Imaging technology for coronary artery disease (CAD) has developed in recent years. Several sorts of images are now available for clinical use and they are roughly divided into invasive or non-invasive modality. Invasive, catheter-base, or intravascular devices have some advantages over non-invasive imaging systems. One is that they offer high-resolution images, and another is their real-time image process. Therefore, invasive imaging devices such as intravascular ultrasound (IVUS), optical coherence tomography (OCT), and coronary angioscopy (CAS) are utilized for evaluation of plaque morphology in the culprit lesion, guidance to percutaneous coronary intervention (PCI), or follow-up observation after the intervention. IVUS displays total cross-section of the coronary artery and provides information on vessel remodeling and amount of the plaques. Micron-scale OCT is suitable for close observation of the vessel walls, and CAS can detect thrombus with high sensitivity. In daily practice, IVUS is supplementary to angiograms during PCI procedures. On one hand, OCT and CAS are mainly used as clinical research tools. If non-inferiority of OCT to IVUS is revealed, OCT-guided PCI may be popularized. In case of difficulty in validating lesion characteristics using digital signals on IVUS or OCT images, CAS may help to diagnose the lesion. Intracoronary imaging devices play an important role in detection of vulnerable lesion including vulnerable plaque or stent. It is necessary to understand each image characteristic and to apply the tools properly.

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Imaging technology for coronary artery disease (CAD) has developed in recent years. Several sorts of images are now available for clinical use and they are roughly divided into invasive or non-invasive modality. Invasive, catheter-base, or intravascular devices have some advantages over non-invasive imaging systems. One is that they offer high-resolution images, and another is their real-time image process. Therefore, invasive imaging devices such as intravascular ultrasound (IVUS), optical coherence tomography (OCT), and coronary angioscopy (CAS) are utilized for evaluation of plaque morphology in the culprit lesion, guidance to percutaneous coronary intervention (PCI), or follow-up observation after the intervention. IVUS displays total cross-section of the coronary artery and provides information on vessel remodeling and amount of the plaques. Micron-scale OCT is suitable for close observation of the vessel walls, and CAS can detect thrombus with high sensitivity. In daily practice, IVUS is supplementary to angiograms during PCI procedures. On one hand, OCT and CAS are mainly used as clinical research tools. If non-inferiority of OCT to IVUS is revealed, OCT-guided PCI may be popularized. In case of difficulty in validating lesion characteristics using digital signals on IVUS or OCT images, CAS may help to diagnose the lesion. Intracoronary imaging devices play an important role in detection of vulnerable lesion including vulnerable plaque or stent. It is necessary to understand each image characteristic and to apply the tools properly.

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Background: We analyzed the incidence of angiographically confirmed vasospastic angina (VSA) patients and these coronary risk factors from 1991 and 2009 in a local Ehime prefecture in Japan, retrospectively. Methods and Results: We performed total diagnostic 4435 coronary angiography (CAG), 1307 percutaneous coronary intervention (PCI) and 2244 spasm provocation tests from 1991 and 2009. Angiographically confirmed 624 VSA patients were diagnosed by the definition of transient luminal narrowing >90% and usual chest pain or ischemic ECG changes. We compared the annual incidence of VSA and coronary risk factors from 1991–2000 and 2001–2009. Whereas the number of PCI increased twice and the number of spasm provocation tests decreased in 2001–2009, the total number of VSA diagnosed by angiography increased in 2001–2009 compared with that in 1991–2000 (339 pts vs 285 pts). The value of VSA pts/year significantly increased in 2001–2009 (37.7±11.4 vs 28.5±11.8 pts/year, p<0.01). Variant angina decreased and post PCI patients increased in 2001–2009. The incidence of dyslipidemia was significantly increased in 2001–2009. The values of total cholesterol, triglycerides, low-density-lipoprotein (LDL) cholesterol, fasting blood sugar were also significantly increased in 2001–2009. Conclusions: The frequency of VSA in Ehime has increased. We should pay more attention to coronary artery spasm in the cardiac catheterization laboratory.

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Background: We made a long-term assessment of saphenous vein graft (SVG) neo-intima after coronary bypass (CABG) using intracoronary angioscopy. Methods: Seventy-eight SVGs from 78 patients were assessed after CABG. The patients were divided into two groups: group I consisted of 34 patients whose SVG had yellow plaque of more than grade II; group II consisted of 44 patients whose SVG neo-intima was clear white. Follow-up duration, serum lipid level, type of statin and anti-thrombus drugs, among other factors, were compared between the groups. Results: Age, sex, prevalence of coronary risk factors, and follow-up duration were similar. The serum LDL level (I: 122.3±56.3 vs II: 85.8±26.1 mg/dl) and LDL/HDL ratio (I: 2.93±1.37 vs II: 1.68±0.69) were significantly higher in group I than in group II, whereas the serum HDL level (I: 43.4±11.5 vs II: 54.1±15.3 mg/dl) was significantly lower in group I (P=0.0003) than in group II. More than 85% of patients in both groups received statin therapy, but 88.2% of group I patients were administered a mild statin, whereas 95.5% of group II patients were administered a strong statin. All patients were under aspirin therapy, but additional ticlopidine was prescribed to significantly more patients in group II (I: 14.7% vs II: 70.5%, P<0.0001). On the other hand, additional warfarin therapy was administered significantly more in group I (I: 29.4% vs II: 0.4%, P=0.0351). The incidence of floating white thrombi was significantly higher in group I (I: 27 SVGs, 81.8% vs II: 4 SVGs, 10%, P<0.0001). Conclusion: Intensive lipid-lowering therapy with strong statins could be quite an attractive method of avoiding post-CABG SVG disease. Ticlopidine in addition to aspirin therapy inhibited SVG thrombi, but warfarin had no effect.

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Background: Flow-mediated dilation (FMD) and nitroglycerin-induced dilation (NMD) in the brachial artery are well-known indices for evaluating endothelial function (ECF). The fixed-dose combination of olmesartan, an angiotensin receptor blocker (ARB, 10 mg), and azelnidipine (Ca-channel blocker; CCB, 8 mg: ARB-CCB) might effectively lower blood pressure in patients with uncontrolled hypertension and possibly ameliorate ECF. Methods: To investigate the subacute effect of low dose ARB-CCB on ECF in hypertensive patients uncontrolled by amlodipine (2.5 mg daily), 42 patients were randomly assigned to an amlodipine dose maintenance group with additional behavioral modification such as diet and/or exercise therapy (CTRL group, n=21, age 71±5 years) or to an amlodipine dose maintenance group with the same behavioral modification and an ARB-CCB (ARB-CCB-group, n=21; age 70±7 years). Before and after 4 weeks of therapy, FMD and NMD were measured in both groups. Results: Although the baseline FMD was not different between the two groups, FMD increased in the ARB-CCB group (2.89% ± 0.77% to 4.01% ± 1.08%, P<0.01), whereas no significant change was seen in the CTRL group (3.01% ± 0.53% to 3.08% ± 1.22%, NS). Changes in NMD did not differ between the two groups. Blood pressure was decreased significantly more in the ARB-CCB group than in the CTRL group. Conclusions: The addition of even a low dose of a fixed-dose combination of olmesartan and azelnidipine had a significant ameliorating effect on ECF subacutely, suggesting that this combination might have both antihypertensive and anti-atherosclerotic effects in hypertensive patients.

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Background: Ischemic cardiomyopathy (ICM) is defined as diffuse akinesis of the left ventricle (LV) due to chronic myocardial ischemia. Due to poor prognosis by isolated coronary revascularization, surgical ventricular restoration (SVR) had been developed. Surgical strategy for ICM was studied by our experiences over 12 years. Patients and methods: Between 2000 and 2012, 173 patients with ICM underwent surgery. The NYHA functional class was in class III for 97 and IV for 76. Since 2005, speckle-tracking echocardiography was applied to determined accurate akinetic area. The patients were followed up for a mean of 41.3±37.1 months up to139 months. Results: SVR was performed for the anterior wall in 150 patients and for the posterior in 23. Hospital death was 6 in 149 elective operations and 5 in 24 emergent operations. After SVR, the NYHA functional class improved to class I–II in 107 patients. The late death occurred in 33 patients. The five- or ten-year overall survival rate was 66.7% or 55.9%, respectively. Since 2005, the five-year survival rate improved to 80.1% after introduction of speckle-tracking echocardiography (P=0.0106) due to effective reduction of LV volume. The LV end-systolic volume index (LVESVI) became less than 100 ml/m² in 74 patients (Group-S) and greater than 100 ml/m² in 33 patients (Group-L). In Group-S, the five- or ten-year survival rate was 81.7% or 75.5%, while in Group-L, the five-year survival rate was 45.0% with significant poor outcome (P<0.0001). Multivariate analysis showed that post-operative LVESVI (<100 ml/m²) and tricuspid annuloplasty due to tricuspid regurgitation were independent risk factors for long-term survival (LVESVI: hazard ratio 4.7058; 95% confidence interval 1.3490–16.4156; P=0.0151, tricuspid anuloplasty: hazard ratio 3.1059; 95% confidence interval 1.6545–5.8308; P=0.004), while no statistical differences in mitral valve surgery, coronary artery bypass grafting or three kinds of SVRs. Conclusion: For patients with ICM, accurate detection of myocardial lesion by speckle-tracking echocardiography is very important for SVR. Effective volume reduction contributes to a better long-term survival.

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Background: We sometimes experience the negative acetylcholine (ACh) findings in young rest angina patients irrespective of a strong suspicious VSA patient. We compared the positive frequency of provoked spasm by ACh test in rest angina patients between <40 years old and ≥40 years old. Methods and Results: We performed ACh spasm provocation tests during 22 years (1991–2012) in 1440 patients including 380 rest angina patients. We classified these 380 patients into two groups consisting of 12 younger patients (<40) and 368 older patients (≥40). We compared the coronary risk factors and spasm positive rate between the two groups. There was no difference concerning the coronary risk factors and organic stenosis between the two groups, while spasm positive rate by ACh was significantly lower in younger group than the older group (33.3% vs 71.5%, p<0.05). In advanced age, hypertension and diabetes mellitus increased. The cumulative coronary risk factors in younger group were significantly lower than those in older group. Positive spasm was obtained in one patient by ergonovine (ER) test and in 3 patients by adding ACh after ER test. Provoked spasm positive rate in younger group became similar to that in older group by performing sequential spasm provocation tests (66.7% vs 71.5%, ns). Conclusions: We recommend performing sequential spasm provocation tests in young rest angina patients.

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The patient was 13 years old boy. He woke up early in the morning at 5 o’clock because of chest oppression on September 10, 2011. He had sometimes chest oppression on dynamic exercise since 11 years old. His cardiac echocardiogram showed decreased percent fractional shortening at the near clinic. Long-acting calcium channel antagonist was administered in the morning once a day. Two weeks later, his percent fractional shortening on echocardiogram dramatically improved and also his chest discomfort on both rest and effort decreased about a half level. However he had residual chest oppression on exercise. Cardiac catheterization was performed under no medication at least 48 hours. Coronary angiogram showed no fixed stenosis. Intracoronary administration of acetylcholine caused diffuse narrowing on the right coronary and the left anterior descending artery accompanied by significant ECG changes and his chest pain. Intracoronary administration of ergonovine did not cause spasm or no chest pain/ECG changes. Adding intracoronary administration of acetylcholine after ergonovine injection caused severe spasm on the left anterior descending artery and the left circumflex artery (so called as withered branch), accompanied by severe chest pain/cold sweating and significant ECG changes. He was diagnosed as multiple coronary spastic angina.

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We present a case of an anomalous right coronary artery (aRCA) from the left sinus of Valsalva, which is a rare congenital anomaly. A 69-year-old man was evaluated in our hospital for precordial discomfort. On coronary angiography, the left coronary artery was normal and there was good collateral connection from the left anterior descending artery to the right coronary artery (RCA). The existence of the collateral artery suggested a severely stenotic or occlusive RCA, but the orifice of RCA was not detectable by various diagnostic catheter procedures and aortography. Multislice computed tomography (MSCT) revealed a totally occlusive lesion at the proximal portion and significant diffuse narrowing in the mid to distal portion or aRCA. Percutaneous coronary intervention for aRCA was undertaken with reference to the MSCT findings. In this case, MSCT was very useful to detect aRCA and as a convenient complementary tool for the intervention.

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We describe a rare case of coronary spastic angina (CSA) causing myocardial stunning with reversible wall thinning and motion abnormality of the left ventricle (LV). A 70-year-old woman presented with sudden resting angina. A 12-lead electrocardiogram showed typical ST-T changes of acute myocardial infarction. Although left ventriculography revealed akinesis from the apex to the mid-anterior LV, urgent coronary angiography did not show an obstructed coronary artery. Cardiac magnetic resonance imaging (MRI) identified thinning of the anterior wall in the akinetic region, without any late gadolinium enhancement. Cardiac single photon emission computed tomography (SPECT), using ¹²³iodine beta methyl-iodophenyl pentadecanoic acid (¹²³I-BMIPP) and ²⁰¹thallium (²⁰¹Tl), showed a mismatch congruent with the akinetic region. An acetylcholine provocation test performed during hospitalization revealed multivessel coronary spasms in all 3 epicardial arteries. After initiation of treatment with coronary vasodilators, the wall thinning and motion abnormality gradually recovered to the normal range. In the present case, CSA caused myocardial stunning associated with reversible wall thinning and motion abnormality in the acute phase. CSA can occasionally lead to two conditions associated with LV wall abnormalities: myocardial infarction and stunning. Although the findings of the 2 conditions are similar in the acute phase, stunning can be differentiated from infarction using multiple imaging modalities. Cardiac MRI and SPECT are useful tools for determining whether the myocardium is infarcted or stunned.

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Three surgical cases of acute ventricular septal perforation (VSP) successfully repaired with flat and conic patches are reported. The first case was a 58-year-old man who had undergone a double patch closure with two flat patches for VSP following acute myocardial infarction. On the third postoperative day, however, a redo operation became necessary due to recurrent VSP, and in this surgery flat and conic patches were used. The second and third cases were 82-year-old and 81-year-old women, respectively, who from the first underwent VSP closures with flat and conic patches. Although in the third case the patient died of hypoxic ischemic encephalopathy 2 months after operation, the others recovered well and were discharged at 2 months. Our procedure consists of an infarct exclusion technique and a double patch technique. The flat patch is for directly covering the infracted ventricular septum including the VSP through a left ventriculotomy. The conic patch is for three-dimensionally lining the infracted endocardium of the left ventricle. Similar procedures applying the same concept have been reported as effective for repairing acute VSP. The combination of both an infarct exclusion technique and a double patch technique can be thought of as an ideal strategy and our procedure provides one such option.

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