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Coughlan JJ, Aytekin A, Lahu S, Scalamogna M, Wiebe J, Pinieck S, Kufner S, Xhepa E, Joner M, Kuna C, Voll F, Laugwitz KL, Schunkert H, Kastrati A, Cassese S. Derivation and validation of the ISAR score to predict the risk of repeat percutaneous coronary intervention for recurrent drug-eluting stent restenosis. EUROINTERVENTION 2023; 18:e1328-e1338. [PMID: 36785947 PMCID: PMC10068863 DOI: 10.4244/eij-d-22-00860] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 12/16/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND The treatment of drug-eluting stent (DES) in-stent restenosis (ISR) is challenging as it has a high risk of recurrence. AIMS The aim of this analysis was to develop and validate a model to predict the risk of repeat percutaneous coronary intervention (PCI) for recurrent DES-ISR. METHODS A retrospective, observational analysis was performed including consecutive patients treated with PCI for DES-ISR at two centres in Germany. Included patients were randomly divided into training and validation cohorts. Two regression analyses identified factors associated with repeat PCI for recurrent DES-ISR up to 1 year. The discriminative ability of the resultant model was then compared to a benchmark ISR classification model using bootstrap resampling. A classification and regression tree analysis and a numerical scoring system (the ISAR score) were used to predict the risk of repeat PCI for recurrent DES-ISR based on the identified predictors. RESULTS We included 1,986 patients in the current analysis, divided randomly into training (1,471 patients, 1,778 lesions) and validation (515 patients, 614 lesions) cohorts. Four factor variables (a non-focal ISR pattern, a time interval to ISR of <6 months, ISR of the left circumflex artery and ISR in a calcified vessel) were associated with repeat PCI for recurrent DES-ISR at 1-year follow-up. On bootstrap resampling analysis, the C-statistic for the model including these four variables was 0.60 (95% confidence interval [CI]: 0.57-0.63), whereas the C-statistic for the benchmark ISR classification model was 0.54 (95% CI: 0.52-0.57), a difference that was statistically significant (delta C-statistic 0.062; 95% CI: 0.035-0.094; p<0.001). The cumulative incidence of repeat PCI for recurrent DES-ISR was over three times higher in DES-ISR lesions with an ISAR score of ≥3 in comparison to lesions with an ISAR score of 0. CONCLUSIONS This study developed and validated a risk prediction model for repeat PCI for recurrent DES-ISR at 1-year follow-up. This model served to generate the ISAR score, a standardised tool that can be used to predict the 1-year risk of repeat PCI for recurrent DES-ISR.
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Affiliation(s)
- J J Coughlan
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alp Aytekin
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Shqipdona Lahu
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Maria Scalamogna
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Jens Wiebe
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Susanne Pinieck
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Constantin Kuna
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Felix Voll
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Karl Ludwig Laugwitz
- DZHK (German Center for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
- Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner site Munich Heart Alliance, Munich, Germany
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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Yin D, Mintz GS, Song L, Chen Z, Lee T, Kirtane AJ, Parikh MA, Moses JW, Fall KN, Jeremias A, Ali ZA, Shlofmitz RA, Maehara A. In-stent restenosis characteristics and repeat stenting underexpansion: insights from optical coherence tomography. EUROINTERVENTION 2020; 16:e335-e343. [DOI: 10.4244/eij-d-18-01191] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kammler J, Blessberger H, Lambert T, Kellermair J, Grund M, Nahler A, Lichtenauer M, Schwarz S, Reiter C, Steinwender C, Kypta A. In-stent restenosis after interventional treatment of carotid artery stenoses: a long-term follow-up of a single center cohort. Clin Res Cardiol 2017; 106:493-500. [DOI: 10.1007/s00392-017-1078-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 01/10/2017] [Indexed: 11/28/2022]
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Piraino D, Cimino G, Buccheri D, Dendramis G, Andolina G, Cortese B. Recurrent in-stent restenosis, certainty of its origin, uncertainty about treatment. Int J Cardiol 2016; 230:91-96. [PMID: 28038808 DOI: 10.1016/j.ijcard.2016.12.073] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 11/18/2016] [Accepted: 12/16/2016] [Indexed: 02/01/2023]
Abstract
Treatment of recurrent in-stent restenosis is a real brainteaser for the interventional cardiologist who cannot resort to the guidelines to have indications about the type of treatment to be preferred. The use of intracoronary imaging may provide insights into the underlying mechanisms of this complication and use of drug-coated balloons may be a valid alternative and especially a thoughtful treatment when the repeated and perseverant use of drug-eluting stents clearly fails. In this setting, we present a review of the literature about this interesting topic, going deep into the heart of the problem, its origin and possible treatment options.
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Affiliation(s)
- Davide Piraino
- Interventional Cardiology, "P. Giaccone" University Hospital of Palermo, Italy.
| | - Giuliana Cimino
- Interventional Cardiology, "P. Giaccone" University Hospital of Palermo, Italy
| | - Dario Buccheri
- Interventional Cardiology, "P. Giaccone" University Hospital of Palermo, Italy
| | - Gregory Dendramis
- Interventional Cardiology, "P. Giaccone" University Hospital of Palermo, Italy
| | - Giuseppe Andolina
- Interventional Cardiology, "P. Giaccone" University Hospital of Palermo, Italy
| | - Bernardo Cortese
- Interventional Cardiology, Fatebenefratelli Hospital, Milan, Italy
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Poerner TC, Duderstadt C, Goebel B, Kretzschmar D, Figulla HR, Otto S. Fractional flow reserve-guided coronary angioplasty using paclitaxel-coated balloons without stent implantation: feasibility, safety and 6-month results by angiography and optical coherence tomography. Clin Res Cardiol 2016; 106:18-27. [PMID: 27379610 PMCID: PMC5226992 DOI: 10.1007/s00392-016-1019-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/30/2016] [Indexed: 12/11/2022]
Abstract
Background Percutaneous coronary interventions (PCI) with drug-coated balloons (DCB) might be a promising trade-off between balloon angioplasty and drug-eluting stents, since DCB inhibit neointimal proliferation and limit duration of dual antiplatelet therapy. We investigated the safety, feasibility, and 6-month results of fractional flow reserve (FFR)-guided use of the paclitaxel-coated SeQuent Please® balloon without stenting for elective PCI of de novo lesions. Methods and results In 46 patients (54 lesions) with stable symptomatic coronary artery disease (CAD), a FFR-guided POBA (plain old balloon angioplasty) was performed. In case of a sufficient POBA result with residual stenosis < 40 %, FFR > 0.8 and no severe dissection, the target lesion was finally dilated using the DCB. Quantitative coronary angiography (QCA) was performed before and after the index procedure and at 6-month follow-up (f/u) to calculate late lumen loss (LLL) and net luminal gain (NLG). Optical coherence tomography (OCT) was performed at f/u to assess vascular remodeling. DCB-only treatment was applied to 43 patients (51 lesions), while 3 patients (3 lesions) needed provisional stenting. Invasive f/u was completed in 39 patients (47 lesions). At the stenotic site, the lumen diameter showed a trend toward progressive increase at f/u (LLL: −0.13 ± 0.44 mm, n.s.; NLG: 1.10 ± 0.53 mm, p < 0.001) without aneurysm formation or restenosis after DCB-only treatment. Conclusions FFR-guided DCB-only PCI of de novo lesions appeared feasible and safe in stable CAD with clopidogrel discontinuation after 4 weeks, showing a trend toward positive vessel remodeling without lumen loss at 6 months. Clinical trial registration http://www.clinicaltrials.gov. Unique identifier: NCT02120859 Electronic supplementary material The online version of this article (doi:10.1007/s00392-016-1019-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tudor C Poerner
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Corinna Duderstadt
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Björn Goebel
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Daniel Kretzschmar
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Hans R Figulla
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany
| | - Sylvia Otto
- Division of Cardiology, 1st Department of Medicine, University Hospital of Jena, 07747, Jena, Germany.
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Morphine interaction with prasugrel: a double-blind, cross-over trial in healthy volunteers. Clin Res Cardiol 2015; 105:349-55. [PMID: 26493304 PMCID: PMC4805697 DOI: 10.1007/s00392-015-0927-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/15/2015] [Indexed: 01/01/2023]
Abstract
Background Morphine decreases the concentrations and effects of clopidogrel, which could lead to treatment failure in myocardial infarction. Objectives To clarify whether more potent P2Y12-inhibitors may provide an effective alternative, we examined drug–drug interactions between morphine and prasugrel. Methods Twelve healthy volunteers received 60 mg prasugrel with placebo or 5 mg morphine intravenously in a randomized, double-blind, placebo-controlled, cross-over trial. Pharmacokinetics were determined by liquid chromatography tandem mass spectrometry, and prasugrel effects were measured by platelet function tests. Results Morphine neither diminished total drug exposure (AUC), which was the primary endpoint, nor significantly delayed drug absorption of prasugrel. However, morphine reduced maximal plasma concentrations (Cmax) of prasugrel active metabolite by 31 % (p = 0.019). Morphine slightly, but not significantly, delayed the onset of maximal inhibition of platelet plug formation under high shear rates (30 vs. 20 min). Whole blood aggregation was not influenced. Conclusions Although morphine significantly decreases the maximal plasma concentrations of prasugrel active metabolite, it does not diminish its effects on platelets to a clinically relevant degree in healthy volunteers. However, it should be considered that the observed decrease in Cmax of prasugrel active metabolite caused by morphine co-administration may gain relevance in STEMI patients. Clinical Trial Registration: NCT01369186, EUDRA-CT#: 2010-023761-22.
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Schulz A, Hauschild T, Kleber FX. Treatment of coronary de novo bifurcation lesions with DCB only strategy. Clin Res Cardiol 2014; 103:451-6. [PMID: 24522798 DOI: 10.1007/s00392-014-0671-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/14/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This observational study investigated the value of drug-coated balloons (DCB) only strategy in bifurcation lesions in a consecutive series of all comer percutaneous coronary intervention. BACKGROUND Local application of paclitaxcel by DCB has clinical benefits in various settings including coronary bifurcations. While so far most bifurcation studies investigated sequential application of DCBs to the main (MB) and side branch (SB) with stenting of the MB, we report first results after DCB intervention without additional stenting of the MB or SB. METHODS We performed 39 consecutive DCB only interventions in de novo bifurcation lesions with SB ≥ 2 mm and scheduled follow-up angiography after 4 months. Patients refusing angiography had telephone follow-up. RESULTS Follow-up angiograms were obtained in 30 out of 39 DCB only interventions. 33.3 % were located in the left main (LM) bifurcation, 28.2 % in left anterior descending (LAD), 20.5 % in left circumflex (LCX) and 17.9 % in the right coronary artery. Four months after index procedure no patient had died, experienced myocardial infarction or stroke. Follow-up angiograms showed restenosis in 3 out of 30 interventions (10 %), 2 developing in the distal main (6.7 %) and 1 in the SB (3.3 %). All three patients had been treated for LM/LAD/LCX bifurcations and suffered from most severe coronary artery disease, but had not been eligible for CABG for various reasons. Target lesion revascularization was performed in 3 out of 39 patients consistent with a MACE rate of 7.7 %. CONCLUSION Treatment of de novo bifurcation lesions with DCB only intervention without additional stenting is a safe therapy with low rates of restenosis and TLR.
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