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Background@#The risk of device thrombosis and device-oriented clinical outcomes with bioresorbable vascular scaffold (BVS) was reported to be significantly higher than with contemporary drug-eluting stents (DESs). However, optimal device implantation may improve clinical outcomes in patients receiving BVS. The current study evaluated mid-term safety and efficacy of Absorb BVS with meticulous device optimization under intravascular imaging guidance. @*Methods@#The SMART-REWARD and PERSPECTIVE-PCI registries in Korea prospectively enrolled 390 patients with BVS and 675 patients with DES, respectively. The primary endpoint was target vessel failure (TVF) at 2 years and the secondary major endpoint was patientoriented composite outcome (POCO) at 2 years. @*Results@#Patient-level pooled analysis evaluated 1,003 patients (377 patients with BVS and 626 patients with DES). Mean scaffold diameter per lesion was 3.24 ± 0.30 mm in BVS group.Most BVSs were implanted with pre-dilatation (90.9%), intravascular imaging guidance (74.9%), and post-dilatation (73.1%) at proximal to mid segment (81.9%) in target vessel.Patients treated with BVS showed comparable risks of 2-year TVF (2.9% vs. 3.7%, adjusted hazard ratio [HR], 1.283, 95% confidence interval [CI], 0.487–3.378, P = 0.615) and 2-year POCO (4.5% vs. 5.9%, adjusted HR, 1.413, 95% CI, 0.663–3.012,P = 0.370) than those with DES. The rate of 2-year definite or probable device thrombosis (0.3% vs. 0.5%, P = 0.424) was also similar. The sensitivity analyses consistently showed comparable risk of TVF and POCO between the 2 groups. @*Conclusion@#With meticulous device optimization under imaging guidance and avoidance of implantation in small vessels, BVS showed comparable risks of 2-year TVF and device thrombosis with DES.

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Introducción y objetivos El índice de resistencia microcirculatoria (IRM) medido tras una angioplastia primaria (ICPp) por infarto agudo de miocardio con elevación del segmento ST (IAMCEST) se asocia con la aparición de obstrucción microvascular (OMV) y eventos clínicos adversos. Para evaluar la OMV tras una ICPp exitosa por IAMCEST sin guías de presión ni administración de agentes hiperémicos, variables que parecen limitar la adopción del IRM en el laboratorio de hemodinámica, se investiga la viabilidad y la utilidad de la medición del IRM mediante resonancia magnética cardiaca (RMC) (angio-IRM). Métodos El estudio incluyó a 285 pacientes con IAMCEST sometidos a ICPp y RMC. Con un programa informático comercial, se calculó el angio-IRM del vaso culpable tras la ICPp exitosa. Se evaluaron la OMV, el tamaño del infarto y el índice de rescate miocárdico medidos una mediana de 3 [rango intercuartílico, 3-5] días después de la ICPp. Resultados De la población total, 154 pacientes (54,0%) mostraron valores de angio-IRM elevados (> 40 U) en el vaso culpable. La OMV fue significativamente más frecuente en los pacientes con angio-IRM> 40 U que en aquellos con angio-IRM ≤ 40 U (el 88,3 frente al 32,1%; p <0,001). El tamaño del infarto, la extensión de la OMV y el área en riesgo fueron significativamente mayores en los pacientes con angio-IRM> 40 U que con angio-IRM ≤ 40 U (p <0,001 para todas las comparaciones). El angio-IRM mostró una capacidad de discriminación de OMV significativamente mayor que el grado de flujo TIMI o de blush miocárdico (área bajo la curva, 0,821, 0,504 y 0,496 respectivamente; p <0,001). Conclusiones El angio-IRM se asoció significativamente con el tamaño del infarto, la extensión de la OMV y el área en riesgo. Cifras altas del angio-IRM (> 40 U) tras una ICPp por IAMCEST fueron muy predictivas de OMV en la RMC (AU)

Introduction and objectives The index of microcirculatory resistance (IMR) measured after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is associated with microvascular obstruction (MVO) and adverse clinical events. To evaluate MVO after successful primary PCI for STEMI without pressure wires or hyperemic agents, we investigated the feasibility and usefulness of functional angiography-derived IMR (angio-IMR). Methods The current study included a total of 285 STEMI patients who underwent primary PCI and cardiac magnetic resonance (CMR). Angio-IMR of the culprit vessel after successful primary PCI was calculated using commercial software. MVO, infarct size, and myocardial salvage index were assessed using CMR, which was obtained a median of 3.0 days [interquartile range, 3.0-5.0] after primary PCI. Results Among the total population, 154 patients (54.0%) showed elevated angio-IMR (> 40 U) in the culprit vessel. MVO was significantly more prevalent in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (88.3% vs 32.1%, P <.001). Infarct size, extent of MVO, and area at risk were significantly larger in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (P <.001 for all). Angio-IMR showed a significantly higher discriminatory ability for the presence of MVO than thrombolysis in myocardial infarction flow grade or myocardial blush grade (area under the curve: 0.821, 0.504, and 0.496, respectively, P <.001). Conclusions Angio-IMR was significantly associated with CMR-derived infarct size, extent of MVO, and area at risk. An elevated angio-IMR (> 40 U) after primary PCI for STEMI was highly predictive of the presence of MVO in CMR (AU)

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BACKGROUND AND OBJECTIVES@#Ergonovine stress echocardiography (ErgECHO) has been proposed as a noninvasive tool for the diagnosis of coronary vasospasm. However, concern over the safety of ErgECHO remains. This study was undertaken to investigate the safety and prognostic value of ErgECHO in a large population.@*METHODS@#We studied 3,094 consecutive patients from a single-center registry who underwent ErgECHO from November 2002 to June 2009. Medical records, echocardiographic data, and laboratory findings obtained from follow-up periods were analyzed.@*RESULTS@#The overall positive rate of ErgECHO was 8.6%. No procedure-related mortality or myocardial infarction (MI) occurred. Nineteen patients (0.6%) had transient symptomatic complications during ErgECHO including one who was successfully resuscitated. Cumulative major adverse cardiac events (MACEs) occurred in 14.0% and 5.1% of the patients with positive and negative ErgECHO results, respectively (p 220 mg/dL, and positive ErgECHO result itself were independent factors associated with MACEs.@*CONCLUSIONS@#ErgECHO can be performed safely by experienced physicians and its positive result may be an independent risk factor for long-term adverse outcomes. It may also be an alternative tool to invasive ergonovine-provoked coronary angiography for the diagnosis of vasospastic angina.

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BACKGROUND AND OBJECTIVES: Ergonovine stress echocardiography (ErgECHO) has been proposed as a noninvasive tool for the diagnosis of coronary vasospasm. However, concern over the safety of ErgECHO remains. This study was undertaken to investigate the safety and prognostic value of ErgECHO in a large population. METHODS: We studied 3,094 consecutive patients from a single-center registry who underwent ErgECHO from November 2002 to June 2009. Medical records, echocardiographic data, and laboratory findings obtained from follow-up periods were analyzed. RESULTS: The overall positive rate of ErgECHO was 8.6%. No procedure-related mortality or myocardial infarction (MI) occurred. Nineteen patients (0.6%) had transient symptomatic complications during ErgECHO including one who was successfully resuscitated. Cumulative major adverse cardiac events (MACEs) occurred in 14.0% and 5.1% of the patients with positive and negative ErgECHO results, respectively (p 220 mg/dL, and positive ErgECHO result itself were independent factors associated with MACEs. CONCLUSIONS: ErgECHO can be performed safely by experienced physicians and its positive result may be an independent risk factor for long-term adverse outcomes. It may also be an alternative tool to invasive ergonovine-provoked coronary angiography for the diagnosis of vasospastic angina.

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Mitral regurgitation (MR) is defined as the reflux of blood from the left ventricle into the left atrium during systole, resulting from the loss of adequate closure of the mitral valve. Echocardiography has become the primary noninvasive imaging method for evaluating mitral valvular regurgitation, since it provides structural and hemodynamic information. The echocardiographic assessment of mitral regurgitation should quantify the regurgitation, assess the valve anatomy and function, and evaluate the consequences of mitral regurgitation on the cardiac chambers. In clinical practice, the management of patients with mitral regurgitation is based largely on the echocardiography results. This article describes the echocardiographic assessment of mitral regurgitation, emphasizing the usefulness of echocardiography in primary care.

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An 83-year-old female patient visited the emergency department for abdominal pain and dyspnea with hemodynamic instability. Abdominal computed tomography showed multiple liver abscesses and a large volume of pericardial effusion. A transthoracic echocardiography revealed features suggestive of cardiac tamponade, including massive pericardial effusion and diastolic collapse of the right atrial wall. Emergency percutaneous pericardial drainage and percutaneous transhepatic drainage were performed. Klebsiella pneumoniae (KP) was isolated from both the pericardial effusion and bile. The first case of cardiac tamponade secondary to a liver abscess in Korea was reported in 1981, and it was caused by amoebal infection via fistula formation between the pericardium and abscess. We recently experienced a case of pyogenic liver abscess caused by KP complicating cardiac tamponade via direct invasion. This is an unusual complication of KP infection because KP is more frequently associated with hematogenous spread.

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As techniques and device technology have improved, the success rates and long patency of ilio-femoral occlusive disease have also improved. In the case of extensive iliac occlusive disease, however, wire passage and handling remain a challenge due to the relatively weak guiding catheter backup support with the contralateral femoral approach. There has been no report on methods to overcome this problem. We performed a successful percutaneous translunimal angioplasty for long ilio-femoral occlusive disease including the iliac ostium by a dual approach including simultaneous brachial and contralateral femoral arteries for subintimal angioplasty.

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PURPOSE: Vascular access flow (Qa) measurements are important in the surveillance protocol of hemodialysis vascular access stenosis. The glucose pump technique (GPT) is a technique for Qa measurement based on the dilution technique of a constant glucose infusion that was introduced in 1995. The aim of this study is to verify the clinical efficacy of GPT in vascular access surveillance compared with ultrasound dilution technique. METHODS: In 31 chronic hemodialysis patients with a AV fistula, we compared Qa measurements performed with GPT in pre-dialysis and the ultrasound dilution technique (Transonic HD01, Transonic System Inc., Ithaca, NY) during hemodialysis. RESULTS: Mean Qa was 1171 ml/min by GPT versus 1028 ml/min by HD01 (p=0.262). There was a strong linear correlation between the two methods (r=0.61; p<0.01). Ultrasound dilution technique HD01 yielded 6 cases of high risk Qa measurements and GPT yielded 4 cases of high risk Qa measurements. The diagnostic accuracy of GPT tested with the ROC curve was similar with ultrasound dilution technique HD01. The specificity and sensitivity was 80% and 66.7% according to Qa=600 ml/min. But sensitivity was 83.3% according to Qa=750 ml/min. CONCLUSION: GPT offers the advantage of a simple and economic bedside procedure easily performed before dialysis and had a similar diagnostic accuracy and efficiency compared with ultrasound dilution technique HD01.

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PURPOSE: There are methods to prevent intradialytic hypotension such as cool dialysate and sodium profiling but hemodynamic effects of these methods are not proved yet. We studied hemodynamic effects of cool dialysate and sodium profiling through brachial pulse monitoring which is simple and not invasive. METHODS: Ten patients selected by single, blind, randomized study are enforced control phase, cool dialysate phase, and sodium profiling phase and checked brachial pulse for 10 minutes after dialysis and 10 minutes before finishing. Hemodynamics is checked by DynaPulse 5200A (Pulse metric, Inc. San Diego, CA, USA). RESULTS: In control, central artery systolic blood pressure is decreased after dialysis. Brachial and central artery compliance is increased but brachial artery resistance is decreased. The central artery systolic pressure, brachial mean artery pressure, and brachial artery resistance is increased, but compliance is decreased in cool dialysate as compared with control dialysis. The comparison of intradialytic changes of hemodynamic parameters between control dialysis and sodium profiling shows that intradialytic changes of hemodynamic parameters are similar, but pre-hemodialytic weight is increased in sodium profiling. Number of episodes of symptomatic hypotension per dialysis treatment in cool dialysate and sodium profiling is decreased more than in control dialysis. CONCLUSION: Our study suggests changes of compliance and resistance are most important in hemodynamic parameters of intradialytic hypotension, especially changes of compliance and resistance of vessel in cool dialysate are useful in preventing intradialytic hypotension.

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