Author + information
- Michael S. Lee, MD⁎ (, )
- Jon Kobashigawa, MD,
- Raymond Zimmer, MD,
- Richard Shemin, MD,
- Fardad Esmailian, MD,
- Abbas Ardehali, MD,
- Murray Kwon, MD and
- Jonathan Tobis, MD
- ↵⁎UCLA Medical Center, Adult Cardiac Catheterization Laboratory, 10833 Le Conte Avenue, Room BL-394 CHS, Los Angeles, California 90095
We have read with interest the thoughtful response from Dr. Movahed to our recent article entitled “Comparison of Percutaneous Coronary Intervention With Bare-Metal and Drug-Eluting Stents for Cardiac Allograft Vasculopathy” (1) and appreciate the opportunity to address the points raised in the letter.
Our study indicates an advantage with the use of drug-eluting stents (DES) compared with bare-metal stents (BMS) in terms of late lumen loss and rates of in-stent restenosis (ISR). More recent data support low rates of ISR when patients undergo percutaneous coronary intervention (PCI) with DES for coronary artery vasculopathy (CAV) (2). Similarly, a study from Poland reported that the use of DES was associated with a lower rate of ISR and longer time of freedom from ISR (3). Whereas other clinical end points were not reported for each group in our study, only 21% of all patients underwent target vessel revascularization, indicating that PCI is a viable treatment option for patients with CAV. Although our study reports that 13% of the cohort patients underwent repeat orthotopic heart transplantation (OHT) and 22% died, the mortality rate was measured over the entire follow-up period. The 22% mortality rate also included some patients who had undergone repeat OHT, producing a lower combined rate of death and repeat OHT. Prospective randomized trials comparing DES with BMS for CAV patients are needed to better ascertain clinical and angiographic outcomes with these modalities.
There is uncertainty regarding clopidogrel therapy in patients who are relisted for OHT and who have undergone PCI with DES within 12 months. Premature discontinuation of dual antiplatelet therapy after PCI with DES in patients who are relisted for OHT might increase the risk of stent thrombosis. Although the risk of bleeding might be increased if OHT is performed while patients continue clopidogrel, our transplant surgeons have performed OHT on patients who continue clopidogrel and feel it is an acceptable risk to operate on such patients, because the consequences of stent thrombosis can be catastrophic. The case-fatality rate of DES thrombosis is 45% (4). Studies examining outcomes of patients receiving clopidogrel therapy undergoing OHT would determine the true bleeding risk of patients who undergo OHT with clopidogrel, the results of which would help clarify the optimal antiplatelet therapy in patients with DES who require repeat OHT.
- American College of Cardiology Foundation