ctivation of platelets is considered to be the main cause of thrombotic occlusion after coronary stenting 1,2 and several antiplatelet agents have been shown to be useful for the prevention of subacute thrombosis (SAT). The combination of aspirin and ticlopidine, a selective adenosine diphosphate (ADP) receptor blocker, has prevented SAT after coronary stenting in several randomized studies. [3][4][5][6] Cilostazol, a cyclic adenosine monophosphate phosphodiesterase inhibitor, has also been shown to be a potent antiplatelet agent with antiproliferative properties, suggesting that it should prevent both thrombosis and restenosis after coronary stenting when coadministered with aspirin. [7][8][9] We conducted a prospective randomized study to compare the preventive effects against SAT and restenosis after coronary stenting between ticlopidine plus aspirin and cilostazol plus aspirin. Methods Study DesignThe study included 282 consecutive patients who successfully underwent coronary stenting for the treatment of acute myocardial infarction or angina pectoris. Patients who had already received ticlopidine or cilostazol were excluded. Patients with contraindications to treatment with aspirin, ticlopidine, or cilostazol were also excluded. All patients gave informed consent to participate in this study.The patients were randomized to the ticlopidine (200 mg/day) plus aspirin (81 mg/day) group or the cilostazol (200 mg/day) plus aspirin (81 mg/day) group. Patients scheduled for elective stenting started on either therapy 2 days before stenting. Those who underwent unplanned stenting because of a suboptimal result after balloon angioplasty or bailout stenting after failed balloon angioplasty received either therapy in the catheterization laboratory. The treatment was continued until follow-up angiography was performed. Coronary AngiographyThe cardiac catheterization and stent implantation were performed according to standard techniques. The technical issues, including the stent type, length, and diameter, and the dilation pressure, were left to the discretion of each attending physician. Coronary angiography was performed before, immediately after and 6 months after stenting.All of the initial angiographic approaches were also used at follow-up. Images with optimum delineation of the target lesions were selected from among all technically suitable angiograms, and quantitative coronary angiography (QCA) was performed using Integris Quantitative Coronary Analysis (Philips Medical Systems Nederland, The Netherlands) by 2 physicians without any knowledge of the patient's clinical history. The measurements were calibrated using a guide catheter for reference. The reference diameter, minimum luminal diameter (MLD), percent diameter stenosis (%DS) and the gain were determined. Effects of Antiplatelet Agents on Subacute Thrombosis and Restenosis After Successful Coronary Stenting A Randomized Comparison of Ticlopidine and CilostazolMakoto Sekiguchi, MD; Hiroshi Hoshizaki, MD; Hitoshi Adachi, MD; Shigeru Ohshima, MD; Koichi Tan...

SummaryCardiac function during exercise is assumed to be important in determining exercise tolerance. The aims of this study were to evaluate changes in left ventricular diastolic function (LVDF) during exercise and its effect on exercise tolerance assessed by a noninvasive method, exercise-stress tissue Doppler echocardiography. Twenty-six men with sinus rhythm (controls, hypertension, and cardiomyopathy) underwent cardiopulmonary exercise testing. To assess LVDF during exercise, exercise-stress Doppler echocardiography was performed with a constant workload at rest, and at 50%, 100%, and 120% of anaerobic threshold (AT). Doppler variables related to LVDF increased significantly as the workload increased (P < 0.05). Resting E' correlated significantly with AT (r = 0.424, P = 0.0308) and peak V 4 O 2 (r = 0.471, P = 0.0152). However, the difference in E' between rest and 120% AT (∆E') was closely correlated with AT (r = 0.744, P < 0.0001) and peak V 4 O 2 (r = 0.748, P < 0.0001). Moreover, ∆E' was correlated independently with AT (P = 0.0321) and peak V 1) However, the correlation between objective measurements of exercise tolerance and systolic left ventricular function is poor.2) It is clear that left ventricular diastolic function (LVDF) is an important determinant of exercise tolerance in normal individuals and in patients with various cardiac diseases. Recently, several studies have shown correlationsFrom the

SummaryWe report a case of simultaneous right and left coronary occlusion during percutaneous coronary intervention in the right coronary artery. An aortocoronary dissection induced by the forceful manipulation extended from the right to left sinus of Valsalva and occluded the ostia of both coronary arteries. The patient suffered cardiogenic shock and ventricular fibrillation. However, after successful rapid stenting to right and left coronary arteries, safe discharge was possible. (Int Heart J 2009; 50: 663-667)

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Objectives We aimed to investigate strategies for reattempted percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs) by highly skilled operators after a failed attempt. Background Development of complex techniques and algorithms has been standardized for CTO‐PCI. However, there is no appropriate strategy for CTO‐PCI after a failed procedure. Method From 2014 to 2016, the Japanese CTO‐PCI Expert Registry included 4,053 consecutive CTO‐PCIs (mean age: 66.8 ± 10.9 years; male: 85.6%; Japanese CTO [J‐CTO] score: 1.92 ± 1.15). Initial outcomes and strategies for reattempted CTO‐PCIs were evaluated and compared with first‐attempt CTO‐PCIs. Results Reattempt CTO‐PCIs were performed in 820 (20.2%) lesions. The mean J‐CTO score of reattempt CTO‐PCIs was higher than that of first‐attempt CTO‐PCIs (2.86 ± 1.03 vs. 1.68 ± 1.05, p < .001). The technical success rate of reattempt CTO‐PCIs was lower than that of first‐attempt CTO‐PCIs (86.7% vs. 90.8%, p < .001). Regarding successful CTO‐PCIs, the strategies comprised antegrade alone (reattempt: 36.1%, first attempt: 63.8%), bidirectional approach (reattempt: 54.4%, first attempt: 30.3%), and antegrade approach following a failed bidirectional approach (reattempt: 9.4%, first attempt: 5.4%). Parallel wire technique, intravascular ultrasound guide crossing, and bidirectional approach technique were frequently performed in reattempt CTO‐PCIs. Reattempt CTO‐PCIs showed higher rates of myocardial infarction (2.1% vs. 0.9%, p < .001) and coronary perforation (6.9% vs. 4.2%, p = .002) than first‐attempt CTO‐PCIs. Conclusions The technical success rate of reattempt CTO‐PCIs is lower than that of first‐attempt CTO‐PCIs. However, using more complex strategies, the success rate of reattempt CTO‐PCI can be improved by highly skilled operators.