read the article by Meneveau et al 1 with great interest. The authors concluded that in patients with non-ST-elevation myocardial infarction, optical coherence tomography-guided percutaneous coronary intervention (PCI) is associated with higher postprocedure fractional flow reserve (FFR) than PCI guided by angiography alone without an increase in periprocedural complications. Several concerns surround the use of FFR as a surrogate end point. The utility of FFR is firmly established in stable coronary artery disease but has been widely debated in patients with non-ST-elevation myocardial

We read with interest the letters by Vallurupalli and Uretsky and also Dr Nadir relating to the results of the DOCTORS study (Does Optical Coherence Tomography Optimize Results of Stenting). 1 We thank the authors for their insightful remarks. Vallurupalli and Uretsky raise an interesting point when they underline that a prolonged inflation time is superior to a rapid inflation/deflation technique in terms of both stent expansion and apposition. We acknowledge that we did not take stent inflation time into account in the case report form of the DOCTORS study. The arguments put forward by Vallurupalli and Uretsky suggest ...

We read with interest the results of the DOCTORS study (Does Optical Coherence Tomography Optimize Results of Stenting) of the use of optical coherence tomography to optimize stent implantation in non-ST-elevation myocardial infarction. 1 The finding that stent underexpansion detected by optical coherence tomography occurs in 42% of implants and often goes undetected by angiography is sobering and calls for the interventional …

BACKGROUND: No randomized study has investigated the value of optical coherence tomography (OCT) in optimizing the results of percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndromes. METHODS: We conducted a multicenter, randomized study involving 240 patients with non-ST-segment elevation acute coronary syndromes to compare OCT-guided PCI (use of OCT pre- and post-PCI; OCT-guided group) to fluoroscopy-guided PCI (angiography-guided group). The primary end point was the functional result of PCI assessed by the measure of post PCI fractional flow reserve. Secondary end points included procedural complications and type 4a periprocedural myocardial infarction. Safety was assessed by the rate of ...

Background— We previously described a strong association between fibromuscular dysplasia (FMD) and spontaneous coronary artery dissection. Angiographic manifestations of coronary FMD aside from dissection were considered rare. However, we observed several coronary FMD angiographic abnormalities with corresponding optical coherence tomography abnormalities. Methods and Results— Baseline demographics and imaging of patients with suspected coronary FMD at Vancouver General Hospital were reviewed. Presence of multifocal (string-of-beads) extracoronary FMD was confirmed by 2 specialists. In these patients, coronary angiographic findings (excluding dissected segments) were reviewed and classified by 2 experienced angiographers for irregular stenosis, that is, stenosis with irregular borders in a focal ...

Background— Although disturbed flow is thought to play a central role in the development of advanced coronary atherosclerotic plaques, no causal relationship has been established. We evaluated whether inducing disturbed flow would cause the development of advanced coronary plaques, including thin cap fibroatheroma. Methods and Results— D374Y -PCSK9 hypercholesterolemic minipigs (n=5) were instrumented with an intracoronary shear-modifying stent (SMS). Frequency-domain optical coherence tomography was obtained at baseline, immediately poststent, 19 weeks, and 34 weeks, and used to compute shear stress metrics of disturbed flow. At 34 weeks, plaque type was assessed within serially collected histological sections and coregistered to ...

Background— Optical coherence tomography (OCT) was recently introduced to optimize percutaneous coronary intervention. However, the exact incidence and significance of poststent OCT findings are unknown. Methods and Results— A total of 900 lesions treated with 1001 stents in 786 patients who had postprocedure OCT imaging were analyzed to evaluate the incidence of poststent OCT findings and to identify the OCT predictors for device-oriented clinical end points, including cardiac death, target vessel–related myocardial infarction, target lesion revascularization, and stent thrombosis. Patients were followed up to 1 year. Stent edge dissection was detected in 28.7% of lesions, and incomplete stent ...

A 60-year-old woman experienced exertional chest pain. She underwent percutaneous coronary intervention with a drug-eluting stent (Nobori, Terumo Corporation, Tokyo) at the midportion of the left anterior descending artery. In the 3-month follow-up angiography, there was an in-stent restenosis at the midportion of the left anterior descending artery, which was also the site of a previous stent implantation (arrow, Figure 1A). In optical coherence tomography, neointimal hyperplasia proliferation with a heterogeneous pattern was observed with a minimal lumen area of 1.7 mm 2 (asterisk, Figure 1A). Angioplasty with a drug-coated balloon (Sequent please; B. Braun, Melsungen, Germany) was performed ...

Background —Optical coherence tomography (OCT) was recently introduced to optimize percutaneous coronary intervention. However, the exact incidence and significance of post-stent OCT findings are unknown. Methods and Results —A total of 900 lesions treated with 1001 stents in 786 patients who had post-procedure OCT imaging were analyzed to evaluate the incidence of post-stent OCT findings and to identify the OCT predictors for device-oriented clinical endpoints (DoCE), including cardiac death, target vessel-related myocardial infarction, target lesion revascularization (TLR) and stent thrombosis. Patients were followed up to 1 year. Stent edge dissection was detected in 28.7% of lesions and incomplete stent ...

A 83-year-old man included in the ABSORB cohort B trial underwent successful percutaneous coronary intervention of the middle left anterior descending artery with a 3.0×18-mm bioresorbable scaffold (Absorb, Abbott Vascular, CA) that was postdilated with a 3.0-mm noncompliant balloon at 24 atm (Figure 1A and 1B). The 2-dimensional and 3-dimensional (3D) optical coherence tomography (OCT) confirmed the absence of structural discontinuity after the procedure (Figure 2B and Figure 3A’). At 6 months, the planned angiography showed the absence of restenosis but an ectasia in the scaffolded segment (Figure 1C). Intravascular ultrasound revealed a focal vessel and lumen ...

A 55-year-old white man received 4 coronary stents, 3 Resolute zotarolimus-eluting stents (R-ZES; Medtronic, Santa Rosa, CA) and 1 XIENCE Xpedition (CoCr-EES; Abbott Vascular, Santa Clara, CA), for unstable angina pectoris 238 days antemortem. The patient was found dead and had recently been seen without any complaints. The patient had a history of hypertension, hyperlipidemia, and smoking. At the time of stent placement, coronary angiography revealed diffuse disease in the left anterior descending artery (LAD) with severe stenosis of the proximal LAD and moderate to severe stenosis of the mid LAD. Percutaneous coronary intervention was carried out, and 4 overlapping ...

A 42-year-old female presented with sudden onset severe left-sided chest pain radiating to the left arm while watching a movie at home. She was rushed to the hospital within 10 minutes. She was found having ST elevation myocardial infarction on ECG and ventricular fibrillation arrest 2 times requiring cardiac resuscitation and defibrillation. Retrospectively, the patient recalled some ill-defined episodes of chest pain with exercise in the past few months before the admission. Her past surgical history 20 years previous was significant for video-assisted thoracoscopic surgery and pericardial window for removal of large, nonhemorrhagic pericardial effusion of 1.2 L, which ...

In-stent neoatherosclerosis (NA) has been reported after drug-eluting stent (DES) and bare-metal stent implantation. 1 NA is not only more frequent but also occurs earlier in patients undergoing DES implantation compared with those treated with bare-metal stents. 1 This phenomenon has major potential implications because complicated NA (mainly from rupture of a thin-cap fibroatheroma) may result in very late stent thrombosis. 2 Although NA can be visualized using intravascular ultrasound (IVUS), optical coherence tomography (OCT), because of its unique resolution (15 μm), appears ideally suited to detect this phenomenon in vivo. 2 We report on a patient treated with a ...

A 50-year-old man, a former smoker, presented with an ST-segment elevation anterior myocardial infarction that was treated with thrombolysis in another center. Because of the absence of reperfusion criteria, he was referred to our hospital for a rescue coronary intervention. A transthoracic echocardiogram showed that the overall left-ventricle systolic function was preserved but with apical akinesia. Coronary angiography revealed an occlusive lesion (100%) in the mid-left anterior descending coronary artery distal to a segment with a tapering caliber (Figure 1A). At that time, the patient was asymptomatic, and, therefore, a conservative management was decided, including dual antiplatelet therapy and full ...

A 55-year-old man with a previous history of cerebral infarct and hypertension presented to our cardiovascular center complaining of angina in November 2011. Chronic total occlusion in the proximal left anterior descending artery was identified by coronary angiography (Figure 1A). The patient subsequently underwent percutaneous coronary intervention. Wiring was done successfully with a tapered stiff wire (Conquest Pro 20; ASAHI INTECC). After multiple predilation, a single drug-eluting stent (3.0 × 18 mm) of an open-cell design and bioabsorbable polymer (Nobori; Terumo, Tokyo, Japan) was implanted using a 3.5-mm noncompliant balloon (inflation pressure, 24 atmospheric pressure; Quantum Maverick Balloon; Boston ...

Coronary angiography falls short in accurately delineating anatomy of epicardial vessels as it provides only a two-dimensional visualization of the lumen. Moreover, angiographic lesion assessment is impeded in cases of diffuse disease of reference vessels, lesion foreshortening and eccentricity as well as overlap of several arterial branches. Conversely, intravascular ultrasound - a sound wave based technology - provides superior spatial resolution of 80-150 μm and extends diagnostic information enabling more precise assessment of lumen and vessel wall dimensions including atheroma burden and vessel remodeling.

Introduction Most coronary artery fistulas (CAFs) have a congenital origin. Acquired CAF is a rare entity that may occur without an identifiable causative link. We present here the case of an acquired CAF in which optical coherence tomography was instrumental in outlining that its possible cause was a spontaneously ruptured, communicating, subadventitial coronary hematoma. Case Presentation A man aged 67 years was admitted for oppressive chest pain and sudden-onset dyspnea. He was a former smoker, had dyslipidemia and diabetes mellitus, and was in permanent atrial fibrillation. He also had had 2 mechanical valves implanted in the mitral and aortic positions ...

A 33-year-old male soccer player started to experience chest discomfort briefly after taking a blow from an opponent’s knee into his chest during a dribbling maneuver on the pitch. He completed the game but then consulted a referring hospital because of waxing and waning chest complaints irradiating to his left arm. The ECG demonstrated ST-T–segment changes compatible with inferoposterior ischemia (Figure 1). Cardiac enzyme markers were elevated. Echocardiography confirmed inferior wall hypokinesis. The patient was loaded with aspirin and clopidogrel. He subsequently underwent transradial invasive coronary angiography, which demonstrated Thrombolysis In Myocardial Infarction (TIMI) 2 flow in the ...

Case presentation : A 56-year-old man presented to the hospital with chest pain and a non–ST-segment elevation myocardial infarction. Thrombotic plaque rupture in the left anterior descending coronary artery was treated with an everolimus-eluting stent. After stent deployment, angiography demonstrated the presence of a hazy opacity at the distal edge of the stent, and there was concern about a possible edge dissection. Optical coherence tomography (OCT) imaging of the opacity showed residual thrombus and no dissection. Subsequent aspiration thrombectomy and balloon dilation effectively treated the lesion without deployment of an additional stent. Introduction OCT is an intravascular imaging modality that ...

Tako-Tsubo (TT) cardiomyopathy is a rare clinical entity, initially described in Japan, characterized by a transient apical dyskinesia of unknown origin.1,2 Patients present with signs and symptoms typical of myocardial infarction, but the epicardial coronary arteries are normal and left ventricular wall motion abnormalities spontaneously resolve during follow-up.1–2 Although different etiologies have been proposed to explain the pathophysiology of TT, its cause remains unknown. Here we describe optical coherence tomography findings of a patient presenting with TT. A 63-year-old woman with a history of hypertension was admitted for prolonged chest pain. An ECG showed widespread 1- ...

A 58-year-old man, included in cohort A of the Bioabsorbable Vascular Solutions First in Man Clinical Investigation: A Clinical Evaluation of the Bioabsorbable Vascular Solutions Everolimus Eluting Coronary Stent System in the Treatment of Patients With Single de Novo Native Coronary Artery Lesions (ABSORB) trial,1 had undergone implantation of a bioresorbable everolimus-eluting scaffold (BVS; Abbott Vascular, Santa Clara, CA) in June 2006 because of stable angina class III with a positive exercise test (Figure 1). He had a positive family history for coronary artery disease. At implantation, his total cholesterol was 207 mg/dL, his low-density lipoprotein level was ...

Spontaneous coronary artery dissection (SCAD) is a rare clinical entity of unknown cause that typically affects young women without coronary risk factors.1–5 Initial reports were scarce and based on autopsy findings after episodes of sudden cardiac death, suggesting that the condition had a dismal prognosis.1,2 An intimal tear was seldom found in autopsy series and, therefore, primary disruption with bleeding of vasa vasorum and intramedial hemorrhage was proposed as the underlying mechanism.1,2 Alternatively, an intimal tear may lead to separation of coronary wall layers and, eventually, to a double lumen. Pressure-driven expansion of the ...

A 78-year-old man with a history of dilated cardiomyopathy diagnosed 5 years previously was admitted to our clinic with accelerating chest pain and dyspnea. The initial ECG showed sinus tachycardia and left bundle-branch block. Laboratory tests revealed elevated levels of troponin T (0.409 ng/mL), creatinine kinase (218 U/L), and creatinine kinase-MB isoenzyme (9.8 μg/L). The peak level of creatinine kinase-MB isoenzyme was 41.9 μg/L. Transthoracic echocardiography revealed a more progressed left ventricular remodeling in comparison with an echocardiography conducted 2 years previously. Compared with the previous study, the end-diastolic dimension of the left ...