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Rotational atherectomy (RA) is considered to be the last resort for a severely calcified coronary artery lesion. Severe complications such as vessel perforation or burr entrapment is closely associated with forceful burr manipulation during RA. The instructions for use of Rotablator (Boston Scientific, Marlborough, MA, USA) prohibit forceful burr manipulation when rotational resistance occurs. Nevertheless, RA operators tend to forcefully manipulate the burr if it cannot cross the lesion, because there has been no established strategy for an uncrossable lesion. We present a case with a severely calcified coronary lesion, which was uncrossable by a burr 1.5 mm with RotaWire Floppy (Boston Scientific). We intentionally switched 2 burrs (1.5-mm and 1.25-mm) and 2 RotaWires (Floppy and Extra-support) to cross the lesion. Uniquely, we downsized the burr (from 1.5-mm to 1.25-mm) initially for better penetration force, and upsized the burr (from 1.25-mm to 1.5-mm) finally for better contact to the calcification within the lesion. Our case suggests that 4 different types of combinations might work in a mutually complementary manner for an uncrossable calcified lesion. < Learning Objective: In rotational atherectomy, severe complications such as vessel perforation or burr entrapment are closely associated with forceful burr manipulation. We present a case with a severely calcified coronary lesion, which was uncrossable by a burr 1.5 mm with RotaWire Floppy. We intentionally switched 2 burrs and 2 RotaWires to cross the lesion. Our case suggests that 4 different types of combinations might work in a mutually complementary manner for an uncrossable calcified lesion.>

Aims To investigate the exact prevalence of glucose metabolism disorders, and their impact on left atrial (LA) remodelling and reversibility in patients with atrial fibrillation (AF). Methods and results We examined 204 consecutive patients with AF who underwent their first catheter ablation (CA). Oral glucose tolerance test was used to evaluate glucose metabolism disorders in 157 patients without known diabetes mellitus (DM). Echocardiography was performed before and 6 months after CA. Oral glucose tolerance test identified abnormal glucose metabolism in 86 patients [11 with newly diagnosed DM, 74 with impaired glucose tolerance (IGT) and 1 with impaired fasting glucose (IFG)]. Ultimately, 65.2% of patients had abnormal glucose metabolism. Diabetes mellitus group had the worst LA reservoir strain and LA stiffness (both P &lt; 0.05), while there was no significant difference in baseline LA parameters between normal glucose tolerance (NGT) group and IGT/IFG group. The prevalence of LA reverse remodelling (≥15% decrease in the LA volume index at 6 months after CA) was significantly higher in NGT group compared with IGT/IFG and DM group (64.1 vs. 38.6 vs. 41.5%, P = 0.006). Both DM and IFG/IGT carry a significant risk of lack of LA reverse remodelling independent of baseline LA size and AF recurrence. Conclusion Approximately 65% of patients with AF who underwent their first CA had abnormal glucose metabolism. Patients with DM had significantly impaired LA function compared with non-DM patients. Impaired glucose tolerance/IFG as well as DM carries significant risk of unfavourable LA reverse remodelling. Our observations may provide valuable information regarding the mechanisms and therapeutic strategies of glucose metabolism-related AF.

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Aims Patients with chronic coronary syndrome (CCS) suffer from subsequent cardiovascular events, even after complete revascularization; thus, elucidation of the underlying pathophysiological mechanisms is required. Epicardial adipose tissue (EAT) is increasingly recognized as a metabolically active organ with a key role in the pathogenesis of metabolic-related cardiac diseases. The present study investigated the association between EAT burden and left heart remodeling in patients with CCS. Methods and Results We studied 267 CCS patients (210 men; 71 ± 9 years) with complete revascularization and normal left ventricular (LV) ejection fraction who underwent follow-up echocardiography. All patients underwent the measurement of EAT thickness and speckle-tracking analysis to evaluate LV global longitudinal strain (LVGLS) and left atrial (LA) phasic strain. The mean EAT thickness was 5.0 ± 1.8 mm. Age, sex, body mass index and diabetes mellitus were independently associated with EAT thickness (all p &lt; 0.05). Multivariable linear regression analysis demonstrated that EAT thickness was significantly associated with LV mass index, early diastolic mitral annular velocity and LA conduit strain independent of age, sex, and cardiovascular risk factors (all p &lt; 0.05). On the other hand, there was no relationship between EAT thickness and LV systolic parameters including LV ejection fraction and LVGLS. Conclusions CCS patients with increased EAT thickness had unfavorable left heart remodeling. The assessment of EAT thickness by echocardiography may have clinical utility as a simple surrogate to aid in risk stratification for impaired left heart function in CCS patients.