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Goel R, Spirito A, Gao M, Vogel B, N Kalkman D, Mehran R. Second-generation everolimus-eluting intracoronary stents: a comprehensive review of the clinical evidence. Future Cardiol 2024; 20:103-116. [PMID: 38294774 PMCID: PMC11216266 DOI: 10.2217/fca-2023-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 01/08/2024] [Indexed: 02/01/2024] Open
Abstract
Percutaneous coronary intervention with implantation of second-generation drug-eluting stents (DES) has emerged as a mainstay for the treatment of obstructive coronary artery disease given its beneficial impact on clinical outcomes in these patients. Everolimus-eluting stents (EES) are one of the most frequently implanted second-generation DES; their use for the treatment of a wide range of patients including those with complex coronary lesions is supported by compelling evidence. Although newer stent platforms such as biodegradable polymer DES may lower local vessel inflammation, their efficacy and safety have not yet surpassed that of Xience stents. This article summarizes the properties of the Xience family of EES and the evidence supporting their use across diverse patient demographics and coronary lesion morphologies.
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Affiliation(s)
- Ridhima Goel
- Center for Interventional Cardiovascular Research & Clinical Trials, Icahn School Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Internal Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Alessandro Spirito
- Center for Interventional Cardiovascular Research & Clinical Trials, Icahn School Medicine at Mount Sinai, New York, NY 10029, USA
| | - Michael Gao
- Center for Interventional Cardiovascular Research & Clinical Trials, Icahn School Medicine at Mount Sinai, New York, NY 10029, USA
| | - Birgit Vogel
- Center for Interventional Cardiovascular Research & Clinical Trials, Icahn School Medicine at Mount Sinai, New York, NY 10029, USA
| | - Deborah N Kalkman
- Center for Interventional Cardiovascular Research & Clinical Trials, Icahn School Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Clinical & Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC – University of Amsterdam, Amsterdam, 1105, The Netherlands
| | - Roxana Mehran
- Center for Interventional Cardiovascular Research & Clinical Trials, Icahn School Medicine at Mount Sinai, New York, NY 10029, USA
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Yan R, Cigliola V, Oonk KA, Petrover Z, DeLuca S, Wolfson DW, Vekstein A, Mendiola MA, Devlin G, Bishawi M, Gemberling MP, Sinha T, Sargent MA, York AJ, Shakked A, DeBenedittis P, Wendell DC, Ou J, Kang J, Goldman JA, Baht GS, Karra R, Williams AR, Bowles DE, Asokan A, Tzahor E, Gersbach CA, Molkentin JD, Bursac N, Black BL, Poss KD. An enhancer-based gene-therapy strategy for spatiotemporal control of cargoes during tissue repair. Cell Stem Cell 2023; 30:96-111.e6. [PMID: 36516837 PMCID: PMC9830588 DOI: 10.1016/j.stem.2022.11.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 10/06/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022]
Abstract
The efficacy and safety of gene-therapy strategies for indications like tissue damage hinge on precision; yet, current methods afford little spatial or temporal control of payload delivery. Here, we find that tissue-regeneration enhancer elements (TREEs) isolated from zebrafish can direct targeted, injury-associated gene expression from viral DNA vectors delivered systemically in small and large adult mammalian species. When employed in combination with CRISPR-based epigenome editing tools in mice, zebrafish TREEs stimulated or repressed the expression of endogenous genes after ischemic myocardial infarction. Intravenously delivered recombinant AAV vectors designed with a TREE to direct a constitutively active YAP factor boosted indicators of cardiac regeneration in mice and improved the function of the injured heart. Our findings establish the application of contextual enhancer elements as a potential therapeutic platform for spatiotemporally controlled tissue regeneration in mammals.
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Affiliation(s)
- Ruorong Yan
- Duke Regeneration Center, Duke University, Durham, NC, USA; Department of Cell Biology, Duke University Medical School, Durham, NC, USA
| | - Valentina Cigliola
- Duke Regeneration Center, Duke University, Durham, NC, USA; Department of Cell Biology, Duke University Medical School, Durham, NC, USA
| | - Kelsey A Oonk
- Duke Regeneration Center, Duke University, Durham, NC, USA; Department of Cell Biology, Duke University Medical School, Durham, NC, USA
| | - Zachary Petrover
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Sophia DeLuca
- Department of Cell Biology, Duke University Medical School, Durham, NC, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - David W Wolfson
- Duke Regeneration Center, Duke University, Durham, NC, USA; Department of Cell Biology, Duke University Medical School, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Durham, NC, USA; Center for Advanced Genomic Technologies, Duke University, Durham, NC, USA
| | - Andrew Vekstein
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | - Garth Devlin
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Muath Bishawi
- Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Matthew P Gemberling
- Department of Biomedical Engineering, Duke University, Durham, NC, USA; Center for Advanced Genomic Technologies, Duke University, Durham, NC, USA
| | - Tanvi Sinha
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Michelle A Sargent
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Allen J York
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Avraham Shakked
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | | | - David C Wendell
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, NC, USA
| | - Jianhong Ou
- Duke Regeneration Center, Duke University, Durham, NC, USA
| | - Junsu Kang
- Department of Cell and Regenerative Biology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Joseph A Goldman
- Department of Biological Chemistry and Pharmacology, Ohio State University, Columbus, OH, USA
| | - Gurpreet S Baht
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA; Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Ravi Karra
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Adam R Williams
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Dawn E Bowles
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Aravind Asokan
- Duke Regeneration Center, Duke University, Durham, NC, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Durham, NC, USA; Center for Advanced Genomic Technologies, Duke University, Durham, NC, USA
| | - Eldad Tzahor
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Charles A Gersbach
- Duke Regeneration Center, Duke University, Durham, NC, USA; Department of Cell Biology, Duke University Medical School, Durham, NC, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Surgery, Duke University School of Medicine, Durham, NC, USA; Center for Advanced Genomic Technologies, Duke University, Durham, NC, USA; Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Jeffery D Molkentin
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Nenad Bursac
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Brian L Black
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Kenneth D Poss
- Duke Regeneration Center, Duke University, Durham, NC, USA; Department of Cell Biology, Duke University Medical School, Durham, NC, USA; Center for Advanced Genomic Technologies, Duke University, Durham, NC, USA.
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3
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Rymer JA, Kirtane AJ, Farb A, Malone M, Jaff MR, Seward K, Stephens D, Barakat MK, Krucoff MW. One-Year Follow-Up of Vascular Intervention Trials Disrupted by the COVID-19 Pandemic: A Use-Case landscape. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 45:67-73. [PMID: 35953406 PMCID: PMC9323208 DOI: 10.1016/j.carrev.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The COVID-19 pandemic had an unprecedented impact on cardiovascular clinical research. The decision-making and state of study operations in cardiovascular trials 1-year after interruption has not been previously described. METHODS In the spring of 2020, we created a pandemic impact task force to develop a landscape of use case scenarios from 17 device trials of peripheral artery disease (PAD) and coronary artery disease (CAD) interventions. In conjunction with publicly available (clinictrials.gov) study inclusion criteria, primary endpoints and study design, information was shared for this use-case landscape by trial leadership and data owners. RESULTS A total of 17 actively enrolling trials (9 CAD and 8 PAD) volunteered to populate the use case landscape. All 17 were multicenter studies (12 in North America and 5 international). Fifteen studies were industry-sponsored, of which 13 were FDA approved IDEs, one was PCORI-sponsored and two were sponsored by the NIH. Enrollment targets ranged from 150 to 9000 pts. At the time of interruption, 5 trials were <20 % enrolled, 9 trials were 50-80 % enrolled and 3 trials were >80 % enrolled. At 1 year, the majority of studies were continuing to enroll in the context of more sporadic but ongoing pandemic activity. CONCLUSIONS At 1 year from the first surge interruptions, most trials had resumed enrollment. Trials most heavily interrupted were trials early in enrollment and those trials not able to pivot to virtual patient and site visits. Further work is needed to determine the overall impact on vascular intervention trials disrupted during the COVID-19 pandemic.
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Affiliation(s)
- Jennifer A. Rymer
- Duke University School of Medicine, Durham, NC, United States of America,Duke Clinical Research Institute, Durham, NC, United States of America,Corresponding author at: Duke University Medical Center, 2301 Erwin Road, Durham, NC 27705, United States of America
| | - Ajay J. Kirtane
- Columbia University Irving Medical Center, New York, United States of America
| | - Andrew Farb
- US Food and Drug Administration, Silver Spring, MD, United States of America
| | - Misti Malone
- US Food and Drug Administration, Silver Spring, MD, United States of America
| | - Michael R. Jaff
- Boston Scientific Corporation, Marlborough, MA, United States of America
| | - Kirk Seward
- Mercator MedSystems, Inc., Emeryvlle, CA, United States of America
| | - Dan Stephens
- Boston Scientific Corporation, Marlborough, MA, United States of America
| | - Mark K. Barakat
- CeloNova BioSciences, San Antonio, TX, United States of America
| | - Mitchell W. Krucoff
- Duke University School of Medicine, Durham, NC, United States of America,Duke Clinical Research Institute, Durham, NC, United States of America
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4
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Exarchos V, Zacharova E, Neuber S, Giampietro C, Motta SE, Hinkov H, Emmert MY, Nazari-Shafti TZ. The path to a hemocompatible cardiovascular implant: Advances and challenges of current endothelialization strategies. Front Cardiovasc Med 2022; 9:971028. [PMID: 36186971 PMCID: PMC9515323 DOI: 10.3389/fcvm.2022.971028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiovascular (CV) implants are still associated with thrombogenicity due to insufficient hemocompatibility. Endothelialization of their luminal surface is a promising strategy to increase their hemocompatibility. In this review, we provide a collection of research studies and review articles aiming to summarize the recent efforts on surface modifications of CV implants, including stents, grafts, valves, and ventricular assist devises. We focus in particular on the implementation of micrometer or nanoscale surface modifications, physical characteristics of known biomaterials (such as wetness and stiffness), and surface morphological features (such as gratings, fibers, pores, and pits). We also review how biomechanical signals originating from the endothelial cell for surface interaction can be directed by topography engineering approaches toward the survival of the endothelium and its long-term adaptation. Finally, we summarize the regulatory and economic challenges that may prevent clinical implementation of endothelialized CV implants.
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Affiliation(s)
- Vasileios Exarchos
- Cardiosurgical Research Group, Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- Translational Cardiovascular Regenerative Technologies Group, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
| | - Ema Zacharova
- Cardiosurgical Research Group, Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- Translational Cardiovascular Regenerative Technologies Group, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
- Department of Life Sciences, IMC University of Applied Sciences Krems, Krems an der Donau, Austria
| | - Sebastian Neuber
- Cardiosurgical Research Group, Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- Translational Cardiovascular Regenerative Technologies Group, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
| | - Costanza Giampietro
- Experimental Continuum Mechanics, Empa Swiss Federal Laboratories for Materials Science and Technology, Dübendorf, Switzerland
- Department of Mechanical and Process Engineering, Institute for Mechanical Systems, ETH Zürich, Zurich, Switzerland
| | - Sarah E. Motta
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Hristian Hinkov
- Cardiosurgical Research Group, Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- Translational Cardiovascular Regenerative Technologies Group, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
| | - Maximilian Y. Emmert
- Cardiosurgical Research Group, Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- Translational Cardiovascular Regenerative Technologies Group, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
- Clinic for Cardiovascular Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Timo Z. Nazari-Shafti
- Cardiosurgical Research Group, Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- Translational Cardiovascular Regenerative Technologies Group, Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Center for Regenerative Therapies, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité (Junior) (Digital) Clinician Scientist Program, Berlin, Germany
- *Correspondence: Timo Z. Nazari-Shafti,
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5
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Search for holy grail of stent coating will go on. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 42:100-101. [DOI: 10.1016/j.carrev.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/19/2022]
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Hara H, Serruys PW, O'Leary N, Gao C, Murray A, Breslin E, Garg S, Bureau C, Reiber JH, Barbato E, Aminian A, Janssens L, Rosseel L, Benit E, Campo G, Guiducci V, Casella G, Santarelli A, Franzè A, Diaz VAJ, Iñiguez A, Brugaletta S, Sabate M, Amat-Santos IJ, Amoroso G, Wykrzykowska J, von Birgelen C, Somi S, Liu T, Hofma SH, Curzen N, Trillo R, Ocaranza R, Mathur A, Smits PC, Escaned J, Baumbach A, Wijns W, Sharif F, Onuma Y. Angiography-derived physiology guidance vs usual care in an All-comers PCI population treated with the healing-targeted supreme stent and Ticagrelor monotherapy: PIONEER IV trial design. Am Heart J 2022; 246:32-43. [PMID: 34990582 DOI: 10.1016/j.ahj.2021.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Current ESC guidelines recommend the use of intra-coronary pressure guidewires for functional assessment of intermediate-grade coronary stenoses. Angiography-derived quantitative flow ratio (QFR) is a novel method of assessing these stenoses, and guiding percutaneous coronary intervention (PCI). METHODS/DESIGN The PIONEER IV trial is a prospective, all-comers, multi-center trial, which will randomize 2,540 patients in a 1:1 ratio to PCI guided by angiography-derived physiology or usual care, with unrestricted use in both arms of the Healing-Targeted Supreme sirolimus-eluting stent (HT Supreme). The stent's fast, biologically healthy, and robust endothelial coverage allows for short dual-antiplatelet therapy (DAPT); hence the antiplatelet regimen of choice is 1-month DAPT, followed by ticagrelor monotherapy. In the angiography-derived physiology guided arm, lesions will be functionally assessed using on-line QFR, with stenting indicated in lesions with a QFR ≤0.80. Post-stenting, QFR will be repeated in the stented vessel(s), with post-dilatation or additional stenting recommended if the QFR<0.91 distal to the stent, or if the delta QFR (across the stent) is >0.05. Usual care PCI is performed according to standard clinical practice. The primary endpoint is a non-inferiority comparison of the patient-oriented composite endpoint (POCE) of all-cause death, any stroke, any myocardial infarction, or any clinically, and physiologically driven revascularization with a non-inferiority risk-difference margin of 3.2%, at 1-year post-procedure. Clinical follow-up will be up to 3 years. SUMMARY The PIONEER IV trial aims to demonstrate non-inferiority of QFR-guided PCI to usual care PCI with respect to POCE at 1-year in patients treated with HT Supreme stents and ticagrelor monotherapy. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov UNIQUE IDENTIFIER: NCT04923191 CLASSIFICATIONS: Interventional Cardiology.
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Affiliation(s)
- Hironori Hara
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; NHLI, Imperial College London, London, United Kingdom.
| | - Neil O'Leary
- CORRIB Research Centre, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway
| | - Chao Gao
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; Deparment of Cardiology. Radboudumc, Nijmegen, The Netherlands; Department of Cardiology, Xijing Hospital, Xi'an, China
| | - Alicia Murray
- CORRIB Research Centre, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway
| | - Elaine Breslin
- CORRIB Research Centre, College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | | | - Johan Hc Reiber
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Emanuele Barbato
- Cardiovascular Research Center Aalst, OLV-Clinic, Aalst, Belgium and Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Luc Janssens
- Department of Cardiology, Imeldaziekenhuis, Bonheiden, Belgium
| | - Liesbeth Rosseel
- Department of Cardiology, Algemeen stedelijk ziekenhuis, Aalst, Belgium
| | - Edouard Benit
- Hartcentrum Jessa Ziekenhuis, Campus Virga Jesse, Hasselt, Belgium
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, Italy
| | | | | | | | - Alfonso Franzè
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital (Orbassano) and Rivoli Infermi Hospital (Rivoli), Turin, Italy
| | | | - Andrés Iñiguez
- Department of Cardiology, Hospital Universitario de Vigo, Vigo, Spain; Department of Cardiology, Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | - Salvatore Brugaletta
- Cardiology Department, Clinic Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain
| | - Manel Sabate
- Cardiology Department, Clinic Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, IDIBAPS, Barcelona, Spain
| | | | | | - Joanna Wykrzykowska
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Clemens von Birgelen
- Department of Cardiology, Medisch Spectrum Twente, Thoraxcentrum Twente, Enschede, the Netherlands; Department of Health Technology and Services Research, Faculty BMS, Technical Medical Centre, University of Twente
| | - Samer Somi
- Department of Cardiology, Haga Hospital, The Hague, the Netherlands
| | - Tommy Liu
- Department of Cardiology, Haga Hospital, The Hague, the Netherlands
| | - Sjoerd H Hofma
- Department of Cardiology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, and University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Ramiro Trillo
- Department of Cardiology, University Clinic Hospital, CIBERCV, Santiago de Compostela, Spain
| | - Raymundo Ocaranza
- Interventional Cardiology Section, Lucus Augusti University Hospital, Lugo, Spain
| | - Anthony Mathur
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, UK; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London
| | | | - Javier Escaned
- Hospital Clinico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London; Barts Heart Centre, London, United Kingdom; Yale University School of Medicine, New Haven, USA
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, NUIG, Galway, Ireland
| | - Faisal Sharif
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; SFI infrastructure funding, NUIG, Galway, Ireland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
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Simonato M, Ben-Yehuda O, Vincent F, Zhang Z, Redfors B. Consequences of Inaccurate Assumptions in Coronary Stent Noninferiority Trials: A Systematic Review and Meta-analysis. JAMA Cardiol 2022; 7:320-327. [PMID: 35107583 PMCID: PMC8811709 DOI: 10.1001/jamacardio.2021.5724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
IMPORTANCE The outcome and interpretation of noninferiority trials depend on the magnitude of the noninferiority margin and whether a relative or absolute noninferiority margin is used and may be affected by imprecision in event rate estimation. OBJECTIVE To assess the consequence of imprecise event rate estimations on interpretation of peer-reviewed randomized clinical trials. DATA SOURCES PubMed/MEDLINE was searched for articles published between January 1, 2015, and April 30, 2021. STUDY SELECTION Noninferiority randomized clinical trials of coronary stents published in selected journals with clinical events as the primary end point. DATA EXTRACTION AND SYNTHESIS Two reviewers (M.S. and F.V.) independently extracted data on trial characteristics, noninferiority assumptions, primary end point clinical outcomes, and study conclusions. Overestimation or underestimation of the control event rate was evaluated by dividing the assumed control event rate by the observed control event rate. For noninferiority end points with absolute margins, the assumed corresponding relative margin was defined as the ratio of the absolute margin and the assumed event rate, and the observed corresponding relative margin as the ratio between the absolute margin and the observed event rate in the control arm. Noninferiority comparisons with absolute margins were reanalyzed using the assumed corresponding relative margin and the Farrington-Manning score test for relative risk. MAIN OUTCOMES AND MEASURES Overestimation or underestimation, assumed and observed corresponding relative margins, and relative reanalysis of the primary end points of trials with absolute margins. RESULTS A total of 106 989 patients from 58 trials were included. The event rate in the control arms was overestimated by a median (IQR) of 28% (2%-74%). Most noninferiority trials used absolute rather than relative margins (55 of 58 trials [94.8%]). Owing to overestimation, absolute noninferiority margins became more permissive than originally assumed (median [IQR] of observed relative noninferiority margin, 1.62 [1.50-1.80] vs assumed relative noninferiority margin, 1.47 [1.39-1.55]; P < .001). Among trial comparisons that met noninferiority with an absolute noninferiority margin, 17 of 50 trials (34.0%) would not have met noninferiority with a corresponding assumed relative noninferiority margin. CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, assumed event rates were often overestimated in noninferiority coronary stent trials. Because most of these trials use absolute margins to define noninferiority, such overestimation results in excessively permissive relative noninferiority margins.
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Affiliation(s)
- Matheus Simonato
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York,NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York,Division of Cardiology, University of California, San Diego
| | - Flavien Vincent
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York,Centre Hospitalier Universitaire de Lille, Lille, France
| | - Zixuan Zhang
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York,NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York,Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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8
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Jia B, Zhang X, Ma N, Mo D, Gao F, Sun X, Song L, Liu L, Deng Y, Xu X, Zhang Y, Liu Z, Guan S, Zhang F, Li B, Zheng H, Liu X, Liu Y, Chen K, Shuai J, Wan J, Wang J, Shi X, Li T, Chang B, Liebeskind DS, Yu W, Miao Z. Comparison of Drug-Eluting Stent With Bare-Metal Stent in Patients With Symptomatic High-grade Intracranial Atherosclerotic Stenosis: A Randomized Clinical Trial. JAMA Neurol 2022; 79:176-184. [PMID: 34982098 PMCID: PMC8728659 DOI: 10.1001/jamaneurol.2021.4804] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance In-stent restenosis (ISR) is the primary reason for stroke recurrence after intracranial stenting in patients who were treated with a standard bare-metal stent (BMS). Whether a drug-eluting stent (DES) could reduce the risk of ISR in intracranial atherosclerotic stenosis (ICAS) remains unclear. Objective To investigate whether a DES can reduce the risk of ISR and stroke recurrence in patients with symptomatic high-grade ICAS. Design, Settings, and Participants A prospective, multicenter, open-label randomized clinical trial with blinded outcome assessment was conducted from April 27, 2015, to November 16, 2018, at 16 medical centers in China with a high volume of intracranial stenting. Patients with symptomatic high-grade ICAS were enrolled, randomized, and followed up for 1 year. Intention-to-treat data analysis was performed from April 1 to May 22, 2021. Interventions Patients were randomly assigned to receive DES (NOVA intracranial sirolimus-eluting stent system) or BMS (Apollo intracranial stent system) treatment in a 1:1 ratio. Main Outcomes and Measures The primary efficacy end point was ISR within 1 year after the procedure, which was defined as stenosis that was greater than 50% of the luminal diameter within or immediately adjacent to (within 5 mm) the implanted stent. The primary safety end point was any stroke or death within 30 days after the procedure. Results A total of 263 participants (194 men [73.8%]; median [IQR] age, 58 [52-65] years) were included in the analysis, with 132 participants randomly assigned to the DES group and 131 to the BMS group. The 1-year ISR rate was lower in the DES group than in the BMS group (10 [9.5%] vs 32 [30.2%]; odds ratio, 0.24; 95% CI, 0.11-0.52; P < .001). The DES group also had a significantly lower ischemic stroke recurrence rate from day 31 to 1 year (1 [0.8%] vs 9 [6.9%]; hazard ratio, 0.10; 95% CI, 0.01-0.80; P = .03). No significant difference in the rate of any stroke or death within 30 days was observed between the DES and BMS groups (10 [7.6%] vs 7 [5.3%]; odds ratio, 1.45; 95% CI, 0.54-3.94; P = .46). Conclusions and Relevance This trial found that, compared with BMSs, DESs reduced the risks of ISR and ischemic stroke recurrence in patients with symptomatic high-grade ICAS. Further investigation into the safety and efficacy of DESs is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT02578069.
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Affiliation(s)
- Baixue Jia
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuelei Zhang
- Stroke Center, Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lian Liu
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yiming Deng
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaotong Xu
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Zengpin Liu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Sheng Guan
- Neurointerventional Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Fan Zhang
- Department of Cerebrovascular Disease, Hainan General Hospital, Haikou, Hainan, China
| | - Bing Li
- Department of Neurology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Hongbo Zheng
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinfeng Liu
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yajie Liu
- Department of Neurology, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Kangning Chen
- Department of Neurology, The Southwest Hospital of Army Medical University, Chongqing, China
| | - Jie Shuai
- Department of Neurology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jieqing Wan
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Jun Wang
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xiangqun Shi
- Department of Neurology, General Hospital of Lanzhou Military Command, Lanzhou, China
| | - Tianxiao Li
- Neurointerventional Department, Henan Provincial People’s Hospital, Zhengzhou University, Zhengzhou, Henan, China
| | - Binge Chang
- Department of Neurosurgery, Tianjin First Central Hospital, Tianjin, China
| | | | - Wengui Yu
- Department of Neurology, University of California, Irvine, Irvine
| | - Zhongrong Miao
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Industry news update covering October 2021. Ther Deliv 2022. [PMID: 35005987 DOI: 10.4155/tde-2021-0088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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10
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Mori M, Sakamoto A, Sato Y, Kawakami R, Kawai K, Cornelissen A, Abebe B, Ghosh S, Romero ME, Kolodgie FD, Virmani R, Finn AV. Overcoming challenges in refining the current generation of coronary stents. Expert Rev Cardiovasc Ther 2021; 19:1013-1028. [PMID: 34860134 DOI: 10.1080/14779072.2021.2013810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Late stent thrombosis caused by delayed vascular healing and prolonged local inflammation were major drawbacks of 1st generation drug-eluting stents (DES). Strut design, biocompatibility of polymer, and drug-release profiles were improved in 2nd and 3rdgeneration DES. Accordingly, the indications for percutaneous coronary intervention with DES have been expanded to more complex patients and lesions. Despite these improvements, significant barriers such as greater flexibility in the duration of dual-antiplatelet therapy (DAPT) as well as reducing long-term stent-related events remain. To achieve ideal short- and long-term results, these existing limitations need to be overcome. AREAS COVERED We will discuss the current limitations of coronary DES and how they might be overcome from pathological and clinical viewpoints. EXPERT OPINION Optimizing DAPT duration after stent implantation and prevention of in-stent neoatherosclerosis are two major issues in current DES. Overcoming these drawbacks is a prerequisite toward achieving better short- and long-term clinical outcomes. New technologies including platform design, polymer types, and anti-proliferative agent itself might lead to further improvements. Although the initial experience with bioresorbable scaffold/stents (BRS) was disappointing, positive results of clinical studies regarding novel BRS are raising expectations. Overall, further device innovation is desired for overcoming the limitations of current DES.
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Affiliation(s)
| | | | - Yu Sato
- CVPath Institute, Inc, Gaithersburg, MD, USA
| | | | - Kenji Kawai
- CVPath Institute, Inc, Gaithersburg, MD, USA
| | | | | | | | | | | | | | - Aloke V Finn
- CVPath Institute, Inc, Gaithersburg, MD, USA.,School of Medicine, University of Maryland, Baltimore, Md, USA
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Leening MJG, Mahmoud KD. Non-efficacy benefits and non-inferiority margins: a scoping review of contemporary high-impact non-inferiority trials in clinical cardiology. Eur J Epidemiol 2021; 36:1103-1109. [PMID: 34792692 PMCID: PMC8629871 DOI: 10.1007/s10654-021-00820-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/02/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Maarten J G Leening
- Department of Cardiology, Erasmus MC - University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Department of Epidemiology, Erasmus MC - University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Karim D Mahmoud
- Department of Cardiology, Erasmus MC - University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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12
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Edelman ER. Karnovsky's Dictum: The Endothelium Is Good-Looking and Smart. Circulation 2021; 143:2166-2168. [PMID: 34061584 DOI: 10.1161/circulationaha.121.054772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA. Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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