Publications by authors named "Woo Jung Chun"

60 Publications

Differential Factors for Predicting Outcomes in Left Main versus Non-Left Main Coronary Bifurcation Stenting.

J Clin Med 2021 Jul 7;10(14). Epub 2021 Jul 7.

Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul 03080, Korea.

Background: No large-scale study has compared the clinical and angiographic predictors of cardiovascular events in patients with left main bifurcation (LMB) and non-LMB stenting after second-generation DES implantation. Herein, we investigated differential clinical and angiographic factors for predicting outcomes in LMB versus non-LMB stenting.

Methods: A total of 2648 patients with bifurcation lesions treated with second-generation DESs from the retrospective patient cohort were divided into an LMB group ( = 935) and a non-LMB group ( = 1713). The primary outcome was the 7-year incidence of target lesion failure (TLF), defined as the composite of cardiac death, myocardial infarction, and target lesion revascularization.

Results: The incidence of TLF was 9.8%. Those in the LMB group were associated with a higher risk of TLF (14.2% versus 7.5%, < 0.001) than those in the non-LMB group. Regarding the LMB group, independent predictors of TLF were chronic kidney disease (CKD), reduced left ventricular ejection fraction (LVEF), and two-stenting. Regarding the non-LMB group, CKD, reduced LVEF, old age, diabetes, and small diameter of the main vessel stent were independent predictors of TLF.

Conclusions: The two-stent strategy could potentially increase TLF for the LMB lesions, and achieving the maximal diameter of the main vessel stent could result in better clinical outcomes for non-LMB lesions.
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http://dx.doi.org/10.3390/jcm10143024DOI Listing
July 2021

Association between polyvascular disease and clinical outcomes in patients with cardiogenic shock: Results from the RESCUE registry.

Int J Cardiol 2021 Jul 8. Epub 2021 Jul 8.

Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: Clinical implications of systemic atherosclerosis in patients with cardiogenic shock (CS) remain unclear. This study investigated the association between polyvascular disease (PVD) and clinical outcome in CS patients.

Methods: A total of 1247 CS patients was enrolled from the RESCUE registry, a multicenter, observational cohort between January 2014 and December 2018. They were divided into two groups according to presence of PVD, defined as ≥2 coexistence of coronary artery disease, peripheral arterial disease, or cerebrovascular disease. Primary outcome was all-cause death during 12 months of follow-up.

Results: 136 (10.9%) patients were diagnosed with PVD. The risk of 12-month all-cause death was significantly higher in the PVD group than in the non-PVD group (54.4% versus 40.4%, adjusted hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.02-1.69, p = 0.034). There was a significant interaction between PVD and vasoactive inotropic score (VIS) (p for interaction = 0.014). Among the 945 patients with VIS <84, PVD was associated with a higher risk of 12-month all-cause death (unadjusted HR 1.77, 95% CI 1.30-2.41, p = 0.030); among the 302 patients with VIS ≥84, the incidence of 12-month all-cause death was similar between the PVD and non-PVD groups (unadjusted HR 1.03, 95% CI 0.68-1.56, p = 0.301).

Conclusions: Presence of PVD was associated with 12-month all-cause mortality in patients with CS, especially for less severe forms of CS patients with VIS <84. Clinicaltrials.govnumber:NCT02985008.
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http://dx.doi.org/10.1016/j.ijcard.2021.07.008DOI Listing
July 2021

Comparison of in-hospital outcomes of patients with vs. without ischaemic cardiomyopathy undergoing veno-arterial-extracorporeal membrane oxygenation.

ESC Heart Fail 2021 Jun 18. Epub 2021 Jun 18.

Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea.

Aims: This study aimed to investigate differences in baseline and treatment characteristics, and in-hospital mortality according to the aetiologies of cardiogenic shock in patients undergoing veno-arterial-extracorporeal membrane oxygenation (VA-ECMO).

Methods And Results: The RESCUE registry is a multicentre, observational cohort that includes 1247 patients with cardiogenic shock from 12 centres. A total of 496 patients requiring VA-ECMO were finally selected, and the study population was stratified by cardiogenic shock aetiology [ischaemic cardiomyopathy (ICM, n = 342) and non-ICM (NICM, n = 154)]. The primary outcome of interest was in-hospital mortality. Sensitivity analyses including propensity-score matching adjustments were performed. Mean age of the entire population was 61.8 ± 14.2, and 30.8% were women. There were significant differences in baseline characteristics; notable differences included the older age of patients with ICM (65.1 ± 13.7 vs. 58.2 ± 13.8, P < 0.001), preponderance of males [258 (75.4%) vs. 85 (55.2%), P < 0.001], and higher prevalence of diabetes mellitus [140 (40.9%) vs. 39 (25.3%), P = 0.001] compared with patients in the NICM aetiology group. Patients with ischaemic cardiogenic shock were more likely to have longer shock duration before VA-ECMO implantation (518.7 ± 941.4 min vs. 292.4 ± 707.8 min, P = 0.003) and were less likely to undergo distal limb perfusion than those with NICM [108 (31.6%) vs. 79 (51.3%), P < 0.001]. In-hospital mortality in the overall cohort was 52.2%; patients with ICM had a higher unadjusted risk of in-hospital mortality [203 (59.4%) vs. 56 (36.4%); unadjusted hazard ratio, 2.295; 95% confidence interval, 1.698-3.100; P < 0.001]. There were no significant differences in the primary outcome between the two aetiologies following propensity-score matching multiple adjustments (adjusted hazard ratio, 1.265; 95% confidence interval, 0.840-1.906; P = 0.260).

Conclusions: Results of the current study indicated among patients with cardiogenic shock undergoing VA-ECMO, ischaemic aetiology does not seem to impact in-hospital mortality. These findings underline that early initiation and appropriate treatment strategies of VA-ECMO for patients with ICM shock are required.
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http://dx.doi.org/10.1002/ehf2.13481DOI Listing
June 2021

Clinical Characteristics and Predictors of In-Hospital Mortality in Patients With Cardiogenic Shock: Results From the RESCUE Registry.

Circ Heart Fail 2021 Jun 15;14(6):e008141. Epub 2021 Jun 15.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center (J.H.Y., K.H.C., T.K.P., J.M.L., Y.B.S., J.-Y.H., S.-H.C., H.-C.G.), Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: In the current era of mechanical circulatory support, limited data are available on prognosis of cardiogenic shock (CS) caused by various diseases. We investigated the characteristics and predictors of in-hospital mortality in Korean patients with CS.

Methods: The RESCUE study (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With CS) is a multicenter, retrospective, and prospective registry of patients that presented with CS. Between January 2014 and December 2018, 1247 patients with CS were enrolled from 12 major centers in Korea. The primary outcome was in-hospital mortality.

Results: In-hospital mortality rate was 33.6%. The main causes of shock were ischemic heart disease (80.7%), dilated cardiomyopathy (6.1%), myocarditis (3.2%), and nonischemic ventricular arrhythmia (2.5%). Vasopressors were used in 1081 patients (86.7%). The most frequently used vasopressor was dopamine (63.4%) followed by norepinephrine (57.3%). An intraaortic balloon pump was used in 314 patients (25.2%) and extracorporeal membrane oxygenator in 496 patients (39.8%). In multivariable analysis, age ≥70years (odds ratio [OR], 2.73 [95% CI, 1.89-3.94], <0.001), body mass index <25 kg/m (OR, 1.52 [95% CI, 1.08-2.16], =0.017), cardiac arrest at presentation (OR, 2.16 [95% CI, 1.44-3.23], <0.001), vasoactive-inotrope score >80 (OR, 3.55 [95% CI, 2.54-4.95], <0.001), requiring continuous renal replacement therapy (OR, 4.14 [95% CI, 2.88-5.95], <0.001), mechanical ventilator (OR, 3.17 [95% CI, 2.16-4.63], <0.001), intraaortic balloon pump (OR, 1.55 [95% CI, 1.07-2.24], =0.020), and extracorporeal membrane oxygenator (OR, 1.85 [95% CI, 1.25-2.76], =0.002) were independent predictors for in-hospital mortality.

Conclusions: The in-hospital mortality of patients with CS remains high despite the high utilization of mechanical circulatory support. Age, low body mass index, cardiac arrest at presentation, amount of vasopressor, and advanced organ failure requiring various support devices were poor prognostic factors for in-hospital mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02985008.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.008141DOI Listing
June 2021

Comparison of 2-Stenting Strategies Depending on Sequence or Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era - Analysis From the COBIS (Coronary Bifurcation Stenting) III Registry.

Circ J 2021 Jun 2. Epub 2021 Jun 2.

Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital.

Background: It has not been determined which specific 2-stenting strategy is the best for bifurcation lesions. Our aim was to investigate the clinical outcomes of various 2-stenting strategies in the era of 2nd-generation drug-eluting stents (2G-DES).Methods and Results:We analyzed 454 patients who finally underwent 2-stenting for a bifurcation lesion, from among 2,648 patients enrolled in the COBIS III registry. The primary outcome was target lesion failure (TLF). Patients were analyzed according to stenting sequence (provisional [main vessel stenting first] vs. systemic [side branch stenting first]) and stenting technique (crush vs. T vs. culotte vs. kissing/V stenting). Overall, 4.4 years' TLF after 2-stenting treatment for bifurcation lesion was excellent: TLF 11.2% and stent thrombosis 1.3%. There was no difference in TLF according to 2-stenting strategy (11.1% vs. 10.5%, P=0.990 for provisional and systemic sequence; 8.6% vs. 14.4% vs. 12.9% vs. 12.2%, P=0.326 for crush, T, culotte, kissing/V technique, respectively). Only left main (LM) disease and a shorter duration of dual antiplatelet therapy (DAPT) were associated with TLF. The distribution of DAPT duration differed between patients with and without TLF, and the time-point of intersection was 2.5 years. Also, the side branch was the most common site of restenosis.

Conclusions: The stenting sequence or technique did not affect clinical outcomes, but LM disease and shorter DAPT were associated with TLF, in patients with bifurcation lesions undergoing 2-stenting with 2G-DES.
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http://dx.doi.org/10.1253/circj.CJ-20-0999DOI Listing
June 2021

Clopidogrel Monotherapy in Patients with and without On-Treatment High Platelet Reactivity: a SMART-CHOICE sub-study.

EuroIntervention 2021 May 25. Epub 2021 May 25.

Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: Although P2Y12 inhibitor monotherapy has been emerged as a promising alternative for dual antiplatelet therapy (DAPT), there remains concern regarding safety of clopidogrel monotherapy.

Aims: We sought to investigate clinical outcomes of clopidogrel monotherapy in patients with and without on-treatment high platelet reactivity (HPR).

Methods: In the SMART-CHOICE study, 3-month DAPT followed by P2Y12 inhibitor monotherapy was compared with 12-month DAPT undergoing percutaneous coronary intervention. Of these, platelet function test was performed for 833 patients with clopidogrel-based therapy. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE: a composite of all-cause death, myocardial infarction, or stroke) at 12 months.

Results: Overall, 108 (13.0%) patients had HPR on clopidogrel. Patients with HPR had a significantly higher rate of MACCE than patients without HPR (8.7% vs 1.5%, adjusted HR 3.036, 95% CI 1.060-8.693, P=0.038). Treatment effect of clopidogrel monotherapy for the 12-month MACCE was not significantly different compared with DAPT among patients with HPR (8.0% vs. 9.4%, adjusted HR 0.718, 95% CI 0.189-2.737, P=0.628) and without HPR (2.2% vs. 0.9%, adjusted HR 2.587, 95% CI 0.684-9.779, P=0.161; adjusted P for interaction=0.170).

Conclusions: Clopidogrel monotherapy showed treatment effects comparable to DAPT for MACCE in patients with or without HPR. However, HPR was significantly associated with an increased risk of MACCE in clopidogrel-treated patients regardless of maintenance of aspirin.
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http://dx.doi.org/10.4244/EIJ-D-21-00223DOI Listing
May 2021

P2Y12 inhibitor monotherapy after coronary stenting according to type of P2Y12 inhibitor.

Heart 2021 Mar 23. Epub 2021 Mar 23.

Department of Cardiology, Korea University Guro Hospital, Seoul, Korea (the Republic of).

Objective: To compare P2Y12 inhibitor monotherapy after 3-month dual antiplatelet therapy (DAPT) with 12-month DAPT according to the type of P2Y12 inhibitor in patients undergoing percutaneous coronary intervention (PCI).

Methods: The Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents (SMART-CHOICE) randomised trial compared 3-month DAPT followed by P2Y12 inhibitor monotherapy with 12-month DAPT. In this trial, 2993 patients undergoing successful PCI with drug-eluting stent were enrolled in Korea. As a prespecified analysis, P2Y12 inhibitor monotherapy after 3-month DAPT versus 12-month DAPT were compared among patients receiving clopidogrel and those receiving potent P2Y12 inhibitor (ticagrelor or prasugrel), respectively. The primary endpoint was a composite of all-cause death, myocardial infarction or stroke at 12 months after the index procedure.

Results: Among 2993 patients (mean age 64 years), 58.2% presented with acute coronary syndrome. Clopidogrel was prescribed in 2312 patients (77.2%) and a potent P2Y12 inhibitor in 681 (22.8%). There were no significant differences in the primary endpoint between the P2Y12 inhibitor monotherapy group and the DAPT group among patients receiving clopidogrel (3.0% vs 3.0%; HR: 1.02; 95% CI 0.64 to 1.65; p=0.93) as well as among patients receiving potent P2Y12 inhibitors (2.4% vs 0.7%; HR: 3.37; 95% CI 0.77 to 14.78; p=0.11; interaction p=0.1). Among patients receiving clopidogrel, P2Y12 inhibitor monotherapy compared with DAPT showed consistent treatment effects across various subgroups for the primary endpoint. Among patients receiving potent P2Y12 inhibitors, the rate of bleeding (Bleeding Academic Research Consortium types 2- 5) was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (1.5% vs 5.0%; HR: 0.33; 95% CI 0.12 to 0.87; p=0.03).

Conclusions: Compared with 12-month DAPT, clopidogrel monotherapy after 3-month DAPT showed comparable cardiovascular outcomes in patients undergoing PCI.

Trial Registration Number: NCT02079194.
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http://dx.doi.org/10.1136/heartjnl-2020-318821DOI Listing
March 2021

Differential Prognostic Implications of Vasoactive Inotropic Score for Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock According to Use of Mechanical Circulatory Support.

Crit Care Med 2021 May;49(5):770-780

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Objectives: To identify whether the prognostic implications of Vasoactive Inotropic Score according to use of mechanical circulatory support differ in the treatment of acute myocardial infarction complicated by cardiogenic shock.

Design: A multicenter retrospective and prospective observational cohort study.

Setting/patient: The REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy registry includes 1,247 patients with cardiogenic shock from 12 centers in Korea. A total of 836 patients with acute myocardial infarction complicated by cardiogenic shock were finally selected, and the study population was stratified by quartiles of Vasoactive Inotropic Score (< 10, 10-30, 30-90, and > 90) for the present study.

Interventions: None.

Measurements And Main Results: Primary endpoint was in-hospital mortality and secondary endpoint was follow-up mortality. Among the study population, 326 patients (39.0%) received medical treatment alone, 218 (26.1%) received intra-aortic balloon pump, and 292 (34.9%) received extracorporeal membrane oxygenation. In-hospital mortality occurred in 305 patients (36.5%) and was significantly higher in patients with higher Vasoactive Inotropic Score (15.6%, 20.8%, 40.2%, and 67.3%, for < 10, 10-30, 30-90, and > 90; p < 0.001). Vasoactive Inotropic Score showed better ability to predict in-hospital mortality in acute myocardial infarction patients with cardiogenic shock who received medical treatment alone (area under the curve: 0.797; 95% CI, 0.728-0.865) than in those who received intra-aortic balloon pump (area under the curve, 0.704; 95% CI, 0.625-0.783) or extracorporeal membrane oxygenation (area under the curve, 0.644; 95% CI, 0.580-0.709). The best cutoff value of Vasoactive Inotropic Score for the prediction of in-hospital mortality also differed according to the use of mechanical circulatory support (16.5, 40.1, and 84.0 for medical treatment alone, intra-aortic balloon pump, and extracorporeal membrane oxygenation, respectively). There was a significant interaction between Vasoactive Inotropic Score as a continuous value and the use of mechanical circulatory support including intra-aortic balloon pump (interaction-p = 0.006) and extracorporeal membrane oxygenation (interaction-p < 0.001) for all-cause mortality during follow-up.

Conclusions: High Vasoactive Inotropic Score was associated with significantly higher in-hospital and follow-up mortality in patients with acute myocardial infarction complicated by cardiogenic shock. The predictive value of Vasoactive Inotropic Score for mortality was significantly higher in acute myocardial infarction patients with cardiogenic shock treated by medical treatment alone than in those treated by mechanical circulatory support such as intra-aortic balloon pump or extracorporeal membrane oxygenation.
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http://dx.doi.org/10.1097/CCM.0000000000004815DOI Listing
May 2021

Pharmacodynamic Profile and Prevalence of Bleeding Episode in East Asian Patients with Acute Coronary Syndromes Treated with Prasugrel Standard-Dose versus De-escalation Strategy: A Randomized A-MATCH Trial.

Thromb Haemost 2021 Jan 5. Epub 2021 Jan 5.

Division of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea.

Compared with Caucasian patients, East Asian patients have the unique risk-benefit trade-off and different responsiveness to antithrombotic regimens. The aim of this study was to compare pharmacodynamic profile in East Asian patients with acute coronary syndromes (ACSs) treated with prasugrel standard-dose versus a de-escalation strategy. Before discharge, ACS patients with age <75 years or weight ≥60 kg ( = 255) were randomly assigned to the standard-dose (10-mg group) or de-escalation strategy (5-mg group or platelet function test [PFT]-guided group). After 1 month, VerifyNow P2Y12 assay-based platelet reactivity (P2Y12 reaction unit [PRU]) and bleeding episodes were evaluated. Primary endpoint was the percentage of patients with the therapeutic window (85 ≤ PRU ≤ 208). The 250 patients completed 1-month treatment. The percentage of patients within the therapeutic window was significantly lower in the 10-mg group ( = 85) compared with the 5-mg ( = 83) and PFT-guided groups ( = 82) (35.3 vs. 67.5 vs. 65.9%) (odds ratio [OR]: 3.80 and 3.54; 95% confidence interval [CI]: 2.01-7.21 and 1.87-6.69, respectively). Compared with the 10-mg group, the bleeding rate was tended to be lower with de-escalation strategies (35.3 vs. 24.1% vs. 23.2%) (hazard ratio [HR]: 0.58 and 0.55; 95% CI: 0.30-1.14 and 0.28-1.09, respectively). "PRU < 127" was the optimal cut-off for predicting 1-month bleeding events (area under the curve: 0.616; 95% CI: 0.543-0.689;  = 0.005), which criteria was significantly associated with early discontinuation of prasugrel treatment (HR: 2.00; 95% CI: 1.28-3.03;  = 0.001). In conclusion, compared with the standard-dose prasugrel, the prasugrel de-escalation strategy in East Asian patients presented with ACS showed a higher chance within the therapeutic window and a lower tendency toward bleeding episodes. REGISTRATION:  URL: https://clinicaltrials.gov. Unique identifier:NCT01951001.
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http://dx.doi.org/10.1055/a-1346-3300DOI Listing
January 2021

Safety of 3-Month Dual Antiplatelet Therapy After Implantation of Ultrathin Sirolimus-Eluting Stents With Biodegradable Polymer (Orsiro): Results From the SMART-CHOICE Trial.

J Am Heart Assoc 2021 01 21;10(1):e018366. Epub 2020 Dec 21.

Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea.

Background This study sought to investigate the safety of 3-month dual antiplatelet therapy (DAPT) in patients receiving ultrathin sirolimus-eluting stents with biodegradable polymer (Orsiro). Methods and Results The SMART-CHOICE (Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Anti- platelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents) randomized trial compared 3-month DAPT followed by P2Y12 inhibitor monotherapy with 12-month DAPT in 2993 patients undergoing percutaneous coronary intervention. The present analysis was a prespecified subgroup analysis for patients receiving Orsiro stents. As a post hoc analysis, comparisons between Orsiro and everolimus-eluting stents were also done among patients receiving 3-month DAPT. Of 972 patients receiving Orsiro stents, 481 patients were randomly assigned to 3-month DAPT and 491 to 12-month DAPT. At 12 months, the target vessel failure, defined as a composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularization, occurred in 8 patients (1.7%) in the 3-month DAPT group and in 14 patients (2.9%) in the 12-month DAPT group (hazard ratio [HR], 0.58; 95% CI, 0.24-1.39; =0.22). In whole population who were randomly assigned to receive 3-month DAPT (n=1495), there was no significant difference in the target vessel failure between the Orsiro group and the everolimus-eluting stent group (n=1014) (1.7% versus 1.8%; HR, 0.96; 95% CI, 0.41-2.22; =0.92). Conclusions In patients receiving Orsiro stents, clinical outcomes at 1 year were similar between the 3-month DAPT followed by P2Y12 inhibitor monotherapy and 12-month DAPT strategies. With 3-month DAPT, there was no significant difference in target vessel failure between Orsiro and everolimus-eluting stents. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02079194.
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http://dx.doi.org/10.1161/JAHA.120.018366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955499PMC
January 2021

Clinical Significance of Low-Flow Time in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation: Results from the RESCUE Registry.

J Clin Med 2020 Nov 7;9(11). Epub 2020 Nov 7.

Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.

Limited data are available on the association between low-flow time and survival in patients with in-hospital cardiac arrest (IHCA) who undergo extracorporeal cardiopulmonary resuscitation (ECPR). We evaluated data from 183 IHCA patients who underwent ECPR as a rescue procedure. Patients were divided into two groups: patients undergoing extracorporeal membrane oxygenation as an adjunct to standard cardiopulmonary resuscitation for less than 38 min ( = 110) or for longer than 38 min ( = 73). The ECPR ≤ 38 min group had a significantly greater incidence of survival to discharge compared to the ECPR > 38 min group (40.0% versus 24.7%, = 0.032). The incidence of good neurologic outcomes at discharge tended to be greater in the ECPR ≤ 38 min group than in the ECPR > 38 min group (35.5% versus 24.7%, = 0.102). The incidences of limb ischemia ( = 0.354) and stroke ( = 0.805) were similar between the two groups, but major bleeding occurred less frequently in the ECPR ≤ 38 min group compared to the ECPR > 38 min group ( = 0.002). Low-flow time ≤ 38 min may reduce the risk of mortality and fatal neurologic damage and could be a measure of optimal management in patients with IHCA.
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http://dx.doi.org/10.3390/jcm9113588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695027PMC
November 2020

A randomized comparison of Coronary Stents according to Short or Prolonged durations of Dual Antiplatelet Therapy in patients with Acute Coronary Syndromes: a pre-specified analysis of the SMART-DATE trial.

EuroIntervention 2020 Nov 3. Epub 2020 Nov 3.

Ewha Womans University College of medicine, Seoul Hospital, Seoul, Korea.

Aims: We sought to compare biodegradable-polymer biolimus-eluting stents(BP-BES) with durable-polymer everolimus-eluting(DP-EES) and zotarolimus-eluting stents(DP-ZES) in patients with acute coronary syndrome(ACS) according to different duration of dual antiplatelet therapy(DAPT).

Methods And Results: In the SMART-DATE trial, 2712 patients with ACS underwent randomization for allocation of DAPT (6-month [n=1357] or 12-month or longer [n=1355]) and type of stents (BP-BES [n=901]), DP-EES [n=904], or DP-ZES [n=907]). At 18 months, primary endpoint (a composite of cardiac death, myocardial infarction, or stent thrombosis) was 2.6% with BP-BES, 2.0% with DP-EES, and 2.1% with DP-ZES (HR 1.29, 95% CI 0.70-2.39, p =0.42 for BP-BES vs. DP-EES and HR 1.23, 95% CI 0.67-2.26, p =0.50 for BP-BES vs. DP-ZES). The treatment effect of BP-BES for the primary endpoint was consistent among patients receiving 6-month DAPT as well as those receiving 12-month or longer DAPT (BP-BES vs. DP-EES, p interaction =0.48 and BP-BES vs. DP-ZES, p interaction =0.87). After excluding 179 patients (101 in the BP-BES group) who did not receive allocated DES, per-protocol analysis showed similar results.

Conclusions: The risk of a composite of cardiac death, myocardial infarction, or stent thrombosis was not significantly different between patients receiving BP-BES vs. DP-EES or DP-ZES across short or prolonged duration of DAPT after ACS.
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http://dx.doi.org/10.4244/EIJ-D-20-00556DOI Listing
November 2020

Impact of stent designs of second-generation drug-eluting stents on long-term outcomes in coronary bifurcation lesions.

Catheter Cardiovasc Interv 2020 Jul 30. Epub 2020 Jul 30.

Division of Cardiology, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Objectives: We compared the long-term clinical outcomes of four different types of second-generation drug-eluting stents (DESs) in coronary bifurcation lesions.

Background: Clinical outcomes of different designs of second-generation DESs are not well known in bifurcation lesions.

Methods: Patients who underwent percutaneous coronary intervention with second-generation DESs for coronary bifurcation lesion were enrolled from 21 centers in South Korea. A total of 2,526 patients was evaluated and divided into four treatment groups according to DES type: bioabsorbable polymer biolimus-eluting stent (BP-BES group, n = 514), platinum chromium everolimus-eluting stent (PtCr-EES group, n = 473), cobalt nickel zotarolimus-eluting stent (CoNi-ZES group, n = 736), or cobalt chromium everolimus-eluting stent (CoCr-EES group, n = 803). Primary outcome was target lesion failure (TLF, defined as a composite of cardiac death, target vessel myocardial infarction, or target lesion revascularization). Inverse probability of treatment weighting (IPTW) was performed to reduce selection bias and potential confounding factors.

Results: For 5 years of follow-up, the rates of TLF among the four DES groups were not significantly different (6.2% for BP-BES group, 8.2% for PtCr-EES group, 6.5% for CoNi-ZES group, and 8.6% for CoCr-EES group, p = .434). The results were consistent after IPTW adjustment (6.8, 8.4, 6.0, and 7.5%, respectively, p = .554). In subgroup analysis, the similarity of long-term outcomes among the four different types of second-generation DES was consistent across subgroups regardless of side branch treatment (p for interaction = .691).

Conclusion: There seems to be no significant difference in long-term clinical outcomes among patients who received different types of second-generation DES for coronary bifurcation lesion.
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http://dx.doi.org/10.1002/ccd.29137DOI Listing
July 2020

Prognostic Effects of Treatment Strategies for Left Main Versus Non-Left Main Bifurcation Percutaneous Coronary Intervention With Current-Generation Drug-Eluting Stent.

Circ Cardiovasc Interv 2020 02 7;13(2):e008543. Epub 2020 Feb 7.

Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea (D.-S.L., S.-J.H.).

Background: Although 1-stent with provisional approach is the preferred strategy for the treatment of bifurcation lesions, the optimal treatment strategy according to lesion location is still debatable. This study aimed to identify whether clinical outcomes according to treatment strategy differed between left main (LM) and non-LM bifurcation lesions in the second-generation drug-eluting stent era.

Methods: The Coronary Bifurcation Stenting registry III is a retrospective multicenter registry of 2648 patients with bifurcation lesions who underwent percutaneous coronary intervention with second-generation drug-eluting stent. Among the study population, 935 (35.3%) patients had an LM bifurcation lesion. The primary outcome was target lesion failure, a composite of cardiac death, myocardial infarction, and target lesion revascularization.

Results: Median follow-up duration was 53 months. LM bifurcation was associated with a higher risk of target lesion failure (HR, 1.846 [95% CI, 1.317-2.588]; <0.001) than non-LM bifurcation. Two-stent strategy was more frequently applied in patients with LM bifurcation than in patients with non-LM bifurcation (27.1% versus 11.7%; <0.001). In the LM bifurcation group, compared with the 1-stent strategy, the 2-stent strategy showed a significantly higher risk of target lesion failure (2-stent versus 1-stent, 17.4% versus 10.6%; HR, 1.848 [95% CI, 1.045-3.266]; =0.035), mainly driven by the higher rate of target lesion revascularization (15.3% versus 5.5%; HR, 2.698 [95% CI, 1.276-5.706]; =0.009). However, the risk of cardiac death or myocardial infarction did not differ between the 2 groups (4.4% versus 6.6%; HR, 0.694 [95% CI, 0.306-1.572]; =0.381). For patients with non-LM-bifurcation, there was no significant difference in the rate of target lesion failure between 1-stent and 2-stent strategies (5.6% versus 6.3%; HR, 0.925 [95% CI, 0.428-2.001]; =0.843).

Conclusions: Even in the second-generation drug-eluting stent era, the 1-stent strategy, if possible, should initially be considered the preferred approach for the treatment of LM bifurcation lesions. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03068494.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008543DOI Listing
February 2020

Effect of P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy on Cardiovascular Events in Patients Undergoing Percutaneous Coronary Intervention: The SMART-CHOICE Randomized Clinical Trial.

JAMA 2019 06;321(24):2428-2437

Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Importance: Data on P2Y12 inhibitor monotherapy after short-duration dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention are limited.

Objective: To determine whether P2Y12 inhibitor monotherapy after 3 months of DAPT is noninferior to 12 months of DAPT in patients undergoing PCI.

Design, Setting, And Participants: The SMART-CHOICE trial was an open-label, noninferiority, randomized study that was conducted in 33 hospitals in Korea and included 2993 patients undergoing PCI with drug-eluting stents. Enrollment began March 18, 2014, and follow-up was completed July 19, 2018.

Interventions: Patients were randomly assigned to receive aspirin plus a P2Y12 inhibitor for 3 months and thereafter P2Y12 inhibitor alone (n = 1495) or DAPT for 12 months (n = 1498).

Main Outcomes And Measures: The primary end point was major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) at 12 months after the index procedure. Secondary end points included the components of the primary end point and bleeding defined as Bleeding Academic Research Consortium type 2 to 5. The noninferiority margin was 1.8%.

Results: Among 2993 patients who were randomized (mean age, 64 years; 795 women [26.6%]), 2912 (97.3%) completed the trial. Adherence to the study protocol was 79.3% of the P2Y12 inhibitor monotherapy group and 95.2% of the DAPT group. At 12 months, major adverse cardiac and cerebrovascular events occurred in 42 patients in the P2Y12 inhibitor monotherapy group and in 36 patients in the DAPT group (2.9% vs 2.5%; difference, 0.4% [1-sided 95% CI, -∞% to 1.3%]; P = .007 for noninferiority). There were no significant differences in all-cause death (21 [1.4%] vs 18 [1.2%]; hazard ratio [HR], 1.18; 95% CI, 0.63-2.21; P = .61), myocardial infarction (11 [0.8%] vs 17 [1.2%]; HR, 0.66; 95% CI, 0.31-1.40; P = .28), or stroke (11 [0.8%] vs 5 [0.3%]; HR, 2.23; 95% CI, 0.78-6.43; P = .14) between the 2 groups. The rate of bleeding was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (2.0% vs 3.4%; HR, 0.58; 95% CI, 0.36-0.92; P = .02).

Conclusions And Relevance: Among patients undergoing percutaneous coronary intervention, P2Y12 inhibitor monotherapy after 3 months of DAPT compared with prolonged DAPT resulted in noninferior rates of major adverse cardiac and cerebrovascular events. Because of limitations in the study population and adherence, further research is needed in other populations.

Trial Registration: ClinicalTrials.gov Identifier: NCT02079194.
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http://dx.doi.org/10.1001/jama.2019.8146DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593635PMC
June 2019

The Proximal Optimization Technique Improves Clinical Outcomes When Treated without Kissing Ballooning in Patients with a Bifurcation Lesion.

Korean Circ J 2019 Jun 22;49(6):485-494. Epub 2019 Feb 22.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background And Objectives: There are limited data regarding the clinical efficacy of the proximal optimization technique (POT) in the treatment of coronary bifurcation lesions. We investigated the influence of POT on the clinical outcomes of patients with coronary bifurcation lesions.

Methods: We enrolled a total of 1,191 patients with a bifurcation lesion with a side branch (SB) diameter ≥2.5 mm treated with a drug-eluting stent from 18 centers between January 2003 and December 2009. The primary outcome was major adverse cardiac events (MACEs: cardiac death, myocardial infarction or target lesion revascularization [TLR]). We performed one-to-many (1:N) propensity score matching with non-fixed matching ratio.

Results: POT was performed in 252 patients. During follow-up (median 37 months), the incidence of MACE was lower in the POT group than it was in the non-POT group (adjusted hazard ratio, 0.43; 95% confidence interval [CI], 0.24-0.79; p=0.006). After propensity score matching, these were 0.34; 95% CI, 0.17-0.69; p=0.003 for MACE and 0.37; 95% CI, 0.17-0.78; p=0.01 for TLR. The use of POT was associated with significantly lower TLR in patients treated without kissing ballooning, but was not in those who underwent kissing ballooning (p for interaction=0.03).

Conclusions: In coronary bifurcation lesions with a large SB, POT may be beneficial to improve long-term clinical outcome, particularly in patients treated without kissing ballooning during the procedure.

Trial Registration: ClinicalTrials.gov Identifier: NCT01642992.
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http://dx.doi.org/10.4070/kcj.2018.0352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6554581PMC
June 2019

Season and myocardial injury in patients with ST-segment elevation myocardial infarction: A cardiac magnetic resonance imaging study.

PLoS One 2019 8;14(2):e0211807. Epub 2019 Feb 8.

Department of Radiology, Cardiovascular Imaging Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Background: Little is known about the causality and pathological mechanism underlying the association of seasonal variation with myocardial injury in patients with ST-segment elevation myocardial infarction (STEMI).

Objective: We evaluated the association of seasonal effect with myocardial injury using cardiovascular magnetic resonance (CMR) imaging in STEMI patients undergoing primary percutaneous coronary intervention (PCI).

Methods: In 279 patients undergoing primary PCI for STEMI, CMR was performed for a median of 3.3 days after the index procedure. Of these, STEMI occurred in 56 patients in the winter (Winter group), 80 patients in the spring (Spring group), 76 patients in the summer (Summer group), and 67 patients in the autumn (Autumn group), respectively. We compared myocardial infarct size, extent of area at risk (AAR), myocardial salvage index (MSI) and microvascular obstruction (MVO) area as assessed by CMR according to the season in which STEMI occurred.

Results: In the CMR analysis, the myocardial infarct size was not significantly different among the Winter group (21.0 ± 10.5%), the Spring group (19.6 ± 11.5%), the Summer group (18.6 ± 10.6%), and the Autumn group (21.1 ± 11.3%) (P = 0.475). The extent of AAR, MSI, and MVO areas were similar among the four groups. In the subgroup analysis, myocardial infarct size, extent of AAR, MSI, and MVO were not significantly different between the Harsh climate (winter + summer) and the Mild climate (spring + autumn) groups.

Conclusions: Seasonal influences may not affect advanced myocardial injury in STEMI patients undergoing primary PCI.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0211807PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6368377PMC
November 2019

Second-generation drug-eluting stenting versus coronary artery bypass grafting for treatment of coronary chronic total occlusion.

J Cardiol 2019 05 2;73(5):432-437. Epub 2019 Jan 2.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. Electronic address:

Background: Limited data are available regarding the long-term clinical outcomes of percutaneous coronary intervention (PCI) using second-generation drug-eluting stents (DESs) versus coronary artery bypass grafting (CABG) for the treatment of coronary artery disease (CAD) with chronic total occlusion (CTO). We compared the clinical outcomes of patients with multivessel CAD including CTO lesions treated with PCI using DESs versus CABG.

Methods: We analyzed data from 423 consecutive patients who underwent successful revascularization for CTO between March 2008 and February 2012. Death or myocardial infarction (MI) and major adverse cardiac and cerebrovascular events (MACCE) were compared between patients treated with PCI using second-generation DESs (n=232, 2nd DES group) versus those treated with CABG (n=191, CABG group). To reduce selection bias according to treatment strategy and other potential confounding factors, inverse probability of treatment weighting (IPTW) was also performed.

Results: During a median follow-up duration of 32 months, there was no significant difference in death or MI [hazard ratio (HR): 0.69; 95% confidence interval (CI): 0.29-1.63; p=0.399] or MACCE (HR: 1.32; 95% CI: 0.74-2.35; p=0.341) between the 2nd DES group and the CABG group based on multivariable analysis. After IPTW adjustment, the incidences of death or MI (HR: 0.72; 95% CI: 0.26-1.95; p=0.518) and MACCE (HR: 1.49; 95% CI: 0.76-2.91; p=0.244) remained similar in the two groups. In subgroup analysis, the effect of second-generation drug-eluting stenting was comparable to that of CABG across various subgroups without a significant p-value for the interaction.

Conclusions: The efficacy of PCI using second-generation DES was comparable to that of CABG in CTO patients with multivessel CAD.
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http://dx.doi.org/10.1016/j.jjcc.2018.12.008DOI Listing
May 2019

Safety and Efficacy of Biodegradable Polymer-biolimus-eluting Stents (BP-BES) Compared with Durable Polymer-everolimus-eluting Stents (DP-EES) in Patients Undergoing Complex Percutaneous Coronary Intervention.

Korean Circ J 2019 Jan 24;49(1):69-80. Epub 2018 Aug 24.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background And Objectives: There are no data comparing clinical outcomes of complex percutaneous coronary intervention (PCI) between biodegradable polymer-biolimus-eluting stents (BP-BES) and durable polymer-everolimus-eluting stents (DP-EES). We sought to evaluate the safety and efficacy of BP-BES compared with DP-EES in patients undergoing complex PCI.

Methods: Patients enrolled in the SMART-DESK registry were stratified into 2 categories based on the complexity of PCI. Complex PCI was defined as having at least one of the following features: unprotected left main lesion, ≥2 lesions treated, total stent length >40 mm, minimal stent diameter ≤2.5 mm, or bifurcation as target lesion. The primary outcome was target lesion failure (TLF), defined as a composite of cardiac death, target vessel-related myocardial infarction (TV-MI), or target lesion revascularization (TLR) at 2 years of follow-up.

Results: Of 1,999 patients, 1,145 (57.3%) underwent complex PCI: 521 patients were treated with BP-BES and 624 with DP-EES. In propensity-score matching analysis (481 pairs), the risks of TLF (3.8% vs. 5.2%, adjusted hazard ratio [HR], 0.578; 95% confidence interval [CI], 0.246-1.359; p=0.209), cardiac death (2.5% vs. 2.5%, adjusted HR, 0.787; 95% CI, 0.244-2.539; p=0.689), TV-MI (0.5% vs. 0.4%, adjusted HR, 1.128; 95% CI, 0.157-8.093; p=0.905), and TLR (1.1% vs. 2.9%, adjusted HR, 0.390; 95% CI, 0.139-1.095; p=0.074) did not differ between 2 stent groups after complex PCI.

Conclusions: Clinical outcomes of BP-BES were comparable to those of DP-EES at 2 years after complex PCI. Our data suggest that use of BP-BES is acceptable, even for complex PCI.
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http://dx.doi.org/10.4070/kcj.2018.0097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6331317PMC
January 2019

Fluoroscopy-guided simultaneous distal perfusion as a preventive strategy of limb ischemia in patients undergoing extracorporeal membrane oxygenation.

Ann Intensive Care 2018 Oct 29;8(1):101. Epub 2018 Oct 29.

Division of Cardiology, Department of Critical Care Medicine and Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-dong, Gangnam-gu, Seoul, 135-710, Republic of Korea.

Background: Limited data are available regarding prevention of limb ischemia in femorally cannulated patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). We investigated the association between strategy of distal perfusion catheter (DPC) insertion and vascular complications like limb ischemia in patients undergoing VA-ECMO.

Methods: We evaluated 230 patients from two tertiary hospitals who received VA-ECMO via femoral cannulation between August 2014 and July 2017. The patients were divided into two groups according to DPC insertion strategy: patients who underwent DPC insertion at the time of primary cannulation (DPC group, n = 96) and patients who were provisionally treated with DPC (No-DPC group, n = 134). The primary outcome was limb ischemia.

Results: Of the 96 patients in the DPC group, 61 (63.5%) underwent insertion under fluoroscopic guidance. The DPC group had a significantly lower incidence of limb ischemia (2.1% vs. 8.2%, p = 0.047) and a lower tendency of in-hospital mortality (38.5% vs. 50.7%, p = 0.067) than the No-DPC group. In the multivariable analysis, fluoroscopy-guided simultaneous insertion of the DPC (odds ratio 0.11; 95% confidence interval 0.01-0.98; p = 0.048) was a significant predictor of reduction of limb ischemia.

Conclusions: Simultaneous insertion of a DPC, particularly under fluoroscopy guidance, can be considered as a preventive strategy for limb ischemia in femorally cannulated patients on VA-ECMO.
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http://dx.doi.org/10.1186/s13613-018-0445-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206319PMC
October 2018

Benefit of Prolonged Dual Antiplatelet Therapy After Implantation of Drug-Eluting Stent for Coronary Bifurcation Lesions: Results From the Coronary Bifurcation Stenting Registry II.

Circ Cardiovasc Interv 2018 07;11(7):e005849

Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (Y.B.S., S.-H.C., S.W.C., B.S.K., H.-C.G., J.-Y.H.).

Background: Whether prolonged dual antiplatelet therapy (DAPT) improves clinical outcomes after percutaneous coronary intervention for coronary bifurcation lesion is uncertain.

Methods And Results: We evaluated 2082 patients who were treated with drug-eluting stent for bifurcation lesions and were event free (no death, myocardial infarction [MI], cerebrovascular accident, stent thrombosis, or any revascularization) at 12 months after the index procedure. Patients were divided into 2 groups: DAPT ≥12-month group (n=1776) and DAPT <12-month group (n=306). Primary outcome was all-cause death or MI. At 4 years after the index procedure, death or MI occurred less frequently in the DAPT ≥12-month group than the DAPT <12-month group (2.8% versus 12.3%; adjusted hazard ratio, 0.21; 95% confidence interval, 0.13-0.35; <0.001). After propensity score matching, incidence of death or MI was still lower in the DAPT ≥12-month group than the DAPT <12-month group (2.6% versus 12.3%; adjusted hazard ratio, 0.22; 95% confidence interval, 0.12-0.38; <0.001). In subgroup analysis, the treatment effect of prolonged DAPT was consistent across subgroups regardless of lesion location, stenting technique, or type of used drug-eluting stent.

Conclusions: The risk of all-cause death or MI was significantly lower in the ≥12-month DAPT group than the <12-month DAPT group after percutaneous coronary intervention for bifurcation lesion using drug-eluting stent. Our results suggest that prolonged DAPT may improve long-term clinical outcomes after percutaneous coronary intervention for bifurcation lesions.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01642992.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.117.005849DOI Listing
July 2018

Long-term Survival Benefit of Statin in Patients with Coronary Chronic Total Occlusion without Revascularization.

J Korean Med Sci 2018 Apr 13;33(18):e134. Epub 2018 Apr 13.

Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: Limited data are available on the efficacy of statin therapy in stable ischemic heart disease with chronic total occlusion (CTO) without revascularization. We investigated whether statin therapy could be beneficial in stable patients with CTO without revascularization.

Methods: From March 2003 to February 2012, 2,024 patients with at least one CTO were enrolled in a retrospective, single-center registry; 664 of these patients were managed conservatively without an initial revascularization strategy. Among them, we excluded CTO cases involving acute coronary syndrome, in-hospital death or incomplete data and classified 551 patients into statin (n = 369) and non-statin (n = 182) groups according to use of statin at discharge. Propensity score matching analysis was also performed in 148 pairs. The primary outcome was cardiac death.

Results: The median overall follow-up duration was 45.7 months (interquartile range: 19.9-70.5 months). Cardiac death occurred in 22 patients (6.0%) in the statin group vs. 24 patients (13.2%) in the non-statin group ( < 0.001). In propensity score matching analysis, statin therapy was associated with a low risk of cardiac death (adjusted hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.18-0.85; = 0.022) and major adverse cardiac events (adjusted HR, 0.66; 95% CI, 0.43-0.98; = 0.043). On multivariate analysis, independent predictors for cardiac death were age > 70 years, renal insufficiency, prior myocardial infarction, left ventricular ejection fraction < 40%, proximal-to-mid CTO location, and no use of statin in CTO patients.

Conclusion: Statin therapy at discharge may be associated with a reduction in long-term cardiac mortality in stable CTO patients without revascularization.
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http://dx.doi.org/10.3346/jkms.2018.33.e134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5920123PMC
April 2018

Bioresorbable Vascular Scaffold Korean Expert Panel Report.

Korean Circ J 2017 Nov 6;47(6):795-810. Epub 2017 Nov 6.

Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

Bioresorbable vascular scaffold (BRS) is an innovative device that provides structural support and drug release to prevent early recoil or restenosis, and then degrades into nontoxic compounds to avoid late complications related with metallic drug-eluting stents (DESs). BRS has several putative advantages. However, recent randomized trials and registry studies raised clinical concerns about the safety and efficacy of first generation BRS. In addition, the general guidance for the optimal practice with BRS has not been suggested due to limited long-term clinical data in Korea. To address the safety and efficacy of BRS, we reviewed the clinical evidence of BRS implantation, and suggested the appropriate criteria for patient and lesion selection, scaffold implantation technique, and management.
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http://dx.doi.org/10.4070/kcj.2017.0300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5711671PMC
November 2017

Clinical outcomes of biodegradable polymer biolimus-eluting BioMatrix stents versus durable polymer everolimus-eluting Xience stents.

PLoS One 2017 10;12(8):e0183079. Epub 2017 Aug 10.

Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

There are limited data about clinical outcomes of biodegradable polymer biolimus-eluting BioMatrix stents (BP-BES) and durable polymer everolimus-eluting Xience stents (DP-EES) in real world practice. We sought to compare the clinical outcomes of BP-BES and DP-EES in real world cohorts of patients undergoing percutaneous coronary intervention. A prospective multicenter registry enrolled 999 patients treated with BP-BES and 1,000 patients treated with DP-EES. The primary outcome was target lesion failure, defined as a composite of cardiac death, target vessel-related myocardial infarction, or target lesion revascularization. Definite or probable stent thrombosis was also compared in total and propensity score-matched cohorts. The median follow-up duration was 24 months, and mean age was 65 years (interquartile range, 56-72 years). Patients receiving BP-BES had a lower prevalence of acute coronary syndrome, prior myocardial infarction, multi-vessel disease, bifurcation lesions, and left anterior descending artery lesions than those receiving DP-EES. After propensity score matching (692 pairs), target lesion failure occurred in 22 patients receiving BP-BES and in 25 patients receiving DP-EES (3.2% versus 3.6%; adjusted hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.53 to 1.60; p = 0.77). The risk of definite or probable stent thrombosis did not differ between the 2 groups (0.4% versus 0.4%; adjusted HR, 1.03; 95% CI, 0.21 to 4.98; p = 0.97). The results were consistent across various subgroups. In the propensity score-matched analysis of real world cohorts, BP-BES showed similar clinical outcomes compared to DP-EES. We need to investigate about whether differences in clinical outcome emerge during long-term follow-up.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0183079PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5552220PMC
October 2017

Clinical Significance of Postinfarct Fever in ST-Segment Elevation Myocardial Infarction: A Cardiac Magnetic Resonance Imaging Study.

J Am Heart Assoc 2017 Apr 24;6(4). Epub 2017 Apr 24.

Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Background: Little is known about causality and pathological mechanism underlying association of postinfarct fever with myocardial injury in patients with ST-segment elevation myocardial infarction.

Methods And Results: In 276 patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction, cardiac magnetic resonance imaging was performed a median of 3.4 days after the index procedure. Forty-five patients had postinfarct fever (peak body temperature within 4 days after primary percutaneous coronary intervention ≥37.7°C; Fever group) whereas 231 did not (no-Fever group). Primary outcome was myocardial infarct size as assessed by cardiac magnetic resonance imaging. Secondary outcomes were extent of area at risk, myocardial salvage index, and microvascular obstruction area. In cardiac magnetic resonance imaging analysis, myocardial infarct size (25.6% [19.7-32.4] in the Fever group versus 17.2% [11.8-25.4] in the no-Fever group; <0.01), extent of area at risk (43.7% [31.9-54.9] versus 35.3% [24.0-43.7]; <0.01), and microvascular obstruction area (4.4% [0.0-13.2] versus 1.2% [0.0-5.1]; =0.02) were greater in the Fever group than in the no-Fever group. Myocardial salvage index tended to be lower in the Fever group compared to the no-Fever group (37.7 [28.5-56.1] versus 47.0 [34.1-56.8]; =0.13). In multivariate analysis, postinfarct fever was associated with larger myocardial infarct (odds ratio, 3.48; 95% CI, 1.71-7.07; <0.01) and lower MSI (odds ratio, 2.10; 95% CI, 1.01-4.08; =0.03).

Conclusions: Postinfarct fever could predict advanced myocardial injury and less salvaged myocardium in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.
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http://dx.doi.org/10.1161/JAHA.117.005687DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5533041PMC
April 2017

Cardioprotective Effects of Intracoronary Morphine in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: A Prospective, Randomized Trial.

J Am Heart Assoc 2017 Apr 3;6(4). Epub 2017 Apr 3.

Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Background: A cardioprotective role of morphine acting via opioid receptors has been demonstrated, and previous preclinical studies have reported that morphine could reduce reperfusion injury and myocardial infarct size in a way similar to that of ischemic periconditioning. This study aimed to evaluate the effect of intracoronary morphine on myocardial infarct size in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Methods And Results: This study was designed as a 2-center, prospective, randomized, open-label, blinded end point trial. A total of 91 ST-elevation myocardial infarction patients with thrombolysis in myocardial infarction flow grade of 0 to 1 undergoing primary percutaneous coronary intervention were randomly assigned to a morphine or control group at a 1:1 ratio. The morphine group received 3 mg of morphine sulfate diluted with 3 mL of normal saline, and the control group received 3 mL of normal saline into a coronary artery immediately after restoration of coronary flow. The primary end point was myocardial infarct size assessed by cardiac magnetic resonance imaging The cardiac magnetic resonance images were evaluated for 42 and 38 patients in the morphine and control groups, respectively. Myocardial infarct size was not different between the 2 groups (25.6±11.2% versus 24.6±10.5%, =0.77), nor was the extent of microvascular obstruction or myocardial salvage index (6.0±6.3% versus 5.1±4.6%, =0.91; 31.1±15.2% versus 30.3±10.9%, =0.75, respectively). There was no difference in peak creatine kinase-MB level, final thrombolysis in myocardial infarction flow, myocardial brush grade, or complete resolution of ST-segment.

Conclusions: Intracoronary morphine administration could not reduce myocardial infarct size in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01738100.
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http://dx.doi.org/10.1161/JAHA.116.005426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5533032PMC
April 2017

Conservative versus aggressive treatment strategy with angiographic guidance alone in patients with intermediate coronary lesions: The SMART-CASE randomized, non-inferiority trial.

Int J Cardiol 2017 Aug 18;240:114-119. Epub 2017 Mar 18.

Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea. Electronic address:

Background: Although coronary angiography is still the technique most widely used to guide percutaneous coronary intervention (PCI), the appropriate angiographic indication of revascularization for intermediate coronary lesions remains controversial. The aim of this study was to compare conservative versus aggressive strategies with angiographic guidance alone in patients with intermediate coronary lesions.

Methods And Results: A total of 899 patients with intermediate coronary lesions between 50% and 70% diameter stenosis by quantitative coronary analysis were randomly assigned to the conservative group (n=449) or the aggressive group (n=450). For intermediate lesions, PCI was performed using everolimus-eluting stents in the aggressive group, but was deferred in the conservative group. The primary end point was a composite of all-cause death, myocardial infarction, or any revascularization at 1year. The number of treated lesions per patient was 0.8±0.9 in the conservative group and 1.7±0.9 in the aggressive group (p<0.001). The cumulative rate of the primary endpoint was 7.3% in the conservative group and 6.8% in the aggressive group (the upper limit of the one-sided 95% confidence interval [CI], 3.4%; p=0.006 for non-inferiority with a predefined non-inferiority margin of 5.0%). The risk of death or myocardial infarction (hazard ratio [HR] 0.50; 95% CI, 0.19-1.33; p=0.17) and revascularization (HR 1.42; 95% CI, 0.80-2.52; p=0.23) was not significantly different between the 2 groups.

Conclusions: Conservative revascularization was non-inferior to aggressive revascularization for intermediate coronary lesions. Revascularization of intermediate lesions can be safely deferred in patients undergoing PCI with angiographic guidance alone.

Clinical Trial Registration: URL: http://ClinicalTrials.gov. Unique identifier: NCT00743899.
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http://dx.doi.org/10.1016/j.ijcard.2017.03.075DOI Listing
August 2017

Clinical implications of residual SYNTAX score after percutaneous coronary intervention in patients with chronic total occlusion and multivessel coronary artery disease: a comparison with coronary artery bypass grafting.

EuroIntervention 2017 May;13(1):97-105

Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea.

Aims: In this study we sought to evaluate the clinical impact of the residual SYNTAX score (rSS) after percutaneous coronary intervention (PCI) in patients with chronic total occlusion (CTO) and multivessel coronary artery disease (CAD).

Methods And Results: We analysed data from 1,043 patients with CTO and multivessel CAD who were treated with PCI or coronary artery bypass grafting (CABG). Patients were divided into three groups: patients with rSS≤12 after PCI (rSS≤12 group, n=445), patients with rSS>12 after PCI (rSS>12 group, n=150), and patients who underwent CABG (CABG group, n=448). We compared the incidence of cardiac death among the three groups. During a median follow-up period of 42 months, cardiac death occurred in 14 patients (3.1%) in the rSS≤12 group, 14 patients (9.3%) in the rSS>12 group, and 29 patients (6.5%) in the CABG group. On multivariate analysis, the rSS≤12 group had a significantly lower incidence of cardiac death than the rSS>12 group (hazard ratio [HR] 0.35, 95% confidence interval [CI]: 0.16 to 0.75; p=0.01), but had an incidence of cardiac death similar to that of the CABG group (HR 0.63, 95% CI: 0.32 to 1.23; p=0.17).

Conclusions: An rSS≤12 after PCI may reduce the risk of cardiac mortality and could be a measure of reasonable incomplete revascularisation in patients with CTO and multivessel CAD.
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http://dx.doi.org/10.4244/EIJ-D-16-00421DOI Listing
May 2017

Combination Therapy of Rosuvastatin and Ezetimibe in Patients with High Cardiovascular Risk.

Clin Ther 2017 Jan 19;39(1):107-117. Epub 2016 Dec 19.

Research & Development Division, Alvogen Korea Co., Ltd., Seoul, Korea.

Purpose: The aim of this study was to evaluate the efficacy and tolerability of rosuvastatin/ezetimibe combination therapy in Korean patients with high cardiovascular risk.

Methods: This was a 12-week, randomized, double-blind, placebo-controlled, multicenter study. A total of 337 patients were screened. After a 4-week run-in period, 245 of these patients with high or moderately high risk as defined by the National Cholesterol Education Program Adult Treatment Panel III guidelines were randomly assigned. Patients received 1 of 6 regimens for 8 weeks as follows: (1) rosuvastatin 5 mg, (2) rosuvastatin 5 mg/ezetimibe 10 mg, (3) rosuvastatin 10 mg, (4) rosuvastatin 10 mg/ezetimibe 10 mg, (5) rosuvastatin 20 mg, or (6) rosuvastatin 20 mg/ezetimibe 10 mg. The primary outcome variable was percentage change in the level of LDL-C at week 8 of drug treatment. Secondary outcome variables included percentage changes of other lipid variables and achievement rates of LDL-C targets. Tolerability analyses were also performed.

Findings: The percentage change of LDL-C ranged from -45% to -56% (mean, -51%) in the monotherapy groups and from -58% to -63% (mean, -60%) in the combination therapy groups. The percentage change was greater in the pooled combination therapy group than in the counterpart (P < 0.001 for the pooled groups); this difference was more obvious for regimens with a lower statin dose. The percentage reductions of total cholesterol and triglycerides were greater in the combination groups than in the monotherapy groups. The LDL-C target achievement rates were 64% to 87% (mean, 73%) in the monotherapy groups and 87% to 95% (mean, 91%) in the combination groups (P = 0.01 for the pooled groups). The rates were significantly greater in patients receiving the combination therapy than in the monotherapy at lower doses of rosuvastatin. The proportions of patients with various adverse events were not significantly different between the groups.

Implications: Rosuvastatin/ezetimibe combination therapy has better efficacy and target achievement rates than rosuvastatin monotherapy in patients with high cardiovascular risk.
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http://dx.doi.org/10.1016/j.clinthera.2016.11.014DOI Listing
January 2017
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