Background: Aortic arch calcium (AAC), which is frequently detected on ungated lung computed tomography (CT) due to a large field of view, can serve as a marker of subclinical atherosclerotic burden. Our study sought to validate novel cardiac screening metrics of subclinical atherosclerosis by evaluating the inter- and intra- observer reproducibility of AAC measurements with ungated lung CT.
Methods: The authors randomly selected 100 ungated lung CT scans from the Multi-Ethnic Study of Atherosclerosis cohort. A Bland-Altman plot analysis was used to test inter- and intra-reader reproducibility, after measuring the total arch calcium score and arch calcium volume.
Results: The intra-reader reproducibility for the total arch calcium score and arch calcium volume in all subjects was excellent at 99% and 97%, respectively. The inter-reader reproducibility for the total arch calcium score and volume in all subjects was similarly excellent at 97% and 96%, respectively.
Conclusions: The high reproducibility of ungated lung CT suggests a potential new method of stratifying the atherosclerotic cardiovascular disease risk among patients undergoing lung CT without requiring additional scanning. This methodology helps promote routine reporting of AAC and coronary artery calcium based on millions of ungated CT images acquired for lung screening purposes.

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Background: Some cardiologists perform vasoreactivity testing on the left coronary artery (LCA) or the right coronary artery (RCA) alone.
Objectives: We retrospectively analyzed the incidence of epicardial spasm (ES) and coronary microvascular spasm (CMS) in Japanese patients with unobstructed coronary artery disease on both coronary artery testing.
Methods: A total of 716 consecutive patients (241 women, mean age 64.3 ± 10.6 years old) who underwent first diagnostic angiography for suspected myocardial ischemia and who had unobstructed coronary arteries (< 50%) were enrolled. For all 716 patients, complete acetylcholine (ACh) testing was performed on both coronary arteries without the administration of nitroglycerine to relieve any provoked spasm in the first artery tested. ES was defined as ≥ 90% stenosis, usual chest symptoms, and ischemic electrocardiogram (ECG) changes, while CMS was defined as < 75% stenosis, usual chest symptoms, and ischemic ECG changes.
Results: Negative spasms for ACh tests were diagnosed in 370 patients (51.7%), whereas the ACh test revealed positive spasms in 346 patients (48.3%), including 314 ESs and 36 CMSs. We obtained positive ES results in 67 patients (9.4%) with only their LCAs, while we obtained positive ES results in 110 patients (15.4%) with only their RCAs. Both the RCA and LCA showed negative ES results in 402 patients (56.1%), whereas both showed positive ES results in 137 patients (19.1%). In contrast, 10 patients (1.4%) had CMS in just their RCA, while 22 patients (3.1%) had CMS in just their LCA. Both the RCA and LCA showed negative CMS results in 680 patients (94.9%), whereas both showed positive CMS results in 4 patients (0.6%).
Conclusions: We found heterogeneity in ACh testing results in the clinic because some cases were positive for the LCA while some were positive for the RCA alone.

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Objects: Surgical site infection (SSI) remains a major morbidity in patients undergoing cardiovascular surgery. This study evaluated the efficacy of subcutaneous suction drainage in decreasing the risk of SSI of the sternal wound in off-pump coronary artery bypass grafting (OPCAB).
Materials and methods: We invested 106 patients, including 25 women (mean age 70.3 ± 9.6 years old), who underwent OPCAB. Patients were categorized into those with subcutaneous suction drainage of the sternal wound (S group, n = 73) and those without subcutaneous suction drainage (N group, n = 33), and their data were analyzed.
Results: Compared with the N group, the S group had a lower incidence of SSI (N vs. S: 9.1% vs. 0.0%, p = 0.029) and significantly shorter hospitalization duration (N vs. S: 23.2 ± 10.5 vs. 16.6 ± 5.7 days, p < 0.001). No bacteria were isolated from patients with SSI. Patients with SSI were treated and completely cured with continuous negative-pressure wound therapy.
Conclusions: Recent approaches to SSI prevention that include a subcutaneous suction drainage system can result in better outcomes by reducing the risk of SSI after OPCAB.

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Objective: Several studies have described predictors for the late development of neoatherosclerosis (NA). However, predictors for the early development of NA after newer generation drug-eluting stent (DES) implantation are unknown. We investigated predictors for the eight-month development of NA using optical coherence tomography (OCT). Patients and methods: We enrolled 117 consecutive patients (134 lesions) with second- and third-generation DESs with findings available for baseline and 8-month follow-up OCT. The lesions were divided into two groups: those with and without NA at eight-month follow-up OCT. NA was defined as lipid neointima including a thin-cap fibroatheroma that was defined as fibroatheroma with fibrous cap of < 65 μm or calcified neointima. Results: NA was detected in 9.0% of all lesions at follow-up. A smoking history and irregular in-stent protrusions (IPs) at post-stent OCT were independent predictors of the eight-month development of NA. A receiver operating characteristic curve revealed that the predictive cut-off value of maximum IP for early development of NA was 80°. In a segmental analysis, the prevalence of segments with NA from segments with IPs was significantly higher than that from segments without IPs (4.2% vs. 0.8%, P < 0.001). Conclusions: IPs at post-stent OCT and a smoking history may be predictors of the eight-month development of NA after second- and third-generation DES implantation. On the serial comparison of OCT findings, early NA showed positional correlation with IPs on post-stent OCT.

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Aortocoronary dissection is an infrequent yet potentially lethal complication of coronary angiography or percutaneous coronary intervention (PCI). Treatment strategies include conservative management, stent implantation, and surgical intervention. We herein report a case of iatrogenic aortocoronary dissection during PCI of the right coronary artery successfully treated by conservative management. Conservative treatment may be a potential alternative to surgical treatment for iatrogenic aortocoronary dissection with limited extension when the patient’s clinical condition is stable under strict hemodynamic management.

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Unprotected left main trunk coronary artery-acute myocardial infarction (ULMCA-AMI) is difficult to treat, even with the widespread use of reperfusion therapy, because of the extensive myocardial damage it causes. Impella^®, a percutaneously inserted left ventricular (LV) assist pump, may help prevent cardiogenic shock (CS) due to ULMCA-AMI by facilitating cardiac rest and enhancing LV unloading. We herein report three patients with ULMCA-AMI and CS who underwent Impella^®-assisted revascularization. One patient experienced CS during revascularization despite intra-aortic balloon pump placement, and another patient had impending cardiopulmonary arrest upon arrival at the hospital and had inadequate time to undergo coronary angiography. In both cases, simple stenosis in the left main coronary artery (LMCA) was the culprit lesion, and Impella^® insertion successfully prevented CS, avoided LV remodeling, and resulted in good outcomes. However, preventing CS in the remaining case was difficult despite Impella insertion, and veno-arterial extracorporeal membrane oxygenation was initiated. In this case, the culprit lesion was in the LMCA, with collateral vessels in the right coronary artery, which may have been associated with both LV and right ventricular (RV) systolic dysfunction. Impella^®, which is an LV assist pump, may therefore not have provided adequate support. Complete revascularization was not possible in this case, and the patient ultimately died. Impella^® for ULMCA-AMI is expected to preserve the hemodynamic stability and enable myocardial protection with complete revascularization. Nevertheless, Impella^® alone may provide insufficient support in cases of ULMCA-AMI with RV dysfunction.

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Myocardial infarction (MI) can be provoked by various conditions including blunt chest trauma or stress. We herein report a case of traumatic pneumothorax of the right side in which ST-segment elevation MI developed later, probably due to stress after trauma. A 63-year-old man presented with chest pain after trauma. Pneumothorax of the right chest accompanied by an 8th right rib fracture was confirmed on chest computed tomography. Although electrocardiography was considered nonspecific on presentation, at 40 minutes after presentation, prominent ST-segment elevation in the precordial and lateral leads were noted. A diagnosis of anterior acute MI was made. Emergency coronary angiography, performed after the insertion of a chest tube into the right chest cavity, revealed total occlusion of the left anterior descending coronary artery. Coronary recanalization was obtained by thrombus aspiration and stent implantation. The clinical course was uneventful. The present case highlights the importance of recognizing trauma not only as a direct trigger but also as an indirect trigger of acute MI.

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Although transcatheter aortic valve replacement (TAVR) is widely used, it remains challenging for patients with severe aortic stenosis (AS) concomitant with coronary artery disease (CAD). The guidelines recommend percutaneous coronary intervention (PCI) prior to TAVR only if the left main (LM) or the proximal left anterior descending (LAD) artery is extensively occluded. However, the priority order of these interventions (i.e. PCI and TAVR) remains undefined in AS patients with severe stenosis of other epicardial arteries. In this paper, we reported two representative AS patients complicated with severe stenosis in the middle part of the right coronary artery (RCA). One patient had entered hemodynamic collapse immediately after plain old balloon angioplasty for the culprit lesion where a vulnerable plaque existed. In the other patient with AS, non-ST-elevated myocardial infarction (NSTEMI) occurred after TAVR in the middle part of the RCA, which was treated conservatively. These two cases suggest that the essential indication for revascularization should be limited to the LM lesion and proximal LAD only, as recommended in the guidelines. However, if coronary artery access after TAVR is anatomically complex and difficult, and if the coronary supply is large enough to affect hemodynamics, PCI prior to TAVR should be considered. During PCI, maximum effort should be made to examine vulnerable plaques with imaging devices, reduce the risk of slow flow with distal protection, and prepare for temporary mechanical circulatory support.

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