DES Show Advantage over BMS for Heart Transplant Complication

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In patients who develop cardiac allograft vasculopathy after heart transplantation, drug-eluting stents (DES) are more effective than bare-metal stents (BMS) while conferring no additional risk, according to a study published online June 20, 2011, ahead of print in the American Journal of Cardiology.

Allograft vasculopathy is a rapid, progressive form of diffuse arterial narrowing that affects 50% of all orthotopic heart transplant patients by 5 years after transplantation. The best treatment is unknown, with bypass surgery and repeat transplantation each having significant drawbacks. PCI with BMS has been used as a palliative therapy, but restenosis rates remain high.

Researchers led by Jennifer A. Tremmel, MD, of Stanford University School of Medicine (Stanford, CA), retrospectively evaluated 34 consecutive cardiac transplant recipients at their center who received either BMS or DES for de novo vasculopathy from 1997 to 2009. DES consisted of sirolimus-eluting Cypher stents (Cordis, Miami Lakes, FL) or paclitaxel-eluting Taxus stents (Boston Scientific, Natick, MA), which were used exclusively from April 2003 forward. Patients treated prior to that date received only BMS.

Overall, patients in the study received a total of 46 stents (27 DES and 19 BMS) for treatment of 38 lesion segments. Baseline clinical and procedural characteristics were similar between the groups. Although twice as many patients in the DES group had diabetes, the difference was not statistically significant. In addition, baseline quantitative coronary angiography revealed no difference in the reference diameter, lesion length, or pre- or post-procedural minimal luminal diameter.

Angiographic, Clinical Endpoints Favor DES

At 12 months, mean lumen loss was significantly lower in the DES group than the BMS group, while there was a trend toward a lower rate of  in-stent restenosis. Rates of TLR and the composite of nonfatal MI and cardiac death also favored DES. (table 1).

Table 1. Angiographic and Clinical Outcomes at 12 Months

There was no significant difference in the rates of revascularization for non-target lesions  between the 2 groups. In addition, no patients experienced stent thrombosis.

According to the authors, their study is the first to suggest a clinical advantage of DES over BMS, although some previous studies showed a trend toward less restenosis with DES.

“Data have shown that transplant patients with restenosis have greater cardiac mortality related to rapid [cardiac allograft vasculopathy] progression than those without restenosis; however, presumably this represents a patient’s overall tendency toward neointimal hyperplasia rather than being related to restenosis according to stent type,” the investigators write. “Still, the heightened ability to focally lower restenosis might prolong the interval to cardiac events, specifically nonfatal myocardial infarction and cardiac death. Future investigations with follow-up [longer than] 1 year would be informative.”

The impact of newer-generation DES remains to be seen, they add.

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Source:
Tremmel JA, Ng MKC, Ikeno F, et al. Comparison of drug-eluting versus bare metal stents in cardiac allograft vasculopathy. Am J Cardiol. 2011;Epub ahead of print.

 

 

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