We report the outcome of patients supported with the Impella device at our institution. Similar to the interim analysis of J-PVAD registry presented at the 84th Annual Scientific Meeting of the Japanese Circulation Society, we observed a worse outcome in patients with AMI cardiogenic shock who received late Impella support. It is also important to highlight that only one patient of this cohort received Impella support before reperfusion at our institute. A door to unloading strategy as opposed to one emphasizing door to balloon combined with earlier initiation of Impella support seems promising¹⁾ and it the creation of a system that embraces door to unloading which is both our institute’s challenge and opportunity to improve outcomes.

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Racial differences regarding coronary vasomotion disorders between Caucasian and Japanese populations are controversial. In the past, coronary epicardial spasm was more often recognized in Japanese people than in Caucasian populations. In contrast, coronary microvascular dysfunction is typically observed in Caucasian patients. Japanese cardiologists perform spasm provocation testing actively in patients with unobstructive coronary artery disease, whereas Caucasian cardiologists except for those in some special institutions may skip coronary reactivity testing in the cardiac catheterization laboratory if they encounter patients with unobstructive coronary artery disease. In this review, we present the racial and ethnic disparities in the incidence and clinical characteristics between Caucasian and Japanese populations with coronary vasomotion disorders.

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A less invasive method of pressure guidewire-free image-based fractional flow reserve (FFR) computation has been developed and investigated comprehensively. Quantitative flow ratio (QFR) is one of the image-based FFR computed using three-dimensional quantitative coronary angiography and estimated flow velocity. Several studies, including meta-analyses have reported that QFR had a good diagnostic accuracy compared with wire-based FFR as reference standards, and was rapidly computed for approximately 5 minutes per vessel. Furthermore, the diagnostic performance of QFR to detect myocardial ischemia has been found to be comparable with that of other modalities, such as instantaneous wave-free ratio, myocardial perfusion imaging and FFR derived from computed tomography (FFR-CT).
Considering the advantages of QFR compared with wire-based FFR, i.e. (1) less invasive, (2) acceptably accurate, and (3) quickly computed, QFR may be potentially preferred in clinical applications for specific situations, such as risk stratification in multivessel disease, non-culprit lesion assessment in ST-segment elevation myocardial infarction (STEMI), strategic guidance for percutaneous coronary intervention (PCI), and post-PCI lesion assessment.
This review article highlights the current usage, clinical implications, and future perspectives of angiography-derived FFR, particularly QFR, one of the primary computations investigated in this field.

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Objective: Atrial fibrillation (AF) is the most common arrhythmia after coronary artery bypass grafting (CABG) even if off-pump procedure is used. Although β-blockers or atrial pacing have been reported to be effective for the prevention of postoperative AF, the efficacy of combination with β-blockers and atrial pacing is still controversial. The purpose of this study was to elucidate the effect of intravenous landiolol infusion with temporary right atrial pacing on the prevention of AF after off-pump CABG. Methods: A prospective observational study was designed to compare 28 consecutive patients who were administered landiolol combined with temporary right atrial pacing to 24 consecutive patients who received landiolol without pacing. All patients received landiolol intravenously to maintain their heart rate at 60-80 bpm immediately after surgery until oral carvedilol intake. Atrial pacing was commenced at a rate of approximately 90 bpm and the dose of landiolol was reduced while ensuring that the intrinsic heart rate did not exceed the pacing rate. The primary endpoint was the incidence of AF. Results: The incidence of postoperative AF in both groups was not different (17.9% vs.12.4% respectively, p=0.602). The dose of landiolol in patients with pacing was significantly lower compared to those without pacing (4.0 γ vs. 6.4 γ respectively, p < 0.05). Conclusions: Temporary right atrial pacing did not have an additive effect on landiolol to prevent the incidence of AF after off-pump CABG. On the other hand, it enabled a reduction in landiolol dose, which might contribute to reducing any adverse effects caused by landiolol.

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Acute myocardial infarction (AMI) with cardiogenic shock (CS) has poor prognosis, despite using mechanical circulatory support devices. An 85-year-old woman with ST-elevation myocardial infarction (STEMI) was transferred to our hospital. STEMI was caused by plaque rupture of the left main trunk (LMT) along with CS and aborted myocardial damage. She suffered cardiopulmonary arrest despite intra-aortic balloon pumping (IABP) support. Veno-arterial extra corporeal membrane oxygenation (VA-ECMO) and Impella CP were immediately inserted to support the circulation and left ventricular unloading. Then she underwent percutaneous coronary intervention (PCI) and managed to survive. Transthoracic echocardiogram in the subacute phase revealed a preserved left ventricular systolic function though the culprit lesion was in LMT and the area at risk for myocardial infarction was extremely large. Left ventricular unloading using Impella CP could contribute to preservation of cardiac function and diminishing of myocardial damage.

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Intravascular ultrasound (IVUS) catheter is a user-friendly imaging device widely used during percutaneous coronary intervention (PCI). However, IVUS catheter entrapment is an infrequent but serious complication associated with PCI. Case 1 was an 87-year-old woman on hemodialysis who had non-ST elevation myocardial infarction with total occlusion in the middle left anterior descending artery (LAD). PCI was performed with two drug-eluting stents (DESs) under IVUS guidance, but the IVUS catheter was entrapped at the implanted stent, leading to stent deformation. Case 2 was an 86-year-old woman on hemodialysis who had stable angina with severe calcified stenosis in the middle LAD. IVUS-guided rotational atherectomy was performed, but the IVUS catheter was stuck in the implanted DES with stent deformation. In both patients, we attempted to use a 0.010-inch guidewire and compatible balloon catheter system that can pass through a 6-Fr guide catheter simultaneously with the IVUS catheter, and the entrapped IVUS catheters were successfully removed from the implanted stents. This retrieval method is very convenient to apply during bailout and should be recommended especially in PCI using a 6-Fr guide catheter.

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