Allograft vasculopathy
Re-stenosis After Drug-eluting Stents in Cardiac Allograft Vasculopathy

https://doi.org/10.1016/j.healun.2008.02.010Get rights and content

Background

Cardiac allograft vasculopathy (CAV) constitutes a primary cause of death after heart transplantation. Balloon angioplasty and bare metal stents have been used for revascularization but they are associated with a high risk of re-stenosis. Limited data have shown favorable results with drug-eluting stents (DES). This study examines the rate of re-stenosis for DES in CAV as well as predictors for its occurrence.

Methods

Cardiac transplant patients who received at least one DES for a previously untreated coronary lesion were included. These patients were retrospectively followed until February 2007. Re-stenosis was defined as ≥50% lumen diameter narrowing on coronary angiography at the site of the DES.

Results

During the study period, 35 patients underwent percutaneous coronary intervention (PCI) on a total of 84 de novo lesions. The mean follow-up was 22 ± 14 months. Twenty-six (31%) lesions developed re-stenosis during follow-up. Re-stenosis rates were 18%, 21% and 26% at 6, 9 and 12 months, respectively. Predictors of re-stenosis included non-white race, ischemic etiology, intervention precipitated by symptoms and severe stenosis (≥90% stenosis) of the target lesion.

Conclusions

Use of DES has a favorable outcome when used in heart transplant patients for the treatment of CAV. An aggressive strategy for the treatment of CAV using DES may provide good long-term outcome compared with other available therapies.

Section snippets

Methods

The study population consisted of all cardiac transplant patients with a diagnosis of transplant vasculopathy who received at least one DES for a previously untreated coronary lesion at the University of Alabama at Birmingham (UAB). These patients were retrospectively followed until February 2007. At our institution, coronary angiograms are routinely performed to screen for CAV at yearly intervals. Once CAV is diagnosed or suspected, angiograms are performed at shorter intervals based on the

Results

The population consisted of 35 patients who underwent PCI with DES on 84 de novo lesions at UAB. The baseline characteristics of the study population are shown in Table 1. The population was 33% women and 31% non-white, with a mean age of 56 ± 12 years.

The characteristics of the coronary lesions treated are listed in Table 2. Of the lesions treated with a DES, 82% were done after a screening coronary angiogram rather than precipitated by symptoms. Cypher stents (Cordis, Johnson & Johnson, San

Discussion

In this study we have reported on the largest series to date investigating the use of DES in de novo lesions of CAV since their introduction into the clinical arena. Patients were followed for a mean of 22 months, clinically and using routine angiograms looking for the progression of coronary vasculopathy, rates of DES re-stenosis and re-vascularization thereafter, complications, death and cardiac re-transplantation.

CAV remains the “Achilles heel” of cardiac transplantation and is the main

References (30)

Cited by (20)

  • Tissue characterization of progressive cardiac allograft vasculopathy in patients with everolimus therapy compared with donor-transmitted atherosclerosis assessed using serial intravascular imaging: A case report

    2014, Transplantation Proceedings
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    A previous study showed that mechanical interventions such as drug-eluting stents produce at least a temporary benefit; however, due to the diffuse nature of the epicardial and intramyocardial arterial lesions observed, stents are a suboptimal treatment. The report concluded that medical therapy, including everolimus, should be more effective than mechanical interventions [2,15]. To this effect, Nakatani et al reported that potent regression of proliferative neointima was observed in CAV after everolimus administration [16].

  • Comparison of drug-eluting versus bare metal stents in cardiac allograft vasculopathy

    2011, American Journal of Cardiology
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    Still, PCI can provide palliation, and our study has demonstrated that DESs offers angiographic and clinical benefit compared to BMSs, with no additional risk conferred. Not all previous studies evaluating the use of stents in transplant recipients with CAV have demonstrated an advantage of lower restenosis with DESs versus BMSs, although there is certainly a trend in that direction.8–12 Only 2 studies have found no difference in restenosis,13,14 and 3 have shown a significantly lower restenosis rate with DES.15–17

  • Diverse morphologic manifestations of cardiac allograft vasculopathy: A pathologic study of 64 allograft hearts

    2011, Journal of Heart and Lung Transplantation
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    CAV is currently not entirely preventable or treatable. Mechanical interventions such as drug-eluting stents20 have shown at least temporary benefit; however, due to the diffuse nature of the epicardial and intramyocardial arterial lesions observed, stents are a sub-optimal treatment. Drug therapy, such as everolimus, should be more effective than mechanical interventions.21

  • Sirolimus-eluting stent fractures leading to restenosis in cardiac allograft vasculopathy

    2010, Cardiovascular Revascularization Medicine
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    Balloon angioplasty and bare-metal stents (BMS) have been used for revascularization of focal lesions, but they are associated with a high risk of restenosis [9]. Limited data have shown favorable results with drug-eluting stents (DES) [10–12]. Several cases of restenosis in DES in association with stent fractures (SFs) were recently reported.

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The first three authors (R.A., B.J.W., F.G.H.) contributed equally to this work.

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