Coronary artery disease
Value of Drug-Eluting Stents in Cardiac Transplant Recipients

https://doi.org/10.1016/j.amjcard.2008.10.042Get rights and content

Transplant allograft vasculopathy (TAV) was a leading cause of death in cardiac transplant recipients after the first year of transplantation. Whether drug-eluting stents (DESs) performed better than bare-metal stents (BMSs) for the treatment of patients with discrete epicardial stenosis was unknown. The aim was to determine the safety and efficacy of DESs compared with BMSs in the treatment of patients with TAV. Outcomes of 32 patients sequentially treated using DESs for TAV were retrospectively reviewed and compared with a historic cohort of 35 patients treated sequentially with BMSs for TAV. Patients treated with DESs were also compared with age- and gender-matched cardiac transplant controls to determine differences in survival. After adjustment for baseline risk factors, there was no difference in 1-year survival between patients treated with DESs or BMSs for TAV. Restenosis rates at 1 year were 49% in lesions treated using BMSs and 19% in those treated using DESs. Compared with an age- and gender-matched control group of cardiac transplant patients who did not have discrete obstructive epicardial TAV, patients who required treatment with DESs for epicardial obstructive disease had significantly worse survival. In conclusion, treatment of patients with TAV with DESs did not seem to alter the natural deleterious history of this disease process.

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Methods

We retrospectively reviewed the charts of all cardiac transplant recipients (n = 32) from Columbia University Medical Center, New York, New York, who were treated sequentially with DESs for TAV from April 2003 onward, when sirolimus-eluting stents (SESs) became available. A historic cohort2 of patients (n = 35) who sequentially received BMSs was used for comparison. Additionally, a second comparator control group of age- and gender-matched transplant recipients (n = 355) without obstructive

Results

Of a population of 1,628 transplant recipients, 32 patients underwent implantation of DESs from February 2004 to August 2007. Patient characteristics are listed in Table 1. Average age at transplantation was 46 years, and ¼ of patients were women. Sixteen patients underwent transplantation for nonischemic cardiomyopathy, and 16 patients, for ischemic cardiomyopathy. Prevalences of diabetes (34%) and hypertension (82%) were high, and 75% of patients were receiving treatment with statins.

Discussion

This study examined the use of DESs as a treatment for patients with TAV. Although the cohort of patients with DESs had less in-stent restenosis (18.6%) than the cohort of patients who received BMSs (49%), risk-adjusted survival in the 2 groups of patients was similar. When TAV requiring PCI has developed, the 1-year mortality rate was 32% and the 2-year mortality rate was 41%, indicating a particularly grim prognosis. Therefore, stent implantation with DESs did not appear to alter the

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Dr. Moses was supported by Cordis, Warren, New Jersey, the manufacturer of Cypher, and is on the advisory board for MIV Therapeutics, Vancouver, Canada, and Caliber Therapeutics, Boston, Massachusetts. Dr. Leon is on the scientific advisory board for Abbott Vascular Santa Clara, California, Boston Scientific Corporation, Natick, Massachusetts, Cordis, and Medtronic Vascular, Santa Clara, California. Dr. Kirtane received an honorarium from Boston Scientific and Medtronic Vascular and was a consultant/SAB/Speakers' Bureau for Abbott Vascular and received lecture fees/consultant.

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