Regarding Comparison of Percutaneous Coronary Intervention With Bare-Metal and Drug-Eluting Stents for Cardiac Allograft VasculopathyProblems With Listing Patients Receiving Clopidogrel for Re-Transplantation
Mohammad Reza Movahed, MD, PhD*
I read with interest the article entitled "Comparison of Percutaneous Coronary Intervention With Bare-Metal and Drug-Eluting Stents for Cardiac Allograft Vasculopathy" (1). This is an interesting study showing a lower in-stent restenosis rate of patients receiving drug-eluting stents (DES) for allograft vasculopathy. There are 2 major points that need clarification. The authors did not report any statistical analysis in regards to important end points such as death, myocardial infarction, or target vessel revascularization in each group. We have to assume that these very important end points, including re-transplantation, were similar between the groups. Death and re-transplantation occurred in 34% of the entire cohort with follow-up of <1 year. This suggests poor prognosis of patients with significant allograft vasculopathy, regardless of stent types used. This is an important observation that needs to be emphasized. The second important point concerns a major dilemma that exists between interventional cardiologists and transplant surgeons regarding duration of clopidogrel therapy after coronary intervention for allograft vasculopathy. In our and many centers, patients receiving clopidogrel therapy would not be listed for re-transplantation due to theoretical risk for bleeding during cardiac transplantation. Consequently, surgeons are proned to early discontinuation of clopidogrel therapy in patients treated with DES, putting them at risk for stent thrombosis. Therefore, it is very important to discuss the choice of stent and duration of clopidogrel therapy with surgeons for each individual patient before coronary intervention in the setting of allograft vasculopathy. In patients who are not candidates for re-transplantation, the use of a DES with prolonged dual antiplatelet therapy is probably the best option. However, for younger patients who are candidates for re-transplantation, the use of DES without consultation with surgeons can lead to early discontinuation of dual antiplatelet therapy or exclusion from retransplantation. It is important to note that clopidogrel does not increase mortality during coronary bypass surgery (2,3). There are no data available evaluating the risk of bleeding or death in patients receiving clopidogrel therapy while undergoing cardiac transplantation.
* Associate Professor of Medicine, Medical Director of Heart Transplant Program, The Southern Arizona VA Health Care System, University of Arizona Sarver Heart Center, Department of Medicine, Division of Cardiology, 1501 North Campbell Avenue, Tucson, Arizona 85724 (Email: rmovahed{at}email.arizona.edu; rmova{at}aol.com).
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REFERENCES
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- Lee M, Kobashigawa J, Tobis J. Comparison of percutaneous coronary intervention with bare-metal and drug-eluting stents for cardiac allograft vasculopathy J Am Coll Cardiol Intv 2008;1:710-715.[Abstract/Free Full Text]
- Picker SM, Kaleta T, Hekmat K, Kampe S, Gathof BS. Antiplatelet therapy preceding coronary artery surgery: implications for bleeding, transfusion requirements and outcome Eur J Anaesthesiol 2007;24:332-339.[CrossRef][Web of Science][Medline]
- Berger JS, Frye CB, Harshaw Q, Edwards FH, Steinhubl SR, Becker RC. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis J Am Coll Cardiol 2008;52:1693-1701.[Abstract/Free Full Text]
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- Michael S. Lee, Jon Kobashigawa, Raymond Zimmer, Richard Shemin, Fardad Esmailian, Abbas Ardehali, Murray Kwon, and Jonathan Tobis
J. Am. Coll. Cardiol. Intv. 2009 2: 474-475.
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