Background: Only few studies have investigated the relationship between the histopathology of retrieved thrombi and clinical outcomes. This study aimed to evaluate thrombus composition and its association with clinical, laboratory, and neurointerventional findings in patients treated by mechanical thrombectomy due to acute large vessel occlusion. Methods: At our institution, 79 patients were treated by mechanical thrombectomy using a stent retriever and/or aspiration catheter between August 2015 and August 2016. The retrieved thrombi were quantitatively analyzed to quantify red blood cells, white blood cells, and fibrin by area. We divided the patients into two groups – a fibrin-rich group and an erythrocyte-rich group – based on the predominant composition in the thrombus. The groups were compared for imaging, clinical, and neurointerventional data. Results: The retrieved thrombi from 43 patients with acute stroke from internal carotid artery, middle cerebral artery, or basilar artery occlusion were histologically analyzed. Erythrocyte-rich thrombi were present in 18 cases, while fibrin-rich thrombi were present in 25 cases. A cardioembolic etiology was significantly more prevalent among the patients with fibrin-rich thrombi than among those with erythrocyte-rich thrombi. Attenuation of thrombus density as shown on computed tomography images was greater in patients with erythrocyte-rich thrombi than in those with fibrin-rich thrombi. All other clinical and laboratory characteristics remained the same. Patients with erythrocyte-rich thrombi had a smaller number of recanalization maneuvers, shorter procedure times, a shorter time interval between arrival and recanalization, and a higher percentage of stent retrievers in the final recanalization procedure. The occluded vessels did not differ significantly. Conclusions: In this study, erythrocyte-rich thrombus was associated with noncardioembolic etiology, higher thrombus density, and reduced procedure time.

A 45-year-old man was referred to our hospital after a prolonged history of exertional dyspnea. Clinical examination revealed systolic and diastolic heart murmurs without any systolic click in the second right sternal border. Chest x-ray showed pulmonary artery dilation ( Figure 1). Multidetector computed tomography showed a huge pulmonary artery aneurysm Ϸ70 mm in diameter (Figure 2). Transthoracic echocardiography showed a huge aneurysm of the pulmonary artery by 2D echocardiography (Figure 3). There was no significant tricuspid regurgitation in either the 4-chamber view or the short-axis view, and pulmonary regurgitation due to dilatation of pulmonary annulus was seen by color-Doppler echocardiography (Movies I through III in the online-only Data Supplement). Cardiac catheterization did not show any pressure gradient between pulmonary artery and right ventricle or any sign of pulmonary hypertension. We diagnosed an idiopathic pulmonary artery aneurysm in this patient.Aneurysmectomy of the pulmonary main trunk with a 24-mm synthetic graft and valvuloplasty of an enlarged pulmonary annulus were performed ( Figure 4). The pathological examination did not show any sign of cystic medial degeneration ( Figure 5).Pulmonary artery aneurysm is a rare anomaly found in Ϸ1 of every 14 000 autopsies; most of these anomalies are present in the main pulmonary artery. 1 The cause of pulmonary artery aneurysm may be idiopathic; however, other causes include congenital shunt disease, syphilis, atherosclerosis, trauma, and pulmonary hypertension. 2 In Ͼ50% of the postmortem cases, pulmonary aneurysms were associated with congenital heart disease, most frequently patent ductus arteriosus. In the remaining reported cases, such aneurysms were associated mainly with secondary acquired lesions, such as syphilis and cystic medial degeneration. In our case, however, no pathological abnormality was shown by the histological sections of aneurysmal wall.Idiopathic pulmonary arterial aneurysm is considered to be a possible cause of rupture, dissection of pulmonary artery, or cardiac sudden death. 3 Most of the pulmonary artery dissections are diagnosed only at necropsy, because of their high mortality rate. The natural history of an untreated idiopathic pulmonary artery aneurysm has not been well elucidated. A case report suggested that the long-term outcome of pulmonary artery aneurysm was favorable without surgical treatment. 4 It is unclear whether there is a size hinge point similar to aortic aneurysms in which the risk of complication increases. Although some recommend medical treatment for such patients, 4 others recommend surgical intervention for those with an aneurysm that has a diameter of 60 mm or greater. 2 Disclosures

BackgroundPeripheral venoarterial extracorporeal membranous oxygenation (ECMO) support is effective in patients with cardiogenic shock or fatal arrhythmia due to fulminant myocarditis. The clinical courses of fulminant myocarditis are still uncertain; therefore, it is difficult to determine the appropriate time for discontinuing ECMO or converting to a ventricular assist device. The purpose of this study was to investigate the prognosis of patients with fulminant myocarditis managed by ECMO.MethodsTwenty-two consecutive patients with fulminant myocarditis managed by peripheral venoarterial ECMO between 1999 and 2013 were enrolled.ResultsSurvival to discharge was 59% (13 patients), and in-hospital mortality was 41% (9 patients). The age in the survivor group was significantly lower than that in the non-survivor group (survivor group vs. non-survivor group; 36.5 ± 4.1 vs. 60.2 ± 5.0 years, p = 0.001). Although the ECMO support duration was similar between the groups (181 ± 22 vs. 177 ± 31 h), the rate of complication related to ECMO was significantly lower in the survivor group (15.3% vs. 66.6%, p = 0.02). When comparing the laboratory data during ECMO management between the groups, the serum bilirubin level on day 7 was significantly lower in the survivor group (total: 4.6 ± 2.8 vs. 13.7 ± 10.8 mg/dL, p = 0.014; direct: 2.2 ± 0.5 vs. 9.8 ± 4.5 mg/dL, p = 0.009).ConclusionsFulminant myocarditis is associated with high mortality rates despite ECMO. An older age and complications related to ECMO are associated with poor prognosis.

Since the number of elderly patients suffering from acute myocardial infarction (AMI) has been increasing in developed countries, primary percutaneous coronary intervention (PCI) for the very elderly aged " 80 years old is already common. The study aimed to examine the determinants of in-hospital death among the very elderly with AMI in current PCI era. We included 412 consecutive AMI patients aged "80 years old who received PCI to the culprit lesion; however, 42 patients (10.2%) died during the index hospitalization. Thus, univariate and multivariate logistic regression analyses were performed to identify the determinants of in-hospital death. Of note, the modified KATZ index, which is a seven-point scale ranging from 0 to 6 (0 point indicating no dependence and six points indicating full dependence), was calculated to evaluate pre-admission activity of daily living (ADL). In multivariate analysis, cardiac arrest (

Objectives This study aimed to compare the mid-term clinical outcomes of intravascular ultrasound (IVUS)-calcified nodules between percutaneous coronary intervention (PCI) with and without rotational atherectomy (RA). Background There has been a debate whether to use RA for the revascularization of calcified nodule. Although RA can ablate the calcified structure within calcified nodule and may facilitate adequate stent expansion, RA may provoke severe coronary perforation, because calcified nodule typically shows eccentric calcification. Methods We included 204 lesions with IVUS-calcified nodule, and divided into 73 lesions treated with RA (RA group) and 131 lesions without RA (non-RA group). After propensity-score matching, 42 lesions with RA (matched RA group) and 42 lesions without RA (matched non-RA group) were selected. We compared the clinical characteristics and outcomes between the 2 groups before and after propensity-score matching. The primary endpoint was ischemia-driven target vessel revascularization (TVR) within 1 year. Results Acute lumen area gain on IVUS was comparable between the matched RA group and matched non-RA group (3.9 ± 2.1 mm2 vs. 3.4 ± 1.6 mm2, p = 0.18). The stent malapposition at calcified nodules was frequently observed in both groups. The ischemia-driven TVR was not different between the 2 groups before (p = 0.82) and after propensity score-matching (p = 0.87). Conclusions The use of RA could not reduce the incidence of ischemia-driven TVR in lesions with IVUS-calcified nodule. Our results do not support the routine use of RA for lesions with IVUS-calcified nodule.