The technical and device refinements in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) has achieved the improvement of outcome in patients with coronary artery disease (CAD). Optimal revascularization methods (PCI or CABG) for severe CAD such as multivessel and / or left main CAD is still in debate in the current clinical practice. In this review, therefore, we discuss the current status of coronary revascularization and outcome in patients with severe CAD on the basis of the evidence of clinical trials in DES era.

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Although the anti-platelet therapy is a standard for a patient with acute coronary syndrome with or without coronary intervention, oral anticoagulant has not been used for long time. Several trials demonstrated the beneficial effects on the prevention of reinfarction or stroke, but the risk of serious bleeding increased. Furthermore, good adherence and control of oral anticoagulant were necessary to improve the clinical outcome. So, oral anticoagulant has not been used for the patients with acute coronary syndrome; however, direct thrombin inhibitor or direct anti-Xa have been proven to be equivalent or even better to warfarin in stroke prevention for patients with atrial fibrillation (AF). These new oral anticoagulant (NOAC) has been tested in patients with acute coronary syndrome, and showed the normal dose of NOAC for stroke prevention with dual antiplatelet increased the bleeding risk, but reduced dose of NOAC might be beneficial for the secondary prevention. This combination of anticoagulant and DAPT is especially interested, because of the anti-thrombotic regimen for patients with AF and coronary heart disease who are treated by stent. Triple therapy (warfarin and DAPT) increased bleeding complication and major cardiovascular events compared to dual therapy (warfarin and single anti-platelet) in stable coronary artery disease; however, no trials in acute coronary syndrome are available right now. Furthermore, no data are available in NOAC. Until then, the appropriate combination of NOAC and anti-platelet would be chosen by the physician who assessed the risk of bleeding and thrombosis for each patient.

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Identification of high-risk coronary plaques is important for management of patients with coronary artery disease (CAD) to prevent future cardiovascular events including death, heart failure, and fatal myocardial infarction. Many studies have described the characteristics of coronary plaques and their clinical outcomes, based on invasive intravascular coronary imaging. Recent technical advancements in multi-slice computed tomography, positron emission tomography, and magnetic resonance imaging (MRI) provide methods for less invasive detection of high-risk coronary atherosclerosis. Our research has focused on understanding the development of coronary atherosclerosis and its clinical outcomes using non-contrast T1-weighted MRI (T1WI), which is non-invasive and does not require the use of ionizing radiation or iodide contrast medium. We have shown that coronary high-intensity plaques (HIPs) detected by non-contrast T1WI are associated with high clinical risk, and therefore might have potential applications in monitoring pharmacological interventions and advancing preemptive medicine in CAD patients. However, the histopathological and molecular mechanisms underlying coronary HIPs remain undetermined. Future studies using a combination of multi-modality images and molecular analysis may facilitate an improved understanding of the molecular dynamics of coronary HIPs.

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Background:It has been reported that various types of vulnerable plaque can cause acute myocardial infarction (AMI). The diagnosis of vulnerable plaques using coronary computed tomography angiography (CCTA) has not been established. We evaluated the plaque characteristics on CCTA in subjects who developed AMI more than 30 days after the CCTA was performed. Methods and Results: The subjects were 31 consecutive patients (M/F=29/2, 67±10 yrs, period to AMI onset, 559±490 days, known CAD: 16) who developed AMI more than 30 days after the CCTA examination. Culprit lesions were observed in the LMT in 2 patients, RCA in 11, LAD in 12 and LCX in 6. No significant stenosis (≤50%) could be found in 24 (77.4%) patients. Positive remodeling (PR: remodeling index >1.1) was found in 24 (77.4%) patients and low-density plaque (LDP: CT values ≤50 HU) was found in 17 (54.8%). Calcification was spotty in 9 patients, moderate in 12, severe in 4 and absent in 6. The period to AMI onset tended to be shorter in patients with ≥75% stenosis, and the patients in the PR(+) group were significantly younger. Vulnerable plaques identified by CCTA were classified into 4 types: Type I (PR(+) and LDP(+)) in 17 (54.8%) patients, Type II (PR(+) and LDP(−)) in 7 (22.6%), Type III (PR(−) and LDP(−)) in 4 (12.9%), and Type IV (PR(−) and severe calcification) in 3 (9.7%). Conclusions: AMI arose from plaques with various manifestations on CCTA, but as many as about half of the AMI events were derived from Type I (PR(+) and LDP(+)) plaques in younger patients.

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Objective : Coronary artery disease ( CAD ) frequently coexists with aortic stenosis ( AS ). During surgical aortic valve replacement, concomitant coronary artery bypass grafting is recommended in patients with significant CAD. However, the management of CAD in patients undergoing transcatheter aortic valve implantation ( TAVI ) is undetermined. Materials and Methods : We analyzed 120 consecutive patients who underwent TAVI between April 2010 and February 2015 in our hospital. Significant CAD was defined as unrevascularized significant coronary artery stenosis. Results : Of 120 patients, 34 ( 28% ) had significant CAD. Thirty-day outcomes were similar between patients with CAD and those without CAD. Among 34 patients with CAD, 15 ( 44% ) underwent percutaneous coronary intervention ( PCI ). PCI was performed safely, except one case of coronary dissection necessitating additional coronary stenting. The clinical outcomes at 30 day were the same in TAVI+PCI group and isolated TAVI group. Ischemic burden evaluated by SYNYAX score ( SS ) and Duke Myocardial Jeopardy Score ( DMJS ) were significantly alleviated by PCI ( SS : 7.2 ± 2.9 vs 0.5 ± 1.1, p < 0.01. DMJS : 5.3 ± 2.8 vs 0.4 ± 0.8, p < 0.01 ). Conclusion : Significant CAD was found in 28% of patients undergoing TAVI. PCI can be performed safely, and significantly alleviates the ischemic burden of CAD.

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A patient who had previously undergone coronary artery bypass grafting presented to our institution with severe coronary insufficiency and colon cancer. We performed two-stage minimally invasive direct coronary artery bypass grafting and simultaneous colectomy. The operative technique is detailed, and justification of the two-stage procedure and simultaneous approach in such patients is discussed.

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Left ventricular free wall rupture is a catastrophic complication following an acute myocardial infarction. The optimal therapeutic strategy is poorly defined. Herein we report a surgical treatment for a postinfarction blow-out type rupture of the left ventricle free wall in a 78-year-old male patient. Direct closure with Teflon felt strips and covering with a fibrin sheet and bovine pericardial patch, to which gelatin-resorcinol-formaldehyde glue was applied, were performed for the ruptured lesion. The patient survived the surgical intervention, although he had hypoxic ischemic encephalopathy probably due to cardiopulmonary arrest occurring at the time of transfer to our hospital.

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