238
Letters to the Editor
Bioresorbable vascular scaffold implantation for treatment of recurrent in-stent restenosis: Insights from optical coherence tomography Anthony C. Camuglia, Shahar Lavi ⁎ London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
a r t i c l e
i n f o
Article history: Received 18 November 2013 Accepted 29 December 2013 Available online 8 January 2014 Keywords: In-stent restenosis Bioresorbable vascular scaffold Optical coherence tomography
chromium alloy bare metal stent four years earlier in the proximal left circumflex artery. Baseline angiography showed severe in-stent and insegment stenosis (Fig. 1F). Optical coherence tomography (OCT) images, obtained after initial pre-dilatation to facilitate contrast flow for OCT, demonstrated significant neointimal proliferation overlying two layers of stent struts and significant atheroma in the proximal non-stented segment (Fig. 1A and B). Intimal dissection was also present due to balloon pre-dilatation. Following aggressive lesion preparation with a cutting balloon, an Absorb 3.5 × 18 mm (Abbott Vascular, Santa Clara, CA) bioresorbable vascular scaffold (BVS) was implanted and allowed for coverage of the
Fig. 1. Optical coherence tomography and angiography of recurrent in-stent restenosis treated with a bioresorbable vascular scaffold.
A 72 year old male with type 2 diabetes mellitus presented with symptomatic severe recurrent in-stent restenosis (ISR) of a sirolimus drug eluting stent (DES) placed within a previously restenosed cobalt–
⁎ Corresponding author at: Cardiovascular Interventional Research, London Health Sciences Centre, 339 Windermere Rd, London, ON N6A 5A5, Canada. E-mail address: [email protected] (S. Lavi).
ISR and proximal disease. OCT following BVS implantation and postdilatation demonstrated satisfactory expansion and apposition over the two pre-existing layers of metallic stent struts (Fig. 1C, D, E) as well as a satisfactory final angiographic appearance (Fig. 1G). Outpatient clinical follow up has been satisfactory. Alternative approaches to managing this situation would have included use of a paclitaxel drug eluting balloon [1,2] however leaving the proximal in-segment area of disease traumatized without strut coverage,
Letters to the Editor
or implantation of a third layer of metal with a further DES. The implantation of a BVS, an emerging effective treatment for de-novo coronary artery disease [3] allowed for satisfactory treatment of both the ISR and the in-segment disease. Figure legend: Optical coherence tomography (OCT) appearance pre-implantation of a bioresorbable vascular scaffold (BVS) with significant neointimal proliferation over two layers of stent struts following pre-dilatation to facilitate adequate contrast flow for OCT (Panel A) with significant atheroma also seen at the proximal nonstented segment (Panel B) with balloon related dissection also present. Absorb 3.5 × 18 mm BVS with adequate BVS expansion and apposition over the two previously placed layers of metallic stent struts (Panels C, D and zoomed up image Panel E). Baseline
239
angiographic image before any balloon dilatation (Panel F) shows severe in-stent and significant in-segment stenosis. Final angiographic appearance post BVS was satisfactory (Panel G).
References [1] Unverdorben M, Vallbracht C, Cremers B, et al. Paclitaxel-coated balloon catheter versus paclitaxel-coated stent for the treatment of coronary in-stent restenosis. Circulation 2009;119:2986–94. [2] Scheller B, Clever YP, Kelsch B, et al. Long-term follow-up after treatment of coronary in-stent restenosis with a paclitaxel-coated balloon catheter. J Am Coll Cardiol Interv 2012;5:323–30. [3] Bourantas CV, Zhang Y, Farooq V, et al. Bioresorbable scaffolds: current evidence and ongoing clinical trials. Curr Cardiol Rep 2012;14:626–34.
0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.212
Revascularization improves mortality in elderly patients with acute myocardial infarction complicated by cardiogenic shock Paul A. Rogers a, Jad Daye a, Henry Huang a, Alvin Blaustein a,b, Salim Virani a,b, Mahboob Alam a, Anirudh Kumar a, David Paniagua a,b, Biswajit Kar a,b, Biykem Bozkurt a,b, Christie M. Ballantyne a, Anita Deswal a,b, Hani Jneid a,b,⁎ a b
Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States The Michael E. Debakey VA Medical Center, Houston, TX, United States
a r t i c l e
i n f o
Article history: Received 2 December 2013 Accepted 30 December 2013 Available online 18 January 2014 Keywords: Cardiogenic shock Elderly Revascularization Myocardial infarction
Cardiogenic shock (AMI-CS) occurs in 2.5–6% of hospitalized patients with acute myocardial infarction (AMI), and is associated with high morbidity and mortality [1–4]. In the aftermath of the SHOCK trial [5], small observational studies reported on outcomes of elderly (≥75-year old) patients with AMI-CS (Supplement). Uncertainty however still exists regarding the benefits of early revascularization (ER) in elderly patients with AMI-CS. In the current report, we undertook aggregate data meta-analyses of short- and intermediate-term mortality outcomes to examine the impact of an ER strategy versus an initial medical stabilization (IMS) strategy in elderly patients with AMI-CS. We conducted a computerized literature search between 1/1/1985 and 1/31/2011 to identify studies comparing mortality in elderly patients with AMI-CS treated with ER (revascularization during the index hospitalization) versus IMS (no revascularization or selective revascularization after failed IMS strategy) (Supplement). We then conducted a parallel search for studies reporting mortality outcomes in elderly and younger AMI-CS patients receiving ER. The search terms used were: “cardiogenic”, “shock”, “myocardial”, “infarction”, “elderly”. Two authors ⁎ Corresponding author at: Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Division of Cardiology - 3C- 320C, 2002 Holcombe Blvd, Houston, TX, 77030, United States. Tel: + 1 713 794 7823; fax: +1 713 794 8033. E-mail address: [email protected] (H. Jneid).
(P.A.R., H.H.) independently conducted the search and extracted the data; discrepancies were resolved by arbitration by a third investigator (H.J.). Odds ratios for mortality and their 95% confidence intervals were computed using the random effects model. Percentages and means ± SD were computed for categorical and continuous variables, respectively. Continuous variables were compared using the two-tailed Student's t test or the Mann–Whitney-U test, when appropriate. Categorical variables were compared using the Chi-square test. P value ≤ 0.05 was considered statistically significant. The Comprehensive Meta-Analysis Software (Biostat, NJ) was used to estimate the effect size, perform sensitivity analyses, and assess publication bias. A lower rate of successful revascularization was observed in elderly AMI-CS patients compared with their younger counterparts (n = 7 studies; 87.6% vs. 95.2%, P b 0.0001). Elderly patients with AMI-CS who received ER had higher short-term (56.2% vs. 34.4%; OR = 2.38, 95% CI = 1.92–2.96) and intermediate-term (58.8% vs. 36.8%; OR =2.80, 95% CI = 1.97–3.99) mortality compared with younger patients (Supplement). Sensitivity analyses showed that no study single-handedly accounted for the mortality differences between elderly and younger patients (Supplement). Studies reporting short-term (n = 12 studies, 763 ER vs. 2380 IMS patients) and intermediate-term mortality (n = 5 studies, 561 ER vs. 1619 IMS patients) in elderly patients with AMI-CS were included. Elderly patients with AMI-CS receiving ER were more likely to be men, smokers, and have prior revascularization (Supplement). A relatively low average revascularization success rate of 71% was observed in elderly patients receiving ER. Compared with patients treated with IMS, elderly AMI-CS patients who received ER experienced lower short-term (54.5% vs. 72.1%; OR = 0.48, 95% CI = 0.33–0.69) and intermediate-term (60.4% vs. 80.1%; OR = 0.47, 95% CI = 0.27–0.83) mortality (Fig. 1). Sensitivity analyses revealed that no one study single-handedly influenced the estimates of the effect size for shortterm mortality (Fig. 2). Although the exclusion of several studies rendered the estimates of the effect size for intermediate-term
Letters to the Editor
Bioresorbable vascular scaffold implantation for treatment of recurrent in-stent restenosis: Insights from optical coherence tomography Anthony C. Camuglia, Shahar Lavi ⁎ London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
a r t i c l e
i n f o
Article history: Received 18 November 2013 Accepted 29 December 2013 Available online 8 January 2014 Keywords: In-stent restenosis Bioresorbable vascular scaffold Optical coherence tomography
chromium alloy bare metal stent four years earlier in the proximal left circumflex artery. Baseline angiography showed severe in-stent and insegment stenosis (Fig. 1F). Optical coherence tomography (OCT) images, obtained after initial pre-dilatation to facilitate contrast flow for OCT, demonstrated significant neointimal proliferation overlying two layers of stent struts and significant atheroma in the proximal non-stented segment (Fig. 1A and B). Intimal dissection was also present due to balloon pre-dilatation. Following aggressive lesion preparation with a cutting balloon, an Absorb 3.5 × 18 mm (Abbott Vascular, Santa Clara, CA) bioresorbable vascular scaffold (BVS) was implanted and allowed for coverage of the
Fig. 1. Optical coherence tomography and angiography of recurrent in-stent restenosis treated with a bioresorbable vascular scaffold.
A 72 year old male with type 2 diabetes mellitus presented with symptomatic severe recurrent in-stent restenosis (ISR) of a sirolimus drug eluting stent (DES) placed within a previously restenosed cobalt–
⁎ Corresponding author at: Cardiovascular Interventional Research, London Health Sciences Centre, 339 Windermere Rd, London, ON N6A 5A5, Canada. E-mail address: [email protected] (S. Lavi).
ISR and proximal disease. OCT following BVS implantation and postdilatation demonstrated satisfactory expansion and apposition over the two pre-existing layers of metallic stent struts (Fig. 1C, D, E) as well as a satisfactory final angiographic appearance (Fig. 1G). Outpatient clinical follow up has been satisfactory. Alternative approaches to managing this situation would have included use of a paclitaxel drug eluting balloon [1,2] however leaving the proximal in-segment area of disease traumatized without strut coverage,
Letters to the Editor
or implantation of a third layer of metal with a further DES. The implantation of a BVS, an emerging effective treatment for de-novo coronary artery disease [3] allowed for satisfactory treatment of both the ISR and the in-segment disease. Figure legend: Optical coherence tomography (OCT) appearance pre-implantation of a bioresorbable vascular scaffold (BVS) with significant neointimal proliferation over two layers of stent struts following pre-dilatation to facilitate adequate contrast flow for OCT (Panel A) with significant atheroma also seen at the proximal nonstented segment (Panel B) with balloon related dissection also present. Absorb 3.5 × 18 mm BVS with adequate BVS expansion and apposition over the two previously placed layers of metallic stent struts (Panels C, D and zoomed up image Panel E). Baseline
239
angiographic image before any balloon dilatation (Panel F) shows severe in-stent and significant in-segment stenosis. Final angiographic appearance post BVS was satisfactory (Panel G).
References [1] Unverdorben M, Vallbracht C, Cremers B, et al. Paclitaxel-coated balloon catheter versus paclitaxel-coated stent for the treatment of coronary in-stent restenosis. Circulation 2009;119:2986–94. [2] Scheller B, Clever YP, Kelsch B, et al. Long-term follow-up after treatment of coronary in-stent restenosis with a paclitaxel-coated balloon catheter. J Am Coll Cardiol Interv 2012;5:323–30. [3] Bourantas CV, Zhang Y, Farooq V, et al. Bioresorbable scaffolds: current evidence and ongoing clinical trials. Curr Cardiol Rep 2012;14:626–34.
0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.212
Revascularization improves mortality in elderly patients with acute myocardial infarction complicated by cardiogenic shock Paul A. Rogers a, Jad Daye a, Henry Huang a, Alvin Blaustein a,b, Salim Virani a,b, Mahboob Alam a, Anirudh Kumar a, David Paniagua a,b, Biswajit Kar a,b, Biykem Bozkurt a,b, Christie M. Ballantyne a, Anita Deswal a,b, Hani Jneid a,b,⁎ a b
Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, United States The Michael E. Debakey VA Medical Center, Houston, TX, United States
a r t i c l e
i n f o
Article history: Received 2 December 2013 Accepted 30 December 2013 Available online 18 January 2014 Keywords: Cardiogenic shock Elderly Revascularization Myocardial infarction
Cardiogenic shock (AMI-CS) occurs in 2.5–6% of hospitalized patients with acute myocardial infarction (AMI), and is associated with high morbidity and mortality [1–4]. In the aftermath of the SHOCK trial [5], small observational studies reported on outcomes of elderly (≥75-year old) patients with AMI-CS (Supplement). Uncertainty however still exists regarding the benefits of early revascularization (ER) in elderly patients with AMI-CS. In the current report, we undertook aggregate data meta-analyses of short- and intermediate-term mortality outcomes to examine the impact of an ER strategy versus an initial medical stabilization (IMS) strategy in elderly patients with AMI-CS. We conducted a computerized literature search between 1/1/1985 and 1/31/2011 to identify studies comparing mortality in elderly patients with AMI-CS treated with ER (revascularization during the index hospitalization) versus IMS (no revascularization or selective revascularization after failed IMS strategy) (Supplement). We then conducted a parallel search for studies reporting mortality outcomes in elderly and younger AMI-CS patients receiving ER. The search terms used were: “cardiogenic”, “shock”, “myocardial”, “infarction”, “elderly”. Two authors ⁎ Corresponding author at: Baylor College of Medicine and the Michael E. DeBakey VA Medical Center, Division of Cardiology - 3C- 320C, 2002 Holcombe Blvd, Houston, TX, 77030, United States. Tel: + 1 713 794 7823; fax: +1 713 794 8033. E-mail address: [email protected] (H. Jneid).
(P.A.R., H.H.) independently conducted the search and extracted the data; discrepancies were resolved by arbitration by a third investigator (H.J.). Odds ratios for mortality and their 95% confidence intervals were computed using the random effects model. Percentages and means ± SD were computed for categorical and continuous variables, respectively. Continuous variables were compared using the two-tailed Student's t test or the Mann–Whitney-U test, when appropriate. Categorical variables were compared using the Chi-square test. P value ≤ 0.05 was considered statistically significant. The Comprehensive Meta-Analysis Software (Biostat, NJ) was used to estimate the effect size, perform sensitivity analyses, and assess publication bias. A lower rate of successful revascularization was observed in elderly AMI-CS patients compared with their younger counterparts (n = 7 studies; 87.6% vs. 95.2%, P b 0.0001). Elderly patients with AMI-CS who received ER had higher short-term (56.2% vs. 34.4%; OR = 2.38, 95% CI = 1.92–2.96) and intermediate-term (58.8% vs. 36.8%; OR =2.80, 95% CI = 1.97–3.99) mortality compared with younger patients (Supplement). Sensitivity analyses showed that no study single-handedly accounted for the mortality differences between elderly and younger patients (Supplement). Studies reporting short-term (n = 12 studies, 763 ER vs. 2380 IMS patients) and intermediate-term mortality (n = 5 studies, 561 ER vs. 1619 IMS patients) in elderly patients with AMI-CS were included. Elderly patients with AMI-CS receiving ER were more likely to be men, smokers, and have prior revascularization (Supplement). A relatively low average revascularization success rate of 71% was observed in elderly patients receiving ER. Compared with patients treated with IMS, elderly AMI-CS patients who received ER experienced lower short-term (54.5% vs. 72.1%; OR = 0.48, 95% CI = 0.33–0.69) and intermediate-term (60.4% vs. 80.1%; OR = 0.47, 95% CI = 0.27–0.83) mortality (Fig. 1). Sensitivity analyses revealed that no one study single-handedly influenced the estimates of the effect size for shortterm mortality (Fig. 2). Although the exclusion of several studies rendered the estimates of the effect size for intermediate-term
