Residual cardiovascular risks under statin therapy suggest the need to develop additional therapeutic approach to further improve cardiovascular outcomes. Epidemiological and intravascular imaging studies have revealed the relationship of these lipid targets with atherosclerotic cardiovascular disease, indicating triglyceride and high-density lipoprotein cholesterol (HDL-C) as potential targets for achieving better clinical outcomes. However, clinical efficacy of lowering triglyceride and raising HDL-C level has not been established yet. Although findings from clinical trials testing novel agents targeting these lipid markers are disappointing, further search still continues to identify effective therapeutic approach due to their anti- or pro-atherogenic properties. Intravascular imaging modality has contributed to the elucidation of disease mechanism and the evaluation of novel drugs modulating triglyceride and HDL-C. In this review, anti- or pro-atherogenic properties of triglyceride and HDL-C, its association with clinical outcomes and atherosclerotic plaques will be summarized.

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Although the incidence of in-hospital death from acute myocardial infarction (MI) is about 5%, about 40% of the patients who suffer acute MI die mainly before hospitalization. It takes days to weeks from the time of coronary plaque rupture to the onset of acute MI in half of acute MI patients, although it takes only a day for the rest half of the patients. It is also known that a half of acute MI patients have pre-infarction angina days to weeks before the onset of acute MI. This symptom of unstable angina is often disregarded by the patients because it is often a mild chest pain or heartburn of short duration.
However, if we can treat all of those pre-infarction angina patients properly, we can prevent them from suffering MI and reduce the number of MI patients into half. In order to make those patients with pre-infarction angina go to hospital, “STOP MI campaign” has been started by The Japanese Circulation Society.

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Percutaneous coronary intervention is the first choice for treatment of a simple coronary artery lesion due to the progress of coronary stents in recent years. In contrast, patients with multiple, diffuse and severely diseased coronary lesions must undergo coronary artery bypass grafting (CABG); these patients also often have multiple comorbidities and severe preoperative conditions. Off-pump CABG has been developed to lessen the complications caused by the use of cardiopulmonary bypass, as cardiopulmonary bypass is considered more risky in patients with multiple atherosclerotic diseases. The necessity for off-pump CABG may increase in the future, as it is expected that patients with more severe atherosclerotic disease will be candidates for CABG with further progress of coronary stent techniques. This review aimed to investigate the safety and efficacy of off-pump CABG as a standard revascularization strategy.

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Directional coronary atherectomy (DCA) was developed in 1990 in the USA and expected to reduce the abrupt closure rate and the late restenosis of balloon angioplasty. However, the first large randomized clinical trial (CAVEAT study)¹⁾ failed to demonstrate the superiority of DCA compared to balloon angioplasty. Coronary stents became available in 1994 and were widely accepted, because stenting was simple, easy to perform, and effective. In addition, after the drug-eluting stent became available, DCA device users declined with the DCA catheter removed from the device market in 2008. On the other hand, there were some Japanese cardiologists, who strongly desire to revive the DCA device. They reported in 2007 that DCA was useful for limited patients, especially for bifurcated lesions including left main trunk (PERFECT Study)¹⁰⁾. A new DCA catheter has been developed by NIPRO Corporation (Osaka, Japan) and was approved by the Japan Ministry of Health, Labor and Welfare in December 2014. This article introduces the newly developed DCA catheter and considers the role of this device in the drug-eluting stent era.

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Background: In-stent neoatherosclerosis (NA) is a cause of late stent failure. Late stent failure remains a challenging issue after stenting, and its causal mechanism has not been elucidated. Objectives: The aim of this study was to investigate the clinical characteristics of late stent failure with or without NA by optical coherence tomography (OCT). Methods and results: Among 179 patients who had undergone coronary stent implantation (bare metal stent and drug-eluting stent), 22 patients experienced late stent failure with and without NA identified by OCT. The presence of lipid-laden plaque or calcification inside the stent was defined as NA. The 22 patients were divided into two groups according to OCT images: 13 patients with NA (NA group) and 9 patients without NA (non-NA group). OCT analysis also showed that thrombus was more frequently observed and maximum intimal thickness was significantly larger in the NA than in the non-NA group (35.7 % vs 0.0 % and 1.26 mm vs 0.98 mm, p<0.05, respectively). In terms of characteristics, in-stent restenosis lesions and use of oral anticoagulants occurred at a lower frequency, and the minimal lumen diameter was significantly smaller in the NA group than in the non-NA group (7.7 % vs 44.4 %, 0.0 % vs 66.7 %, and 0.33 mm vs 0.83 mm, p<0.05, respectively). Conclusion: In-stent restenosis and use of anticoagulants may be associated with the mechanism of in-stent neoatherosclerosis.

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Background: Diabetes is one of the most frequent comorbidities in patients undergoing coronary artery bypass grafting (CABG). Today, half of the patients who need CABG suffer from diabetes. Those patients tend to present poor prognosis as compared with nondiabetic patients. However, the most influential factor in surgical outcomes of CABG patients with diabetes remains unclear. The purpose of this study was to identify risk factors that contribute to poor post-CABG prognosis in patients with diabetes. Methods: A total of 1,139 patients underwent CABG from January 2000 through July 2015. Of those patients, 599 patients had diabetes (DM group), and the other 540 patients did not (non-DM group). We retrospectively investigated early and late clinical outcomes between the 2 groups. In the DM group, multivariable analysis was performed to identify the risk factors for survival. Results: The diabetic patients had more incidents of comorbidities than the nondiabetic patients. However, hospital mortality after CABGs between the two groups was similar even though the incidence of deep sternal infection, renal failure, and respiratory failure were higher in the DM group than in the non-DM group. All-cause mortality during follow-up was significantly higher in the DM group. The predictors of poor prognosis for diabetic patients after CABGs were old age, peripheral vascular diseases, severity of carotid atherosclerosis, and hemodialysis, not the number of arterial grafts used. Conclusions: Poor prognosis factors after CABGs in diabetic patients were concomitant chronic renal failure and advanced atherosclerosis. The number of arterial grafts used in the CABGs had no influence on the long-term mortality of patients with diabetes.

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Objective: This study was conducted to investigate the perioperative and late-phase results of recently performed cases of coronary artery bypass grafting to clarify if multiarterial atherosclerotic disease and atherosclerosis-related factors have an impact on the results of coronary artery bypass grafting. Materials and Methods: The subjects were 101 consecutive cases undergoing only coronary artery bypass grafting. Preoperatively, atherosclerosis-related factors were measured and the presence or absence of multiarterial atherosclerotic disease was confirmed by diagnostic imaging in all cases, and the impact was retrospectively investigated. Results: There were 96 cases in the uneventful discharge group and 5 in the operative death (death within 30 days) group, and concomitant multiarterial atherosclerotic disease was present in 69 cases (72%) in the uneventful discharge group and 3 cases (60%) in the operative death group, respectively. In the operative death group, levels of glycated hemoglobin and triglycerides (TG), as well as the rate of hemodialysis, were significantly high. The most common concomitant atherosclerotic disease was brain lesions, and advanced calcification of the aorta and iliac arteries was also seen, but only one case of death was due to multiarterial atherosclerotic disease. Nine cases developed partial occlusion of the graft, and TG was significantly higher in this group compared to the group with completely patent grafts. Conclusion: We consider that it is possible to maintain good results of coronary artery bypass grafting in the presence of concomitant multiarterial atherosclerotic disease by performing preoperative systemic tests to be fully aware of the preoperative situation, and to take measures against complications. It is also necessary to strictly manage atherosclerosis-related factors.

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Objectives: Ischemic cardiomyopathy (ICM) is defined as the end-stage of ischemic heart disease. The treatment for ICM is not only medication or heart transplantation, but also non-transplant surgery including surgical ventricular restoration (SVR). We studied the effectiveness of the SVR for ICM and the possibility of alternative treatment to heart transplantation. Methods: Since May 2000, SVR for ICM were performed in 186 patients. There were 163 men and 23 women with a mean age of 62 ± 10 years old. There were 164 elective operations and 22 emergent operations. In addition to routine echocardiogram, speckle tracking echocardiogram was introduced to detect the lesion of LV since 2005. After cardioplegic arrest, complete coronary revascularization, and/or mitral or tricuspid surgery was performed, followed by SVR of either anteroseptal or posterior exclusion. The patients were followed up by transthoracic echocardiography. Results: The procedures of SVR was endoventricular circular patch plasty (EVCPP) in 66, septal anterior ventricular exclusion (SAVE) in 94, and posterior restoration procedure (PRP) in 26 patients. In addition to SVR, CABG was performed in 159, mitral surgery in 121 (plasty 105, replacement 16), and tricuspid annuloplasty in 48. Perioperative intra-aortic balloon pumping (IABP) was required in 46 and the hospital mortality was 4.3 % in elective and 18% in emergent operation. After the operation, 132 patients (75%) improved their functional class to class I or II. In the late follow-up, there were 17 cardiac deaths (congestive heart failure 11, ventricular arrhythmia 6). After 2005, the eight-year survival rates were 76.2% in elective operation. Conclusions: Our results demonstrated that the eight-year survival rate was equivalent to that after heart transplantation and 71% of the indicated patients for SVR could avoid heart transplantation with relief of their symptoms.

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A 74-year old Japanese male was admitted for acute myocardial infarction and underwent implantation of a bare metal stent for total occlusion of the right coronary artery (RCA). He developed acute stent thrombosis (ST) at the implantation site, and was re-treated using balloon angioplasty. Two weeks after discharge he presented to the emergency department with a sore throat and was admitted for treatment of agranulocytosis and esophageal candidiasis. During the first night of hospitalization, his vital signs indicated that he was experiencing cardiogenic shock. An electrocardiogram revealed a junctional rhythm with ST-segment elevations in the inferior leads. An emergency coronary angiography showed total occlusion of the RCA at the site of stent placement. Late ST was diagnosed, and intra-aortic balloon pumping was performed, followed by another thrombectomy and balloon angioplasty. Drug-induced agranulocytosis was highly suspected, and all drugs prescribed to the patient with the exception of aspirin were discontinued. He experienced a smooth recovery and a regimen of sarpogrelate and cilostazol was begun on Day 4 of hospitalization. On Day 7, he presented melena complicating hemorrhagic shock. Therefore, all drugs including aspirin were discontinued. The decision was made to replace clopidogrel with another antithrombotic agent in order to obtain adequate platelet inhibition. Thus while unfractionated heparin continued to be administered, aspirin was begun on Day 19 and sarpogrelate on Day 27. The patient was discharged on Day 34 and his treatment course was good. Thus far the patient has been free of chest pain and has had no need of further hospitalization.

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