Impact of renal function in high bleeding risk patients undergoing percutaneous coronary intervention: a patient-level stratified analysis from four post-approval studies

Data on ischemic and bleeding outcomes after percutaneous coronary intervention (PCI) in high bleeding risk (HBR) patients with chronic kidney disease (CKD) are scarce. We aimed to evaluate the association between CKD and ischemic and bleeding outcomes in HBR patients who underwent PCI. Among 10,502 patients in the four post-approval registries evaluating patients undergoing PCI, 2,300 patients presented with at least one major or two minor ARC-HBR criteria. CKD was defined as eGFR < 60 mL/min/1.73 m². These HBR patients were divided into 3 groups: eGFR < 30 mL/min/1.73 m² defined as severe CKD (N = 221), eGFR 30- < 60 mL/min/1.73 m² defined as moderate CKD (N = 970), eGFR ≥ 60 mL/min/1.73 m² defined as no CKD (N = 1,109). The primary endpoint was the composite of cardiac death, myocardial infarction, or stent thrombosis, and the safety endpoint was major bleeding up to 4-year follow-up. HBR patients with CKD were more often female and had higher rates of comorbidities compared to those without CKD. Reduced renal function was associated with higher rates of the primary endpoint (severe CKD vs. moderate CKD vs. no CKD: 30.2% vs. 12.5% vs. 9.1%, P < 0.01) as well as major bleeding (10.3% vs. 8.9% vs. 6.4%, P = 0.03). After adjustment, severe CKD and moderate CKD in HBR patients remained independent predictors for the primary endpoint (HR [95%CI] 2.84 [1.94-4.16], P < 0.01, 1.48 [1.10-2.00], P < 0.01) compared to those with no CKD. However, decreased renal function was no longer significantly associated with major bleeding after adjustment. In conclusions, in HBR patients undergoing PCI, CKD has an important impact on major ischemic events after PCI.

Recent Least Burdensome Approach for the Approval of Innovative Medical Devices in Japan -Regulatory Approval Review of an Everolimus-eluting Bioresorbable Scaffold

Although a domestic trial in Japan revealed that Absorb bioresorbable vascular scaffold (BVS) has no inferiority to everolimus-eluting stent (EES) cohort in the primary endpoint of the target lesion failure at 12 months, the scaffold/stent thrombosis (ST) rates with the BVS at 24 months were higher than those with the EES (Absorb BVS 3.1% vs. EES 1.5%), the ST rate of 3.1% with Absorb BVS is not an acceptable level in Japan. A cause-of-ST analysis revealed that cases in which diagnostic imaging and ensuing post-dilatation had been performed appropriately had lower ST rates than those without such management (within 1 year: 1.37% vs. 7.69%, from 1 to 2 years: 0.00% vs. 8.33%). Therefore, a further evaluation was needed to confirm that the ST rate with the Absorb BVS would be reduced by a proper implementation procedure. Regulatory approval was given conditionally to initiate rigorous post-marketing data collection in order to ensure the proper use of this device in limited facilities. The One-year Use-Result Survey in Japan for the Absorb BVS revealed no instances of ST. This approach to reducing the premarket regulatory burden of clinical trials and enhancing the post-marketing commitments of medical device regulation is useful for expediting patient access to innovative medical devices.

Differences in clinical outcomes between pre- and post-marketing clinical study following paclitaxel-coated balloon catheter treatment for coronary in-stent restenosis: from the Japanese regulatory viewpoint

In 2013, a drug-coated balloon catheter (DCB) (SeQuent Please) for the treatment of coronary in-stent restenosis (ISR) was approved in Japan. The pre-marketing Japan domestic NP001 study demonstrated better outcomes of the DCB (n = 138) compared to plain balloon angioplasty (n = 72). After the introduction to marketing, a post-marketing surveillance (PMS) (n = 396) was conducted to evaluate the safety and efficacy of the DCB in Japanese routine clinical practice. The aim of this paper was to assess differences between the pre-marketing NP001 study and the PMS. Compared to the NP001 study, more complex lesions were treated in the PMS (type B2/C: 69.0% vs 20.4%, total occlusion: 11.2% vs 0%, p < 0.001, respectively) and target lesion was more frequently ISR related to drug-eluting stent (DES) (79.5% vs 39.4%, p < 0.001). Regarding clinical outcomes, the rate of target lesion revascularization (TLR) was higher in the PMS than in the NP001 study (TLR: 12.9% at 7 months and 17.6% at 12 months vs 2.8% at 6 months, p = 0.001, p < 0.001, respectively). Multivariable logistic regression analysis revealed that DES-ISR was a risk factor of TLR after DCB treatment for ISR (odds ratio: 5.77, 95% CI 1.75-18.95, p = 0.004). Among representative published trials using DCB for ISR, clinical outcomes are often worse in DES-ISR trials than those in bare metal stent-ISR trials. The rates of TLR in previous DES-ISR trials are similar to that in the current PMS (TLR at 12 months: 22.1% for ISAR-DESIRE 3, 15.3% for PEPCAD-DES, and 13.0% for RIBS IV). The effectiveness and safety of DCB for coronary ISR have been confirmed in the Japanese real-world survey. PMS would be useful to evaluate the safety and effectiveness of medical products throughout their total life cycles.

Numerical analysis of paclitaxel-eluting coronary stents: Mechanics and drug release properties

Since theoretical models provide data that cannot be otherwise gathered, numerical methods applied to medical devices analysis have emerged as fundamental tool in preclinical development. Large efforts were done to study mechanical and drug-eluting properties in stents but often the coating modelling is neglected. This work presents a finite element framework to calculate mechanical loads and drug distribution in three commercial drug-eluting stents (Palmaz-Schatz, Palmaz Genesis and Multi Link Vision), to check coatings strength and drug distribution maps in biological tissues. The promising copolymer poly(methylmethacrylate-co-n-butylmethacrylate), loaded with paclitaxel, is analyzed. Results demonstrated that the coating undergoes localized plastic phenomena, and calculated stresses are lower than the ultimate stress, ensuring coating integrity. Computed drug concentration depends on stent geometry and its values are in all cases lower than the toxicity level for this drug.

Efficacy and safety of short-term 1-3 months versus standard 12 months dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a meta-analysis of randomized clinical trials

Dual antiplatelet therapy (DAPT) is the basis of preventing stent thrombosis and ischemic events after percutaneous coronary intervention (PCI), but prolonging the duration of DAPT will increase the risk of bleeding. The optimal duration of DAPT after PCI remains controversial at present. The purpose of this meta-analysis was to investigate the efficacy and safety of short-term DAPT in patients undergoing PCI. PubMed, Embase, Cochrane and Web of science from inception to September 2019 were systematically searched. Randomized controlled trials were included to compare short term (3 months or less) with a standard 12-months DAPT in patients undergoing PCI. Random effect model and fixed effect model wereused to calculate the risk ratio (RR) and 95% confidence interval (CI) of each endpoint. This meta-analysis included 38479 patients undergoing PCI from 8 randomized clinical trials. No difference was observed in the risk of all-cause death (RR 0.92, 95% CI 0.80-1.06, P = 0.25), cardiovascular death (RR 0.88, 0.69-1.12, P = 0.29), myocardial infarction (RR 1.05, 0.94-1.19, P = 0.38), definite or probable stent thrombosis (RR 1.05, 0.80-1.36, P = 0.73), and stroke (RR 1.02, 0.80-1.30, P = 0.89) between short term and standard DAPT. The short-term DAPT could reduce the risk of major bleeding (RR 0.67, 0.48-0.94, P = 0.02) and any bleeding (RR 0.63, 0.48-0.82, P = 0.0005) compared with 12 months of DAPT. In conclusion, the short-term DAPT can reduce the risk of bleeding compared with standard DAPT, without increasing the risk of death or ischemia (Registered by PROSPERO, CRD42020153881).

Electrophysiology devices and the regulatory approval process within the U.S. FDA and abroad

Almost all electrophysiology (EP) devices need to obtain premarket approval before they can be commercially sold and available for use in the community. The US Food and Drug Administration (FDA) has different paths to market approval depending on the intended use and the associated risks of the device. The European Union and Japan have device approval processes that have many similarities as well as differences to the US regulatory system. This paper describes some of the history and background of the US device approval process with an emphasis on EP devices. It provides an overview of the different regulatory pathways in the USA that are currently being utilized and contrasts them to the procedures often used in the European Union and in Japan. It also touches on the impact of the twenty-first Century Cures Act and how the balance between premarket and postmarket regulatory oversight is continually being examined and refined.