Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp dge re-stenosis is a major problem following sirolimus-eluting stent (SES) implantation for the treatment of native coronary artery lesions. 1 To minimize the incidence of these events, longitudinal positioning of SES is considered to be critically important. Due to the current lack of a standard guideline, however, practitioners must decide the landing position by a somewhat arbitrary assessment in the actual clinical setting. The SIRIUS trial that used intravascular ultrasound (IVUS) to investigate lesions reported that the residual plaque burden is associated with edge re-stenosis. 2 Of particular interest, edge re-stenosis was mostly observed in cases of residual plaque area (PA)/volume >50% at the stent margins. According to these observations, we (1) determined unique stepwise IVUS criteria to achieve optimal longitudinal positioning of SES using plaque burden at the peri-stent margins, which might fit a variety of actual lesion subsets (Figure 1), and (2) have put them to practical use continuously. Because long-term clinical and angiographic outcomes are currently available, we verified these new criteria in terms of achievability and their actual impact on margin re-stenosis rates and long-term clinical outcomes. Methods Study PopulationFrom January 2005 to April 2006, 162 consecutive stable angina patients whose native coronary lesions were electively treated with SES were studied at Tokai University School of Medicine. SES were implanted according to the IVUS criteria (Figure 1) of longitudinal stent positioning, which were determined with reference to the previous investigation. 2 A cut-off for plaque burden of <50% in the criteria was determined by either (1) visual assessment with reference to Figure 1 or (2) measurement by manual tracing using a software package installed in the IVUS console during the procedure. The consecutive patients who had completion of poststenting (after final balloon dilation) IVUS pullback were the subjects of the present study. Patients with native coronary

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A 52-year-old woman presenting with shortness of breath and having no related past medical history was diagnosed with takotsubo cardiomyopathy. However, she revealed respiratory failure atypical with takotsubo cardiomyopathy. We diagnosed myasthenia gravis with myasthenic crisis by acetylcholine receptor-binding antibody titer with mediastinal tumor. Physical or emotional stress is well known to trigger the onset of takotsubo cardiomyopathy. Similarly, myasthenia crisis is also triggered by stress. Here, we report a case of simultaneous occurrence of takotsubo cardiomyopathy and myasthenia crisis.