Volume 2 – Number 2 – September 2016

12 January inArchive

Beginning with the history of interventional cardiology in Singapore, this edition of AsiaIntervention is packed with technical reports, imagery and clinical articles, including recommendations from the Asia Pacific Expert Group on technical considerations and practical guidance using BRS, and articles from several registries: one from Jordon on predictions of mortality using the GRACE risk score and another on three-year outcomes of the RESOLUTE China Registry.

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Volume 1 – Number 2 – September 2015

23 September inArchive

The second issue highlights STEMI care in low-to-middle income countries,  debates biodegradable vs durable polymers and asks if the DAPT trial will change practice in the Asia-Pacific region.  Also the role of remote ischaemic preconditioning on myocardial injury in stable patients is reported. And finally how would you treat a common femoral arterial haemorrhage and deep vein thrombosis post percutaneous coronary intervention for non-STelevation myocardial infarction?

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Volume 2 – Number 1 – January 2016

15 January inArchive

This issue of AsiaIntervention begins with an overview of the evolution of interventional cardiology in India and continues with articles touching on such topics as the difference in sizing of the aortavalvular complex by Japanese and French teams, a study evaluating the spatial distribution and magnitude of coronary calcification and stent expansion and two “How should I treats”, from Thailand and Singapore with invited experts from Europe.

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Volume 1 – Number 1 – January 2015

23 September inArchive

AsiaIntervention Journal is an international, English language, peer-reviewed journal whose aim is to create a forum of high quality
research and education in the field of percutaneous and surgical cardiovascular interventions.
It is released twice, in paper and electronic formats. AsiaIntervention will apply for indexation in Science Citation Index® (ISI), SciVerse
Scopus, MEDLINE®/PubMed®.

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Perspectives on cardiovascular interventions in Asia

22 September inArchive

Asia accounts for over 60% of the world population. Alongside its tremendous economic development, the Asian region has experienced the most rapid expansion in interventional cardiology worldwide: approximately 1.2 million percutaneous coronary interventions (PCI) performed in 2014; broad use and good immediate and long-term outcomes of percutaneous treatments for congenital atrial or ventricular septal defect and patent ductus arteriosus (PDA); the introduction of novel techniques and devices, such as transcatheter aortic valve replacement (TAVR), MitraClip (Abbott Vascular, Santa Clara, CA, USA) implantation, left appendage occlusion, and the Parachute® device (CardioKinetix Inc., Menlo Park, CA, USA) to isolate the malfunctioning left ventricular portion in ischaemic heart failure, among others.

Research and development (R&D) of interventional devices has also been unfolding at an unprecedented rate in Asia. Beyond the long-standing R&D centres in Japan for angiography devices such as catheters, guidewires, balloons, stents, drug-eluting stents (DES), and microcatheters (notably those used to treat chronic total occlusion [CTO]), recently, in China and India, we have witnessed the active development of drug-eluting stents (DES), biodegradable polymer DES, fully biodegradable scaffolds and TAVR devices.
Biodegradable sirolimus-eluting scaffolds developed in China are  undergoing clinical trials, and a safe and effective self-expandable TAVR device manufactured in China is awaiting approval from the Chinese Food and Drug Administration (CFDA).

The official launch of AsiaIntervention

06 August inArchive

AsiaIntervention, a new journal dedicated to the field of cardiovascular intervention with particular emphasis on scientific contributions from the Asia-Pacific region, is officially launched with this inaugural issue. The Asia-Pacific interventional cardiology community ought to be congratulated for this achievement.

Alongside its formidable economic development, the Asia-Pacific region, which accounts for over 60% of the world population, has experienced the most rapid expansion in interventional cardiology worldwide. This new era for the region has witnessed an ever growing number of percutaneous coronary interventions (PCI), and the introduction in many Asian countries of transcatheter aortic valve replacement (TAVR) and novel technologies, such as a mitral clip and parachute device to isolate the malfunctioning portion of the left ventricle in ischaemic heart disease, among others.

AsiaIntervention – “you cannot open a book without learning something”

05 August inArchive

In 2005, together with a small team of dedicated individuals, we started EuroIntervention. In the subsequent years, the journal has evolved into an important academic publication within the field of interventional cardiology. Today, EuroIntervention’s submissions continue to grow and the journal has a more than respectable impact factor with its website frequently visited and PDF’s downloaded. The Journal is present not only at EuroPCR but also at other international meetings. Two aspects come to mind when assessing the success of the Journal – the concept of teamwork, and achieving and maintaining a solid and esteemed reputation.

We have been lucky to have been supported by a great team not only “front stage” but also “behind the scenes”. These are colleagues who trust the journal with their papers when submitting and those who advise and guide us in the review process. This great team effort has ensured that the Journal is not only well regarded but also respected within the field and for this we remain sincerely grateful.

The role of the APSIC in the future of interventional cardiology

04 August inArchive

The Asian-Pacific Society of Interventional Cardiology (APSIC) was officially formed during the third live demonstration course held in Singapore in July 1993, in the presence of 35 representatives from the region. Founded initially by 11 eminent cardiologists who were convinced that the growth in interventional cardiology in the 21st century would be in Asia, the group had the vision to provide a forum in which Asia-Pacific experts could share knowledge and expertise in the field of catheter-based therapies, and to develop a joint academic research and education programme. Membership of APSIC was to be conducted through their national cardiac societies. It would come under the umbrella of the Asian-Pacific Society of Cardiology (APSC) and the President would be a member of the APSC Council.

Drs Richard Ng and Arthur Tan were elected to be the first President and Secretary General of APSIC, respectively, for a term of three years. An APSIC newsletter was first published on 29 September 1993, designed to feature regular updates of scientific development, and to share interesting cases and literature reviews among the interventional cardiology fraternity. The APSIC website ( was set up in 2006 to facilitate information flow among members and others.

Peri-stent contrast staining: a stain on the long-term safety of DES?

03 August inArchive

Drug-eluting stents (DES) have contributed to lowering rates of repeat revascularisation due to a reduction in the occurrence of instent restenosis (ISR)1. However, the risk of stent thrombosis (ST) remains prevalent in the DES era, with several studies associating the use of DES with an increased occurrence of late and very late stent thrombosis (VLST). Delayed healing of the stented arterial segment which involves chronic inflammation with persistent fibrin deposition, and ultimately incomplete stent strut coverage, has been recognised as one of the underlying mechanisms for the late occurrence of ST4. Vessel remodelling, with a larger diameter of the stented segment, predisposes to incomplete stent apposition (ISA), a known risk factor for VLST5,6. Recently, Imai et al described the angiographic phenomenon of peri-stent contrast staining (PSS), defined as contrast staining outside the stent struts insufficient to fulfil the definition of a coronary artery aneurysm, as an angiographic correlate of ISA7 that may help identify patients with higher risk of VLST.

New-generation drug-eluting stents in patients with complex coronary artery disease: still a “work in progress”?

02 August inArchive

Treatment of complex obstructive coronary artery disease remains a challenge for physicians in practice around the globe. However, drug-eluting stent (DES) therapy represents an important breakthrough technology which has enabled cardiologists to offer percutaneous intervention to patients with complex disease patterns who were formerly precluded from such treatment due to a high rate of stent failure, mainly as a result of in-stent restenosis. Nevertheless, rates of certain adverse clinical events after stenting remain higher in patients with complex disease and in those where the indication for stenting is deemed “off-label” in comparison to patients with more straightforward disease.

Early-generation DES were associated with some important limitations, including very late stent thrombosis and late catch-up restenosis. The basis for these problems seems to be systematic delayed healing of the stented arterial segment. Although undoubtedly multifactorial in aetiology, persistent inflammatory response to the durable polymer coatings used on these stents plays a central role. However, iterative development of newer-generation DES has resulted in improved healing after stent implantation and has further improved patient outcomes with reduced rates of restenosis and stent thrombosis in comparison to early-generation DES.

Resolute zotarolimus-eluting coronary stent implantation in Asian patients with multivessel disease and long lesions: clinical outcomes in RESOLUTE Asia

01 August inArchive

Two thirds of patients treated with drug-eluting stents (DES) for coronary artery disease in all-comers studies underwent percutaneous coronary intervention (PCI) of complex lesions. Long lesions (>18 mm) and multivessel treatment accounted for 20% and 60% of patients in the RESOLUTE All Comers study, respectively. Longer stent length is associated with higher risk for restenosis. In a study comparing single-vessel and multivessel treatment with DES, the six-month incidence of major adverse cardiac events was more than double among patients undergoing multivessel stenting6. The objective of the RESOLUTE Asia (R-Asia) study is to assess outcomes in Asian patients treated with the Resolute™ zotarolimus- eluting stent (R-ZES; Medtronic Inc., Santa Rosa, CA, USA) for multivessel treatment (R-Asia Dual Vessel cohort) and in long lesions (R-Asia 38 mm cohort).

The pooled one-year outcomes of patients treated with the 38 mm R-ZES in the R-Asia 38 mm cohort and the RESOLUTE US (R-US) 38 mm cohort (n=269) have been previously published. Target lesion failure (TLF) at one year was 5.4% and comprised 1.4% clinically driven target lesion revascularisation (TLR), 0.9% cardiac death, and 3.6% target vessel myocardial infarction (MI). Outcomes in the R-Asia Dual Vessel cohort have not been published.

Impact of thrombus aspiration in patients with ST-elevation versus non-ST-elevation acute coronary syndrome: a report from a multicentre Japanese PCI registry

31 July inArchive

A reduction in coronary flow due to thrombus formation is observed in patients with acute coronary syndrome (ACS) as well as in those with ST-segment elevation myocardial infarction (STEMI) and non-STEMI/unstable angina (NSTEMI/UA). Various pharmacological and device-based strategies have been proposed for the direct intervention on this thrombus formation, among which is manual thrombus aspiration (TA). TA is considered to be a simple, safe, and effective procedure for preventing microvascular obstruction and improving short-term patient prognosis. The clinically effective application of TA during primary percutaneous coronary intervention (PCI) in patients presenting with STEMI – while theoretically plausible – remains a controversial topic, despite a number of randomised clinical trials and meta-analyses published in the literature.

Thrombus formation is the prevailing cause of NSTEMI/UA and accounts for 50-60% of cases of patients presenting with ACS. The risks associated with NSTEMI/UA are known to be similar to those of STEMI. In the clinical setting, NSTEMI/UA patients frequently undergo TA to reduce the risk of distal embolisation, particularly when an angiographically proven intracoronary thrombus is present. However, clinical studies investigating the application and effectiveness of TA in the context of NSTEMI/UA remain sparse.

Second-generation everolimus-eluting stents demonstrate better vascular function, less thrombus formation, and less yellow intima than first-generation drug-eluting stents

30 July inArchive

Drug-eluting stents (DES) have significantly reduced in-stent restenosis and target lesion revascularisation after percutaneous coronary intervention (PCI) as compared with bare metal stents (BMS). In spite of these benefits, concern over increased stent thrombosis (ST) still exists. Although the incidences of ST are low, ST is an immediate life-threatening complication and may occur consistently up to at least five years after implantation of first-generation DES, sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES). Several pathophysiological factors could be associated with ST, such as delayed re-endothelialisation, incomplete stent strut coverage, prolonged inflammation, hypersensitivity reactions, late acquired malapposition, strut fractures, and neoatherosclerosis. In particular, delayed re-endothelialisation and incomplete stent strut coverage have been considered as significant factors with regard to ST in human autopsy studies. The use of durable polymer coating, the thickness of the stent struts, and the dose of the antiproliferative drug and its release kinetics in first-generation DES have been implicated as important contributory factors in these issues.

Meanwhile, second-generation DES, including everolimus-eluting stents (EES), have been developed with different drugs, more biocompatible polymers, improved drug release kinetics and thinner stent struts. Indeed, EES showed better outcomes including a lower risk of ST compared with first-generation DES in realworld patients. This favourable clinical performance might be associated with better vascular response to EES. However, there have been few investigations on endothelial function and arterial healing in EES.

Site-specific neoatherosclerosis assessed by optical coherence tomography in patients with in-stent restenosis

29 July inArchive

In-stent neoatherosclerosis is an important contributing mechanism of late stent failure, such as very late stent thrombosis and in-stent restenosis (ISR), after both bare metal stent and drug-eluting stent implantation. However, the site-specific patterns of neointimal characteristics in ISR lesions still remain unclear. In native coronary artery disease, high-risk atherosclerotic plaques with a large necrotic core are prone to developing at bifurcation sites which are subject to abnormal conditions of endothelial shear stress. Even though bifurcation stenting has been predisposed to stent thrombosis and ISR, the frequency and distribution of unstable neointima which develops after bifurcation stenting has not been known. The aims of this study were to use optical coherence tomography (OCT) to detect advanced neoatherosclerosis in patients with ISR and characterise the patterns of neoatherosclerosis at different sites, namely restenotic lesions located at bifurcation versus non-bifurcation sites and at stent edge versus non-edge segments.

Fate and clinical significance of angiographically visible stent malapposition after drugeluting stent implantation: a long-term clinical follow-up study

28 July inArchive

The initial success of drug-eluting stents in ameliorating restenosis has been tempered by the recognition of an apparently higher incidence of late stent-related complications relative to bare metal stents, including very late stent thrombosis (VLST). Amongst other factors, VLST has been linked to incomplete stent apposition as detected by intravascular ultrasound and/or optical coherence tomography. However, these invasive imaging modalities are not in widespread routine clinical use, and the majority of coronary interventions remain guided by conventional x-ray angiography alone.

While Alfonso and co-workers reported that three patients suffered from VLST associated with angiographic coronary aneurysm, Imai et al described the phenomenon of peri-stent contrast staining (PSS), which they defined as contrast staining outside stent struts insufficient to fulfil the definition of a coronary artery aneurysm (localised dilatation of the lumen; >50% of the diameter of associated reference vessel segment) in a single-centre retrospective cohort study.

Short-term effects of Nano+™ polymer-free sirolimus-eluting stents on native coronary vessels: an optical coherence tomography imaging study

27 July inArchive

Bare metal stents (BMS) have practically been replaced by drugeluting stents (DES), as previous trials have shown a reduction of in-stent-restenosis and repeat revascularisation. To prevent the formation of neointimal hyperplasia, current DES are coated with a thin polymer film which regulates the amount of drug that is eluted into the treated vessel. Accumulating evidence shows that permanent polymer could trigger a chronic inflammatory response, which is characterised by a delayed re-endothelialisation, resulting in incomplete strut coverage and the potential for late stent thrombosis (LST). Based on these considerations, newer generations of DES have focused on the safety profile, changing from durable polymer to biodegradable polymer and ultimately to polymer-free stents in order to diminish vascular inflammation further. The assessment of vascular repair (i.e., to quantify strut coverage) after stent implantation by using optical coherence tomography (OCT) has shown that strut coverage is higher in biodegradable polymer stents than in permanent polymer stents. So far, there have been only a few studies assessing strut coverage at a very short-term time point (three months). Also, there have been only two OCT studies which examined the patterns of strut coverage in polymer-free stents. In the present study, the polymer-free stent with a nano-sized-pore surface has been considered as an alternative modality of local drug delivery. We hypothesised that polymer-free stents have an early arterial healing, thereby reducing the risk of late stent thrombosis, and a controlled growth of neointima, which may reduce the likelihood of restenosis. In our present study, we sought to evaluate the extent of three-month neointimal coverage after the implantation of polymer-free nano-sized-pore surface sirolimus-eluting stents (SES) (Nano+™, Lepu Medical, Beijing, China).

Importance of confirmation by instant stent-accentuated three-dimensional optical coherence tomography during bifurcation stenting: far distal rewiring of iSA3D-OCT

26 July inArchive

An 83-year-old man with effort angina was admitted for percutaneous coronary intervention due to a stenosis in the ostial left anterior descending artery (LAD). After predilatation, the left main LAD was stented with a 3.5×24 mm 2-link biolimus-eluting stent (Nobori™; Terumo, Tokyo, Japan). After proximal optimisation technique and rewiring to the left circumflex artery, the distal rewiring was confirmed by two-dimensional modalities. Instant stent-accentuated three-dimensional optical coherence
tomography (iSA3D-OCT) was reconstructed in about 30 s from OCT (Dragonfly™ JP; St. Jude Medical, St. Paul, MN, USA) by ImageJ v1.47 (National Institutes of Health, Bethesda, MD, USA) with self-made macro programs. According to intraprocedural iSA3D-OCT, the recrossed wire passed through the far distal cell limited the expansion by the link.

Long-term clinical outcomes of mechanical versus bioprosthetic aortic valve replacement in older patients

25 July inArchive

The current American Heart Association guidelines recommend mechanical valves for aortic valve replacement (AVR) in patients younger than 60 years, and bioprosthetic valves in patients older than 70 years. Either a bioprosthetic or a mechanical valve is recommended between 60 and 70 years. This grey zone reflects the current trend towards increasing use of bioprostheses in progressively younger patients, and also the complexities and trade-offs of selecting an aortic valve prosthesis in older patients. Patients with mechanical valves require lifelong anticoagulation, and risk of bleeding events increases with advancing age. In contrast, risk of reoperation in patients with bioprosthetic valves increases with time and decreases with advancing age.

Two historic randomised clinical trials compared outcomes after valve replacement with first-generation bioprosthetic and mechanical valves. Although these trials are notable for their prospective, randomised design, their major limitations are that comparisons were made between first-generation valves, and most of the study population in these trials was under 60 years of age. Furthermore, recent innovation in transcatheter aortic valve replacement (TAVR) is applicable to replace deteriorated biological prostheses, which may affect the strategy in case of reoperation for octogenarians and their late survival.

How should I treat progression of disease of the jailed left anterior descending ostium after bioresorbable vascular scaffold implantation in the left circumflex?

24 July inArchive

A 60-year-old male re-presented with stable angina (CCS class II) and equivocal exercise treadmill test 12 months after undergoing previous elective percutaneous coronary intervention (PCI) with implantation of a bioresorbable vascular scaffold (BVS) for ostial and proximal left circumflex (LCx) lesions. Other past medical history of note included diabetes mellitus, chronic kidney disease (CKD) stage 4 and hypertension.

With regard to his index procedure, he had undergone elective PCI for CCS III stable angina with implantation of a 3.0×28 mm Absorb (Abbott Vascular, Santa Clara, CA, USA) BVS for an ostial and proximal left circumflex (LCx) lesion with final left main stem bifurcation kissing balloon inflation (KBI). According to optical coherence tomography (OCT) findings, prior to KBI, the left anterior descending artery (LAD) orifice was jailed
by BVS struts. Hence, KBI with a 3.0×20 mm non-compliant (NC) (left main coronary artery [LMCA]-LCx) and a 2.5×20 mm NC balloon (LMCA-intermediate) was performed. Though repeat OCT imaging post-KBI was not obtained due to background CKD, the final angiogram indicated an excellent result.