Author + information
- Hector M. Garcia-Garcia, MD, PhD∗ (, )
- Alexandre Hideo-Kajita, MD and
- Kayode O. Kuku, MD
- ↵∗Interventional Cardiology, Medstar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010
We read with interest the report by Shin et al. (1) on the use of intravascular ultrasound (IVUS) guidance for the implantation of new drug-eluting stents (DES). Major adverse cardiac events (MACE) were significantly reduced by 64% by IVUS guidance compared to angiography alone. In cardiovascular medicine, only a few interventions/medications have been shown to reduce clinical outcomes so dramatically as IVUS-guided percutaneous coronary intervention. However, the use of IVUS in this setting has not been widely adopted.
When IVUS guidance was first advocated, during the bare-metal stent era, the proposed IVUS guidance for optimizing stent implantation had multiple criteria, some extremely difficult to achieve in practice. This resulted in very low compliance and culminated in conflicting results using IVUS guidance as shown in the 1998 MUSIC (Multicenter Ultrasound Stenting in Coronaries) study (2). Subsequently, in the DES era, an IVUS guidance strategy was first tested in observational studies using variations of the MUSIC study criteria and again produced inconsistent results. It was not until 2010 that the first randomized clinical trial was reported, but it was rather small and included only first-generation DES (3). Having said this, we would like to congratulate the authors for reporting this patient-level meta-analysis, which may refocus attention on this treatment strategy. There are, however, a few points that merit further discussion. The authors claim that they included only studies with new DES. We would like to challenge that notion since the Endeavor zotarolimus-ES should not be classified in that category. According to the European Society of Cardiology/European Association of Percutaneous Cardiovascular Interventions report the Endeavor zotarolimus-eluting stent (Medtronic, Santa Rosa, California) is considered early generation (4). Further, the choice of the components of MACE is somewhat puzzling when one wants to evaluate the impact of a local coronary treatment. Evidently cardiac death is appropriate, but including spontaneous myocardial infarction (with diverse definitions?) instead of following the universal MI definition is inappropriate, as such events reflect more the progression of disease in nontarget segments rather than the performance of the study device. The omission of target lesion or vessel revascularization (TL/VR) is also puzzling. If anything, IVUS-guided percutaneous coronary intervention aims to reduce stent failures such as TL/VR. Compounding this further, all stent thrombosis is a component of MACE. Definite and probable stent thrombosis, implicating the TL/VR, are a more appropriate measure because possible stent thrombosis (essentially late unexplained death) lacks specificity and is no longer reported in most major trials.
The authors should also refer to the differences in guidance criteria in each of the studies and highlight the extent to which these criteria were met. More importantly, an analysis should be made comparing patients that met the IVUS criteria versus their counterparts.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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