blanket heated the patients, who were divided into 2 groups: group T (thermal therapy) and group C (control). Group T underwent vasodilation using the thermal blanket at 50°C for 40 minutes in addition to drug treatment. The cardiac index increased by 24.1% (P = 0.009), and systemic vascular resistance decreased by 16.0% in group T (P < 0.024) after thermal therapy. Heat as a vasodilator increased the cardiac index and lowered systemic vascular resistance in DHF patients. These data suggest thermal therapy as a therapeutic approach for the adjuvant treatment of DHF patients.

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Although cross-sectional late-phase reinnervation in heart transplantation (HTx) recipients has been demonstrated by several earlier studies, early-phase successive analyses especially for parasympathetic reinnervation remain unknown. Successive heart rate variability (HRV) data calculated by the MemCalc power spectral density method were obtained from 16 non-rejection recipients 1-24 weeks after HTx. High frequency (HF) level representing parasympathetic magnitude increased significantly at 6 months after HTx (from 0.9 ± 0.7 to 4.1 ± 2.8 ms^2*). Only intraoperative shorter cardiopulmonary bypass time (181 ± 59 minutes) correlated with a higher level of HF at post-HTx 6 months among all baseline variables (r = -0.530^*). Higher level of HF was associated with recovery of tachycardia at post-HTx 6 months (r = -0.514^*). In conclusion, parasympathetic reinnervation emerges along with recovery of tachycardia < 6 months after HTx, which is accelerated by shorter intraoperative cardiopulmonary bypass time (^*P < 0.05 for all).

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This study aimed to assess the predictive effect of soluble ST2 (sST2) and depressive symptoms in patients with heart failure (HF) and to determine whether the prognosis of HF patients with preserved ejection fraction (HFpEF) differs from those with reduced ejection fraction (HFrEF). A cohort of 233 HF patients was followed for 1 year. Depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale. The primary endpoint was all-cause mortality and HF-related hospitalization. For the analysis of survival, the left ventricular ejection fraction (LVEF) cut-offs for defining HFpEF were set at 50%, 45%, and 40%, respectively. With increasing LVEF, levels of sST2 were gradually decreased (45.2 ng/mL, 35.8 ng/mL, and 32.1 ng/mL in patients with LVEF ≤ 40%, 41% to 49%, and ≥ 50%, respectively, P for trend < 0.001), as well as the prevalence of depressive symptoms (35.4%, 33.3%, and 20.4%, respectively, P for trend = 0.022). After 1-year follow-up, 128 patients (54.9%) achieved the primary endpoint and 47 patients (20.2%) died. Depressive symptoms were independent risk factors of all-cause mortality and HF-related hospitalization. The combined presence of elevated sST2 (> 36.0 ng/mL) and depressive symptoms was associated with a 4.9-fold increased risk of the primary endpoint. Regardless of LVEF cut-offs, the associated risk of adverse outcomes in HFpEF was as high as in HFrEF after adjustment for significant risk factors including sST2 and N-terminal pro-brain natriuretic peptide. In conclusion, depressive symptoms provided additional prognostic information to that of sST2 in HF patients. The prognosis of HFpEF patients was similar to that of HFrEF patients.

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Coronary artery spasm after coronary artery bypass surgery may result in life-threatening arrhythmias, circulatory collapse, or death. We report two cases of coronary artery spasm after coronary artery bypass surgery, one of which developed ventricular fibrillation requiring extracorporeal membrane oxygenation support. Both patients were discharged in good condition and are currently followed as outpatients. Unexpected sudden hemodynamic compromise could be due to coronary vasospasm, and this should be considered as one of the possible differential diagnoses. We were able to prevent the lethal consequences seen with coronary artery spasm by early diagnosis and management.

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A 94-year-old woman underwent primary percutaneous coronary intervention for a total occlusion of the right coronary artery. A 6-Fr Ikari-left guiding catheter was inserted through the right radial artery. Initially, thrombectomy was performed with a conventional thrombus aspiration catheter. However, only small fragments of thrombus were aspirated and coronary blood flow was still obstructed. Subsequently, a 4.5-Fr straight guiding catheter was advanced through the 6-Fr guiding catheter into the coronary artery and aspiration was reinitiated. During the course of aspiration, the backflow of the blood was blocked. The inner catheter was pulled back slowly, maintaining suction. Just before it reached the tip of the 6-Fr guiding catheter, another vacuum syringe was attached to the side arm of the Y-connecter of the 6-Fr guiding catheter and additional aspiration with the outer guiding catheter was started. After complete retrieval of the 4.5-Fr catheter from the guiding catheter, thrombus was found in the vacuum syringes from both inner and outer guiding catheters. We consider that this double aspiration, with a mother-child catheter technique, is a simple and effective means of aspirating a larger thrombus, and may prevent the dislodgement of thrombus at the tip of the outer guiding catheter, which could cause systemic embolism.

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The prevalence of aortic stenosis (AS) increases in the elderly. They present high surgical risk due to comorbid factors that increase with age. Transcatheter aortic valve implantation (TAVI) is an effective method in patients who present with severe aortic stenosis with a higher surgical risk or who cannot undergo surgical aortic valve replacement (s-AVR). In our case, the presence of saccular thoracic aortic aneurysm with severe AS, which is a vital co-morbidity, requires the treatment of both. The rise in systolic pressure following the TAVI procedure increases the saccular thoracic aneurysm rupture risk and this is why the timing and method of the two treatments become crucial. In this case, which is as far as we know the fi rst and only report in the literature, both TAVI and endovascular thoracic aortic saccular aneurysm repair were applied simultaneously and successfully to the patient via the same transfemoral route. After 1 month, the patient had good functional capacity and there were no complications in control tomography and echocardiography. In this way, we attempted to emphasize with a multidisciplinary study that the patients be assessed carefully before the procedure, and found that even in patients with common peripheral vascular diseases, a transfemoral route could be used together with the proper methods, and that both procedures could be performed simultaneously.

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Cardiac tumors and tumor-like lesions are uncommon; most are true neoplasms. We here report a case of a pericoronary tumor-like lesion surrounding the right coronary artery in a 39-year-old man who presented with fever and chest pain. Although clarithromycin was administered for 1 week, his fever persisted. Helicobacter cinaedi (H. cinaedi) was isolated from blood cultures and found to be sensitive to ceftriaxone. A computed tomography scan showed a tumor-like lesion with no ¹⁸F-fl uorodeoxyglucose uptake surrounding the right coronary artery. After administration of ceftriaxone, the tumor-like lesion diminished in size according to meticulous computed tomography examinations. We therefore concluded that it was caused by H. cinaedi infection. The patient has been followed up closely for 1 year and remains asymptomatic.

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In cases with metastatic invasion of the heart, electrocardiographic abnormalities are commonly seen. However, most of these electrocardiographic changes are nonspecific; certain findings may be highly suggestive of myocardial involvement of the tumor. We report a patient with lung cancer who presented with persistent ST-segment elevation with coexisting reciprocal changes on electrocardiography due to myocardial invasion of the lung cancer.

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