Background: The benefits of transradial access (TRA) over transfemoral access (TFA) for bifurcation percutaneous coronary intervention (PCI) are uncertain because of the limited availability of device selection. This study aimed to compare the procedural differences and the in-hospital and long-term outcomes of TRA and TFA for bifurcation PCI using secondgeneration drug-eluting stents (DESs). Methods: Based on data from the Coronary Bifurcation Stenting Registry III, a retrospective registry of 2,648 patients undergoing bifurcation PCI with second-generation DES from 21 centers in South Korea, patients were categorized into the TRA group (n = 1,507) or the TFA group (n = 1,141). After propensity score matching (PSM), procedural differences, in-hospital outcomes, and device-oriented composite outcomes (DOCOs; a composite of cardiac death, target vessel-related myocardial infarction, and target lesion revascularization) were compared between the two groups (772 matched patients each group). Results: Despite well-balanced baseline clinical and lesion characteristics after PSM, the use of the two-stent strategy (14.2% vs. 23.7%, P = 0.001) and the incidence of in-hospital adverse outcomes, primarily driven by access site complications (2.2% vs. 4.4%, P = 0.015), were significantly lower in the TRA group than in the TFA group. At the 5-year follow-up, the incidence of DOCOs was similar between the groups (6.3% vs. 7.1%, P = 0.639). Conclusion The findings suggested that TRA may be safer than TFA for bifurcation PCI using second-generation DESs. Despite differences in treatment strategy, TRA was associated with similar long-term clinical outcomes as those of TFA. Therefore, TRA might be the preferred access for bifurcation PCI using second-generation DES.

Background and Objectives: Ultimaster™, a third-generation sirolimus-eluting stent using biodegradable polymer, has been introduced to overcome long term adverse vascular events, such as restenosis or stent thrombosis. In the present study, we aimed to evaluate the 12-month clinical outcomes of Ultimaster™ stents in Korean patients with coronary artery disease. Methods: This study is a multicenter, prospective, observational registry across 12 hospitals. To reflect real-world clinical evidence, non-selective subtypes of patients and lesions were included in this study. The study end point was target lesion failure (TLF) (the composite of cardiac death, target vessel myocardial infarction [MI], and target lesion revascularization [TLR]) at 12-month clinical follow up. Results: A total of 576 patients were enrolled between November 2016 and May 2021. Most of the patients were male (76.5%), with a mean age of 66.0±11.2 years. Among the included patients, 40.1% had diabetes mellitus (DM) and 67.9% had acute coronary syndrome (ACS).At 12 months, the incidence of TLF was 4.1%. The incidence of cardiac death was 1.5%, MI was 1.0%, TLR was 2.7%, and stent thrombosis was 0.6%. In subgroup analysis based on the presence of ACS, DM, hypertension, dyslipidemia, or bifurcation, there were no major differences in the incidence of the primary endpoint. Conclusions The present registry shows that Ultimaster™ stent is safe and effective for routine real-world clinical practice in non-selective Korean patients, having a low rate of adverse events at least up to 12 months.

Background: Korea recently established 70 emergency medical service areas. However, there are many concerns that medical resources for stroke could not be evenly distributed through the country. We aimed to compare the treatment quality and outcomes of acute stroke among the emergency medical service areas. Methods: This study analyzed the data of 28,800 patients admitted in 248 hospitals which participated in the 8th acute stroke quality assessment by Health Insurance Review and Assessment Service. Individual hospitals were regrouped into emergency service areas according to the address of the location. Assessment indicators and fatality were compared by the service areas. We defined the appropriate hospital by the performance of intravenous thrombolysis. Results: In seven service areas, there were no hospitals which received more than 10 stroke patients for 6 months. In nine service areas, there were no patients who underwent intravenous thrombolysis (IVT). Among 167 designated emergency medical centers, 50 hospitals (29.9%) responded that IVT was impossible 24 hours a day. There are 97 (39.1%) hospitals that meet the definitions of appropriate hospital. In 23 service areas (32.9%) had no appropriate or feasible hospitals. The fatality of service areas with stroke centers were 6.9% within 30 days and 15.6% within 1 year from stroke onset than those without stroke centers (7.7%, 16.9%, respectively). Conclusions There was a wide regional gap in the medical resource and the quality of treatments for acute stroke among emergency medical service areas in Korea. The poststroke fatality rate of the service areas which have stroke centers or appropriate hospitals were significantly low.

Background/Aims: Cardiorespiratory fitness (CRF), as measured by maximal oxygen consumption (VO2max), is an important independent predictive factor of cardiovascular outcomes in patients with heart failure (HF). However, it is unclear whether conventional equations for estimating CRF are applicable to patients with HF with preserved ejection fraction (HFpEF). Methods: This study included 521 patients with HFpEF (EF ≥ 50%) whose CRF was directly measured by cardiopulmonary exercise test using a treadmill. We developed a new equation (Kor-HFpEF) for half of the patients in the HFpEF cohort (group A, n = 253) and validated it for the remaining half (group B, n = 268). The accuracy of the Kor-HFpEF equation was compared to that of the other equations in the validation group. Results: In the total HFpEF cohort, the directly measured VO2max was significantly overestimated by the FRIEND and ACSM equations (p < 0.001) and underestimated by the FRIEND-HF equation (p <0.001) (direct 21.2 ± 5.9 mL/kg/min; FRIEND 29.1 ± 11.8 mL/kg/min; ACSM 32.5 ± 13.4 mL/kg/min; FRIEND-HF 14.1 ± 4.9 mL/kg/min). However, the VO2max estimated by the Kor-HFpEF equation (21.3 ± 4.6 mL/kg/min) was similar to the directly measured VO2max (21.7 ± 5.9 mL/kg/min, p = 0.124), whereas the VO2max estimated by the other three equations was still significantly different from the directly measured VO2max in group B (all p < 0.001). Conclusions Traditional equations used to estimate VO2max were not applicable to patients with HFpEF. We developed and validated a new Kor-HFpEF equation for these patients, which had a high accuracy.

Background: Exercise capacity is known to be an independent predictor of cardiovascular events and mortality. However, most previous studies were based on Western populations.Further study is warranted for Asian patients according to ethnic or national standards. We aimed to compare prognostic values of Korean and Western nomograms for exercise capacity in Korean patients with cardiovascular disease (CVD). Methods: In this retrospective cohort study, we enrolled 1,178 patients (62 ± 11 years;78% male) between June 2015 and May 2020, who were referred for cardiopulmonary exercise testing in our cardiac rehabilitation program. The median follow-up period was 1.6 years. Exercise capacity was measured in metabolic equivalents by direct gas exchange method during the treadmill test. The nomogram for exercise capacity from healthy Korean individuals and a previous landmark Western study was used to determine the percentage of predicted exercise capacity. The primary endpoint was the composite of major adverse cardiovascular events (MACE; all-cause death, myocardial infarction, repeat revascularization, stroke and hospitalization for heart failure). Results: A multivariate analysis showed that the risk of primary endpoint was more than double (hazard ratio [HR], 2.20; 95% confidence interval [CI], 1.10–4.40) in the patients with lower exercise capacity (< 85% of predicted) by Korean nomogram. The lower exercise capacity was one of the strong independent predictors along with left ventricular ejection fraction, age, and level of hemoglobin. However, the lower exercise capacity by Western nomogram could not predict the primary endpoint (HR, 1.33; 95% CI, 0.85–2.10). Conclusion Korean patients with CVD with lower exercise capacity have higher risk of MACE.Considering inter-ethnic differences in cardiorespiratory fitness, the Korean nomogram provides more suitable reference values than the Western nomogram to determine lower exercise capacity and predict cardiovascular events in Korean patients with CVD.

Background and Objectives: A recent study revealed that calcitonin gene-related protein (CGRP) plays an important role in inflammatory airway diseases. However, the influence of CGRP on chronic rhinosinusitis (CRS) has not been studied. This study investigated the expression, activity, and potential pathogenic role of CGRP in patients with CRS with nasal polyposis (CRSwNP).Subjects and Method Patients with CRSwNP and control subjects were enrolled. The CRSwNP group was divided according to the presence of eosinophilic polyps and non-eosinophilic polyps. Nasal polyps (NPs) and uncinate tissues (UTs) from patients with CRSwNP and UTs from control subjects were obtained to investigate the expression of α-/β-CGRP and chromogranin A. In addition, the expression patterns of cytokines following exposure to exogenous CGRP were analyzed in dispersed nasal polyp cells (DNPCs) from patients with eosinophilic or non-eosinophilic CRSwNP. The effects of CGRP on lipopolysaccharide (LPS)-induced nuclear factor-kappa light chain enhancer of activated B cells (NF-κB) signaling change were evaluated in THP-1 cells. Results: The expression of α-/β-CGRP and number of CGRP-producing cells were significantly higher in NPs from patients with CRSwNP than in UTs from controls. Exogenous CGRP decreased the expression of inflammatory cytokines and increased that of the anti-inflammatory cytokines in DNPCs from patients with eosinophilic nasal polyps (EPs) and also increased the expression of tissue remodeling-related and anti-inflammatory cytokines in DNPCs from patients with non-eosinophilic nasal polyps (N-EPs). CGRP inhibited the nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor (IκB) phosphorylation and NF-κB translocation in LPS-stimulated M1 macrophages. Conclusion CGRP expression in NPs may play a significant role in nasal polypogenesis through inflammatory modulation, and it could be a future target to modulate certain aspects of CRSwNP.

Purpose: We evaluated the diagnostic performance of LI-RADS version 2018 using gadoxetic acid enhanced MRI for recurrent but untreated HCC in patients with prior history of HCC. Materials and Methods: We enrolled 50 consecutive patients who 1) prior history of treatment of HCC, 2) underwent liver surgery for radiological/clinical diagnosis of new HCC between 2013 to 2018, 3) had gadoxetic acid enhanced MRI within one month before surgery, and 4) did not have more than five HCCs or infiltrative tumors only. Two radiologists reviewed MRI and determined the presence of LR3, LR4 and LR5 observations except previously treated tumors based on LI-RADS version 2018 in consensus. We sub-classified LR4 into LR4m (LR4 with major features only) and LR4u (LR4 upgraded from LR3 by ancillary features). LR4u were further sub-classified into LR4ua (with arterial phase hyperenhancement) and LR4un (without arterial phase hyperenhancement). Results: PPV for LR5, LR4 and LR3 observations for recurrent HCC were 100%, 61.5% and 25.0%, respectively. 100% (3/3) of LR4m were HCC. However, PPV of LR4u was 56.5%. PPV of LR4ua and LR4un were 73.3% and 25.0%, respectively. Sensitivity of LR5 and LR5+LR4 observations as a diagnostic threshold were 32.1% and 89.3%, respectively. Sensitivity for LR5+LR4m+LR4ua observations for diagnosis of HCC were 83.7% and significantly superior to that of LR5 without significant deterioration of specificity (75.0%). Conclusion In patients with prior history of HCC, LR4 observations by major features or with APHE may be regarded as recurrent HCCs given high sensitivity and comparable specificity/PPV to LR5 observations.

Objective: We aimed to evaluate the usefulness of arterial subtraction images for predicting the viability of hepatocellular carcinoma (HCC) after locoregional therapy (LRT) using gadoxetic acid-enhanced MRI and the Liver Imaging Reporting and Data System treatment response (LR-TR) algorithm. Materials and Methods: This study included 90 patients (mean age ± standard deviation, 57 ± 9 years) who underwent liver transplantation or resection after LRT and had 73 viable and 32 nonviable HCCs. All patients underwent gadoxetic acid-enhanced MRI before surgery. Two radiologists assessed the presence of LR-TR features, including arterial phase hyperenhancement (APHE) and LR-TR categories (viable, nonviable, or equivocal), using ordinary arterial-phase and arterial subtraction images. The reference standard for tumor viability was surgical pathology. The sensitivity of APHE for diagnosing viable HCC was compared between ordinary arterial-phase and arterial subtraction images. The sensitivity and specificity of the LR-TR algorithm for diagnosing viable HCC was compared between the use of ordinary arterial-phase and the use of arterial subtraction images.Subgroup analysis was performed on lesions treated with transarterial chemoembolization (TACE) only. Results: The sensitivity of APHE for viable HCCs was higher for arterial subtraction images than ordinary arterial-phase images (71.2% vs. 47.9%; p < 0.001). LR-TR viable category with the use of arterial subtraction images compared with ordinary arterial-phase images showed a significant increase in sensitivity (76.7% [56/73] vs. 63.0% [46/73]; p = 0.002) without significant decrease in specificity (90.6% [29/32] vs. 93.8% [30/32]; p > 0.999). In a subgroup of 63 lesions treated with TACE only, the use of arterial subtraction images showed a significant increase in sensitivity (81.4% [35/43] vs. 67.4% [29/43]; p = 0.031) without significant decrease in specificity (85.0% [17/20] vs. 90.0% [18/20]; p > 0.999). Conclusion Use of arterial subtraction images compared with ordinary arterial-phase images improved the sensitivity while maintaining specificity for diagnosing viable HCC after LRT using gadoxetic acid-enhanced MRI and the LR-TR algorithm.