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Hussain Y, Saito S, Curtis M, Kereiakes DJ, Baumbach A, Zidar JP, McLaurin B, Dib N, Smits PC, Jiménez Díaz VA, Cequier Á, Hofma SH, Pietras C, Dressler O, Issever MO, Windecker S, Leon MB, Lansky AJ. The Supreme Biodegradable Polymer DES in Acute and Chronic Coronary Syndromes: A PIONEER III Substudy. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100629. [PMID: 39130696 PMCID: PMC11307614 DOI: 10.1016/j.jscai.2023.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/21/2023] [Accepted: 03/01/2023] [Indexed: 08/13/2024]
Abstract
Background The PIONEER III trial demonstrated noninferiority of 12-month target lesion failure (TLF) with the Supreme DES (Sinomed), a thin-strut cobalt-chromium, biodegradable polymer, sirolimus-eluting stent, compared with a durable polymer, everolimus-eluting (XIENCE/PROMUS) stent (DP-EES). The relative safety and effectiveness of the Supreme DES in patients with acute coronary syndromes (ACS) and those with chronic coronary syndromes (CCS) is not known. Methods PIONEER III was a prospective, multicenter, international, 2:1 randomized trial stratified by clinical presentation. The primary end point was TLF at 12 months (a composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization). Results A total of 1628 patients were enrolled, including 41% of patients with ACS (unstable angina and non-ST-elevation myocardial infarction) randomized to Supreme DES (n = 441) versus DP-EES (n = 232) and 59% of patients with CCS randomized to Supreme DES (n = 645) versus DP-EES (n = 310). Patients with ACS were younger, fewer presented with less diabetes, hypertension, and previous revascularization, but more were current smokers. The primary end point of TLF (6.4% vs 4.4%; P = .1), major adverse cardiac events (8.5% vs 6.5%; P = .16), and stent thrombosis (0.4% vs 0.9%; P = .25) at 12 months were similar in the ACS and CCS groups. There was no difference in TLF at 12 months between Supreme DES and DP-EES among patients with ACS (6.6% vs 6.0%; P = .89) and those with CCS (4.5% vs 4.3%; P = .83); interaction P = .51 for TLF by clinical presentation. Conclusions Compared with the DP-EES, the Supreme DES seemed safe and effective with a similar TLF at 12 months in both patients with ACS and those with CCS.
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Affiliation(s)
- Yasin Hussain
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut
| | | | | | - Dean J. Kereiakes
- The Christ Hospital Heart and Vascular Institute and the Lindner Research Center, Cincinnati, Ohio
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
| | - James P. Zidar
- North Carolina Heart and Vascular, University of North Carolina, Raleigh
| | | | - Nabil Dib
- Mercy Gilbert Medical Center, Gilbert, Arizona
| | | | | | - Ángel Cequier
- Bellvitge Hospital, University of Barcelona, IDIBELL, Barcelona, Spain
| | - Sjoerd H. Hofma
- Medisch Centrum Leeuwarden, Hartcentrum Friesland, Leeuwarden, the Netherlands
| | - Cody Pietras
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut
| | | | | | - Stephan Windecker
- Bern University Hospital, Inselspital, University of Bern, Switzerland
| | - Martin B. Leon
- Cardiovascular Research Foundation, New York, New York
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | | | - PIONEER III Trial Investigators
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut
- Shonan Kamakura General Hospital, Kamakura, Japan
- University of Calgary, Alberta, Canada
- The Christ Hospital Heart and Vascular Institute and the Lindner Research Center, Cincinnati, Ohio
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
- North Carolina Heart and Vascular, University of North Carolina, Raleigh
- AnMed Health Medical Center, Anderson, South Carolina
- Mercy Gilbert Medical Center, Gilbert, Arizona
- Maasstad Ziekenhuis, Rotterdam, the Netherlands
- Hospital Álvaro Cunqueiro, Vigo, Spain
- Bellvitge Hospital, University of Barcelona, IDIBELL, Barcelona, Spain
- Medisch Centrum Leeuwarden, Hartcentrum Friesland, Leeuwarden, the Netherlands
- Cardiovascular Research Foundation, New York, New York
- Bern University Hospital, Inselspital, University of Bern, Switzerland
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
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2
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Zhu YX, Liang L, Parasa R, Li Z, Li Q, Chang S, Ma WR, Feng SL, Wang Y, Xu B, Bourantas CV, Zhang YJ. Early vascular healing after neXt-generation drug-eluting stent implantation in Patients with non-ST Elevation acute Coronary syndrome based on optical coherence Tomography guidance and evaluation (EXPECT): study protocol for a randomized controlled trial. Front Cardiovasc Med 2023; 10:1003546. [PMID: 36910518 PMCID: PMC9995825 DOI: 10.3389/fcvm.2023.1003546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Background There is limited evidence about vessel wall healing response following implantation of next-generation drug-eluting stents (DES) in patients admitted with a non-ST elevation acute coronary syndrome (NSTE-ACS). Cumulative data indicate that optical coherence tomography (OCT) imaging can optimize percutaneous coronary intervention results and expedite stent endothelialization in the general population but there is lack of data in NSTE-ACS patients. Methods The EXPECT study is an investigator-initiated, prospective, randomized trial to assess early vascular healing response following next-generation DES implantation in patients admitted with NSTE-ACS based on OCT guidance and evaluation. Sixty patients are randomized at 1:1:1 ratio to OCT-guided percutaneous coronary intervention (PCI) with 3-month follow-up OCT imaging (O3 group, n = 20), to angiography-guided PCI with 3-month follow-up OCT imaging (A3 group, n = 20) and to angiography-guided PCI with 6-month follow-up OCT imaging (A6 group, n = 20). The primary endpoint of the study is stent strut coverage rate at 3- or 6- month follow-up in the studied groups. The secondary endpoints of the study include OCT imaging endpoints, clinical endpoints, and molecular biology endpoints at the different time points. The clinical endpoints comprised of major cardiovascular adverse events and individual components. The molecular biology endpoints comprised of lipid levels and the levels of inflammatory indicators. Discussion The findings of the EXPECT study are anticipated to provide novel insights into vessel wall healing in NSTE-ACS population following implantation of next-generation DES, underscore the value of OCT imaging in expediting strut coverage in this setting, and explore the potential of an early discontinuation of dual antiplatelet therapy (DAPT) in this population. Clinical Trial Registration ClinicalTrials.gov, NCT04375319.
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Affiliation(s)
- Yong-Xiang Zhu
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Li Liang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Ramya Parasa
- Department of Cardiology, Barts Heart Center, Barts Health NHS Trust, London, United Kingdom.,Cardiovascular Devices Hub, Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Zheng Li
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Qian Li
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Shang Chang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Wen-Rui Ma
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Si-Li Feng
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Yang Wang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Christos V Bourantas
- Department of Cardiology, Barts Heart Center, Barts Health NHS Trust, London, United Kingdom.,Cardiovascular Devices Hub, Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Yao-Jun Zhang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
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3
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Garot P, Leon MB, Saito S, Baumbach A, Kereiakes DJ, Windecker S, Pietras C, Dressler O, Issever MO, Curtis M, Bertolet BD, Zidar JP, Smits PC, Jiménez Diaz VA, McLaurin B, Cequier AR, Hofma SH, Dib N, Namiki A, Takahashi A, Kakuta T, Hirohata A, Lansky AJ. Geographic Variations on the Safety and Efficacy of the Supreme Biodegradable Polymer DES: Results From PIONEER III. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100515. [PMID: 39132534 PMCID: PMC11308104 DOI: 10.1016/j.jscai.2022.100515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 08/13/2024]
Abstract
Background The PIONEER III trial showed the 12-month safety and efficacy of the Supreme drug-eluting stent (DES) vs the durable polymer everolimus-eluting stent. We sought to assess whether the characteristics and clinical outcomes of the Supreme DES in PIONEER III were consistent among patients by enrollment location. Methods This subgroup analysis of the PIONEER III trial compared the characteristics and outcomes of patients recruited from North America, Europe, and Japan and the relative differences in patient outcomes according to the site recruitment volume. Results From October 2017 to July 2019, 1629 patients were recruited in North America (816, 50.1%), Europe (650, 39.9%), and Japan (163, 10%). Procedural success was achieved in 1556 of 1611 procedures (96.6%), with no difference by the geographic location. Target lesion failure at 12 months for combined groups was observed in 84 of 1629 patients (5.2%), with no significant geographic differences (4.7%, 6.5%, and 2.5%, respectively; P =.08), with similar results in the Supreme DES group alone (4.4%, 6.8%, and 3.7%, respectively, P =.20). Cardiac death at 12 months occurred in 0.4%, 0.2%, and 0.0% (P =.79), target vessel-related myocardial infarction occurred in 2.2%, 4.7%, and 3.7%, (P =.10), and clinically driven target lesion revascularization was required in 2.1%, 3.1%, and 0%, respectively (P =.15). Compared with those from high-recruiting sites, results from low-recruiting sites were similar for target lesion failure, major adverse cardiac events, stent thrombosis, and mortality, with a nonsignificant trend for higher rates of myocardial infarction. Conclusions Despite regional differences in patient characteristics, the clinical outcomes between Supreme DES and durable polymer everolimus-eluting stent in the PIONEER III trial were not different, supporting the generalizability and robustness of the findings from this multicenter controlled trial.
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Affiliation(s)
- Philippe Garot
- Institut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, Massy, France
| | - Martin B. Leon
- NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York
- Cardiovascular Research Foundation, New York, New York
| | | | - Andreas Baumbach
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
| | | | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Switzerland
| | - Cody Pietras
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | | | - James P. Zidar
- North Carolina Heart and Vascular, University of North Carolina, Raleigh, North Carolina
| | | | | | | | - Angel R. Cequier
- Bellvitge University Hospital, University of Barcelona, IDIBELL, Barcelona, Spain
| | - Sjoerd H. Hofma
- Medisch Centrum Leeuwarden, Hartcentrum Friesland, Leeuwarden, the Netherlands
| | - Nabil Dib
- Mercy Gilbert Medical Center, Gilbert, Arizona
| | - Atsuo Namiki
- Department of Cardiology, JOHAS Kanto-Rosai Hospital, Kanagwa, Japan
| | | | - Tsunekazu Kakuta
- Department of Cardiology, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Atsushi Hirohata
- Department of Cardiology, The Sakakibara Heart Institute of Okayama, Okayama, Japan
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4
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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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Thomas A, Kereiakes DJ, Baumbach A, Windecker S, Pietras C, Dressler O, Issever MO, Curtis M, Bertolet B, Zidar JP, Smits PC, Jiménez Díaz VA, McLaurin B, Cequier Á, Takahashi A, Cannon LA, Amoroso G, Kakuta T, Saito S, Leon MB, Lansky AJ. Safety and Efficacy of the Supreme Biodegradable Polymer Sirolimus-Eluting Stent in Patients With Diabetes Mellitus. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100033. [PMID: 39132558 PMCID: PMC11307809 DOI: 10.1016/j.jscai.2022.100033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 08/13/2024]
Abstract
Background Patients with diabetes mellitus (DM) have worse outcomes following percutaneous coronary intervention than nondiabetic patients. The novel Supreme DES is a biodegradable polymer sirolimus-eluting stent designed to synchronize early drug delivery, limiting the potential for long-term inflammatory response. The purpose of this study was to evaluate the safety and efficacy of the Supreme DES in patients with DM. Methods This is a prespecified analysis of the diabetic subgroup from the PIONEER III randomized (2:1), controlled trial, comparing the Supreme DES with a durable polymer everolimus-eluting stent (DP-EES). The primary safety and efficacy composite endpoint was target lesion failure at 1 year, a composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Results The PIONEER III trial randomized 1629 patients, of which 494 (30.3%) had DM with 331 (398 lesions) randomly assigned to Supreme DES and 163 (208 lesions) to DP-EES. Among patients with DM, target lesion failure at 1 year was 6.1% (20/331) with Supreme DES vs 3.7% (6/163) with DP-EES (hazard ratio = 1.65; 95% confidence interval = 0.66-4.10, P = .28). The composite of cardiac death or target vessel myocardial infarction was 3.3% (11/331) with Supreme DES and 3.7% (6/163) with DP-EES (hazard ratio = 0.90; 95% confidence interval = 0.33-2.44, P = .83). There were no significant differences in other secondary endpoints. Conclusions This prespecified substudy of the PIONEER III trial demonstrated the relative safety and efficacy of the novel Supreme DES when compared with commercially available DP-EES in diabetics at 1 year. Longer term follow-up will be required to ensure continued safety and efficacy of the Supreme DES.
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Affiliation(s)
- Alexander Thomas
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut
| | | | - Andreas Baumbach
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Switzerland
| | - Cody Pietras
- Division of Cardiology, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | - Barry Bertolet
- Cardiology Associates of North Mississippi, Tupelo, Mississippi
| | - James P. Zidar
- North Carolina Heart and Vascular, University of North Carolina, Raleigh, North Carolina
| | | | | | | | - Ángel Cequier
- Bellvitge Hospital, University of Barcelona, IDIBELL, Spain
| | | | - Louis A. Cannon
- Cardiac and Vascular Research Center of Northern Michigan, Petoskey, Michigan
| | | | | | | | - Martin B. Leon
- Cardiovascular Research Foundation, New York, New York
- College of Physicians and Surgeons, Columbia University, New York, New York
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Abhyankar A, Abizaid A, Chamié D, Patel G. Healing and early stent coverage after ultrathin strut biodegradable polymer-coated sirolimus-eluting stent implantation: SiBi optical coherence tomography study. Catheter Cardiovasc Interv 2021; 98:1335-1342. [PMID: 33247618 DOI: 10.1002/ccd.29371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/03/2020] [Accepted: 10/26/2020] [Indexed: 11/09/2022]
Abstract
AIMS The aim of SiBi study was to evaluate the early vascular healing and neointimal coverage after implantation of ultrathin (60 μm) biodegradable polymer-coated Tetriflex (Sahajanand Medical Technologies Pvt. Ltd., Surat, India) sirolimus-eluting stent (SES) using optical coherence tomography (OCT) at 4 to 6 weeks after implantation. METHODS SiBi was a single-center, observational, investigator-initiated study. From January 15, 2018 to April 15, 2018, total 29 consecutive patients who had consented and underwent OCT examination at 4-6 weeks after Tetriflex SES implantation were enrolled. All OCT images were analyzed at an independent core laboratory by analysts who were blinded to patient and procedural information. RESULTS Of 29 patients, four patients were excluded, as those OCT images were technically inadequate for analysis. Therefore, 25 patients were included in final OCT analysis. Average OCT analysis was performed after 35.3 ± 5 days of Tetriflex implantation. Total 14,024 stent struts in 1,520 cross sections were analyzed. Strut tissue coverage was observed in 91.26 ± 5.53% of struts and malapposed struts were seen in 0.89 ± 1.67%. The mean neointimal hyperplasia (NIH) thickness on the covered struts was 50 ± 30 μm. CONCLUSION A large percentage of struts were found to be covered with thin layer of NIH evenly distributed along the stent length at around 1 month from stent implantation. The results of this pilot study serve as ethical and scientific backbone to conduct an adequately powered clinical trial to evaluate outcomes of short dual-antiplatelet therapy in context of ultrathin strut stent.
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Affiliation(s)
- Atul Abhyankar
- Department of Cardiology, Shree B. D. Mehta Mahavir Heart Institute, Surat, India
| | - Alexandre Abizaid
- Interventional Cardiology Department, University of São Paulo, São Paulo, Brazil
| | - Daniel Chamié
- Invasive Cardiology Department, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
| | - Gaurang Patel
- Department of Cardiology, Shree B. D. Mehta Mahavir Heart Institute, Surat, India
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7
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Aziz MK, Herrmann J, Marmagkiolis K, Balanescu DV, Donisan T, Pushparaji B, Lin HY, Tomakin G, Hoyt T, Pham M, Dijkstra J, Cilingiroglu M, Lopez-Mattei J, Zaha V, Anderson HV, Feldman MD, Molony DA, Iliescu CA. Coronary Stent Healing in Cancer Patients-An Optical Coherence Tomography Perspective. Front Cardiovasc Med 2021; 8:665303. [PMID: 34164440 PMCID: PMC8215158 DOI: 10.3389/fcvm.2021.665303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study assessed stent healing patterns and cardiovascular outcomes by optical coherence tomography (OCT) in cancer patients after drug-eluting stent (DES) placement. Background: Cancer treatment, owing to its cytotoxic and antiproliferative effects, could delay stent healing and increase stent thrombosis risk, especially when dual antiplatelet therapy (DAPT) is discontinued early for oncological treatment. OCT can assess stent endothelialization and other healing parameters, which may provide clinical guidance in these challenging scenarios. Methods: This single-center retrospective study enrolled all cancer patients who underwent OCT for assessment of vascular healing patterns after prior DES placement from November 2009 to November 2018. Primary study endpoints were stent healing parameters, including stent coverage, apposition, degree of expansion, neointimal hyperplasia heterogeneity, in-stent restenosis, stent thrombosis, and overall survival (OS). Results: A total of 67 patients were included in this study. Mean time between DES placement and OCT evaluation was 154 ± 82 days. Stent healing matched published values for DES in non-cancer patients (P ≥ 0.063). At 1 year, the OS was 86% (95% confidence interval [CI]: 78–96%) with 0% incidence of acute coronary syndrome. Advanced cancers and active chemotherapies were associated with inferior OS (P = 0.024, hazard ratio [HR]: 3.50, 95% CI: 1.18–10.42 and P = 0.026, HR: 2.65, 95% CI: 1.13–6.22, respectively), while stent healing parameters were unassociated with OS. Forty-one patients (61%) had DAPT duration ≤6 months. Conclusions: Stent healing of contemporary DES appears similar in cancer and non-cancer patients. Cardiovascular risk of cancer patients after DES placement can be managed to facilitate timely cancer therapies, as the underlying malignancy and active chemotherapy ultimately determine survival.
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Affiliation(s)
- Moez Karim Aziz
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.,McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Konstantinos Marmagkiolis
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | - Teodora Donisan
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, United States
| | - Bala Pushparaji
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Heather Y Lin
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Gerryross Tomakin
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Taylor Hoyt
- Division of Cardiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Martin Pham
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jouke Dijkstra
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Mehmet Cilingiroglu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Juan Lopez-Mattei
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Vlad Zaha
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - H Vernon Anderson
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Marc D Feldman
- Division of Cardiology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Donald A Molony
- McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Cezar A Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.,McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX, United States
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8
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eG Coated Stents Exhibit Enhanced Endothelial Wound Healing Characteristics. Cardiovasc Eng Technol 2021; 12:515-525. [PMID: 34008078 PMCID: PMC8481217 DOI: 10.1007/s13239-021-00542-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 05/05/2021] [Indexed: 11/06/2022]
Abstract
Purpose Despite their widespread use, a significant fraction of coronary stents suffer from in-stent restenosis and stent thrombosis. Stent deployment induces extensive injury to the vascular endothelium. Rapid endothelial wound closure is essential for the success of a stenting procedure. A recent study has demonstrated that the BuMA Supreme® sirolimus-eluting stent exhibits particularly attractive strut coverage characteristics. A unique feature of this stent is the presence of a thin brush layer of poly-butyl methacrylate (PBMA), covalently bonded to the stent’s cobalt-chromium frame via electro-grafting (eG™). The present study aimed to determine whether the PBMA coating has an effect on endothelial cell wound healing and stent strut coverage. Methods We used an in vitro coronary artery model whose wall consisted of an annular collagen hydrogel and whose luminal surface was lined with a monolayer of endothelial cells. Mechanical wounding of the endothelial lining was preformed prior to deployment of a bare cobalt-chromium stent either with or without the PBMA layer. The migration of fluorescently labeled endothelial cells was monitored automatically over a period of 48 h to determine endothelial wound healing rates. Results Quantitative assessment of endothelial wound healing rates within the simulated arterial model is achievable using automated image analysis. Wound healing is significantly faster (44% faster at 48 h) for stents with the PBMA eG Coating™ compared to bare metal stents. Conclusion The PBMA eG Coating™ has the effect of promoting endothelial wound healing. Future studies will focus on elucidating the mechanistic basis of this observation. Supplementary Information The online version contains supplementary material available at 10.1007/s13239-021-00542-x.
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9
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Lansky AJ, Kereiakes DJ, Baumbach A, Windecker S, Hussain Y, Pietras C, Dressler O, Issever O, Curtis M, Bertolet B, Zidar JP, Smits PC, Alfonso Jiménez Díaz V, McLaurin B, Hofma S, Cequier Á, Dib N, Benit E, Mathur A, Brogno D, Berland J, Wykrzykowska J, Piegari G, Brugaletta S, Saito S, Leon MB. Novel Supreme Drug-Eluting Stents With Early Synchronized Antiproliferative Drug Delivery to Inhibit Smooth Muscle Cell Proliferation After Drug-Eluting Stents Implantation in Coronary Artery Disease: Results of the PIONEER III Randomized Clinical Trial. Circulation 2021; 143:2143-2154. [PMID: 33820424 DOI: 10.1161/circulationaha.120.052482] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Accelerated endothelial healing after targeted antiproliferative drug delivery may limit the long-term inflammatory response of drug-eluting stents (DESs). The novel Supreme DES is designed to synchronize early drug delivery within 4 to 6 weeks of implantation, leaving behind a prohealing permanent base layer. Whether the Supreme DES is safe and effective in the short term and can improve long-term clinical outcomes is not known. METHODS In an international, 2:1 randomized, single-blind trial, we compared treatment with Supreme DES to durable polymer everolimus-eluting stents (DP-EES) in patients with acute and chronic coronary syndromes. The primary end point was target lesion failure-a composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. The trial was designed to demonstrate noninferiority (margin of 3.58%) of the Supreme DES at 12 months compared with DP-EES (URL: https://www.clinicaltrials.gov; Unique identifier: NCT03168776). RESULTS From October 2017 to July 2019, a total of 1629 patients were randomly assigned (2:1) to the Supreme DES (N=1086) or DP-EES (N=543). At 12 months, target lesion failure occurred in 57 of 1057 patients (5.4%) in the Supreme DES group and in 27 of 532 patients (5.1%) in the DP-EES group (absolute risk difference, 0.32% [95% CI, -1.87 to 2.5]; Pnoninferiority=0.002]. There were no significant differences in rates of device success, clinically driven target lesion revascularization, or stent thrombosis at 12 months, and the safety composite of cardiovascular death and target vessel myocardial infarction was 3.5% versus 4.6% (hazard ratio, 0.76 [95% CI, 0.46-1.25]) with Supreme DES compared with DP-EES, although rates of combined clinically and non-clinically driven target lesion revascularization at 12 months were higher with Supreme DES. CONCLUSIONS Among patients with acute and chronic coronary syndromes undergoing percutaneous coronary intervention, the Supreme DES proved to be noninferior to the standard DP-EES. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03168776.
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Affiliation(s)
- Alexandra J Lansky
- Division of Cardiology, Yale School of Medicine, New Haven, CT (A.J.L., A.B., Y.H., C.P., A.M.).,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom (A.J.L., A.B., A.M.)
| | - Dean J Kereiakes
- Christ Hospital Heart and Vascular Center, Cincinnati, OH (D.J.K.)
| | - Andreas Baumbach
- Division of Cardiology, Yale School of Medicine, New Haven, CT (A.J.L., A.B., Y.H., C.P., A.M.).,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom (A.J.L., A.B., A.M.)
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Switzerland (S.W.)
| | - Yasin Hussain
- Division of Cardiology, Yale School of Medicine, New Haven, CT (A.J.L., A.B., Y.H., C.P., A.M.)
| | - Cody Pietras
- Division of Cardiology, Yale School of Medicine, New Haven, CT (A.J.L., A.B., Y.H., C.P., A.M.)
| | - Ovidiu Dressler
- Cardiovascular Research Foundation, New York, NY (O.D., O.I., M.B.L.)
| | - Ozgu Issever
- Cardiovascular Research Foundation, New York, NY (O.D., O.I., M.B.L.)
| | | | - Barry Bertolet
- Cardiology Associates of North Mississippi, Tupelo (B.B.)
| | - James P Zidar
- North Carolina Heart and Vascular, University of North Carolina, Raleigh (J.P.Z.)
| | - Pieter C Smits
- Maasstad Ziekenhuis, Rotterdam, The Netherlands (P.C.S.)
| | | | | | - Sjoerd Hofma
- Medisch Centrum Leeuwarden, Hartcentrum Friesland, Leeuwarden, The etherlands (S.H.)
| | - Ángel Cequier
- Bellvitge Hospital, University of Barcelona, IDIBELL, Spain (A.C.)
| | - Nabil Dib
- Mercy Gilbert Medical Center, Gilbert, AZ (N.D.)
| | - Edouard Benit
- Jessa Ziekenhuis, Campus Virga Jesse, Hasselt, Belgium (E.B.)
| | - Anthony Mathur
- Division of Cardiology, Yale School of Medicine, New Haven, CT (A.J.L., A.B., Y.H., C.P., A.M.).,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom (A.J.L., A.B., A.M.)
| | - David Brogno
- College of Physicians and Surgeons, Columbia University, New York, NY (D.B., M.B.L.)
| | | | - Joanna Wykrzykowska
- Academic Medical Center, University of Amsterdam, The Netherlands (J.W.).,Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands (J.W.)
| | - Guy Piegari
- Penn State Health Medical Group-Berks Cardiologists, Wyomissing, PA (G.P.)
| | - Salvatore Brugaletta
- Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Spain (S.B.)
| | - Shigeru Saito
- Shonan Kamakura General Hospital, Kamakura, Japan (S.S.)
| | - Martin B Leon
- Cardiovascular Research Foundation, New York, NY (O.D., O.I., M.B.L.).,College of Physicians and Surgeons, Columbia University, New York, NY (D.B., M.B.L.)
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10
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Short-term healing response after implantation of the thin-strut, fast-releasing sirolimus-eluting biodegradable polymer-coated Alex Plus stent: optical coherence tomography study. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2020; 16:187-191. [PMID: 32636904 PMCID: PMC7333208 DOI: 10.5114/aic.2020.96062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/17/2020] [Indexed: 11/18/2022] Open
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11
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Ozaki Y, Garcia-Garcia HM, Mintz GS, Waksman R. Supporting evidence from optical coherence tomography for shortening dual antiplatelet therapy after drug-eluting stents implantation. Expert Rev Cardiovasc Ther 2020; 18:261-267. [PMID: 32321328 DOI: 10.1080/14779072.2020.1759421] [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: 10/24/2022]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) is required for coronary artery disease treated with drug-eluting stents (DES) implantation. Shortening DAPT duration would be beneficial for patients with high bleeding risk. AREAS COVERED Early healing patterns, especially stent strut coverage, assessed by optical coherence tomography (OCT) as a surrogate of neointima have been investigated to make decisions on whether short DAPT would be a safe alternative. This review evaluates the OCT evidence (i.e. neointimal coverage of stent struts within 3 months) for shortening DAPT duration after DES implantation. EXPERT COMMENTARY Shortening DAPT (i.e. within 3 months) duration after DES implantation might reduce complications including bleeding without increasing stent thrombosis. However, the optimal duration of DAPT after DES implantation is under discussion. Long-term assessment of short DAPT is required for the decision of the new guidelines regarding the recommended duration of DAPT.
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Affiliation(s)
- Yuichi Ozaki
- Section of Interventional Cardiology, MedStar Washington Hospital Center , Washington, DC, USA
| | - Hector M Garcia-Garcia
- Section of Interventional Cardiology, MedStar Washington Hospital Center , Washington, DC, USA
| | - Gary S Mintz
- Section of Interventional Cardiology, MedStar Washington Hospital Center , Washington, DC, USA.,Clinical Trials Center, Cardiovascular Research Foundation , New York, NY, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center , Washington, DC, USA
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12
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Torii S, Jinnouchi H, Sakamoto A, Mori H, Park J, Amoa FC, Sawan M, Sato Y, Cornelissen A, Kuntz SH, Kutyna M, Paek KH, Fernandez R, Braumann R, Mont EK, Surve D, Romero ME, Kolodgie FD, Virmani R, Finn AV. Vascular responses to coronary calcification following implantation of newer-generation drug-eluting stents in humans: impact on healing. Eur Heart J 2020; 41:786-796. [PMID: 31803916 PMCID: PMC7828465 DOI: 10.1093/eurheartj/ehz850] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/18/2019] [Accepted: 11/26/2019] [Indexed: 01/10/2023] Open
Abstract
AIMS Vascular calcification is routinely encountered in percutaneous coronary intervention (PCI) and severe coronary calcification is a known predictor of in-stent restenosis and stent thrombosis. However, the histopathologic mechanisms behind such events have not been systematically described. METHODS AND RESULTS From our registry of 1211 stents, a total of 134 newer-generation drug-eluting stents (DES) (Xience, Resolute-Integrity, PROMUS-Element, and Synergy) with duration of implant ≥30 days were histologically analysed. The extent of calcification of the stented lesions was evaluated radiographically and divided into severe (SC, n = 46) and non-severely calcified lesions (NC, n = 88). The percent-uncovered struts per section {SC vs. NC; median 2.4 [interquartile range (IQR) 0.0-19.0] % vs. 0.0 (IQR 0.0-4.6) %, P = 0.02} and the presence of severe medial tears (MTs) (59% vs. 44%, respectively, P = 0.03) were greater in SC than NC. In addition, SC had a higher prevalence of ≥3 consecutive struts lying directly in contact with surface calcified area (3SC) (52% vs. 8%, respectively, P < 0.0001). Multivariate analysis demonstrated that sections with duration of implantation ≤6 months [odds ratio (OR): 7.7, P < 0.0001], 3SC (OR: 6.5, P < 0.0001), strut malapposition (OR: 5.0, P < 0.0001), and lack of MTs (OR: 2.5, P = 0.0005) were independent predictors of uncovered struts. Prevalence of neoatherosclerosis was significantly lower in SC than that of NC (24% vs. 44%, P = 0.02). CONCLUSION Severe calcification, especially surface calcified area is an independent predictor of uncovered struts and delayed healing after newer-generation DES implantation. These data expand of knowledge of the vascular responses of stenting of calcified arteries and suggests further understand of how best to deal with calcification in patients undergoing PCI.
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Affiliation(s)
- Sho Torii
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Hiroyuki Jinnouchi
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Atsushi Sakamoto
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Hiroyoshi Mori
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Joohyung Park
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Falone C Amoa
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Mariem Sawan
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, USA
| | - Yu Sato
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Anne Cornelissen
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Salome H Kuntz
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Matthew Kutyna
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Ka Hyun Paek
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Raquel Fernandez
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Ryan Braumann
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Eric K Mont
- Forensic Pathology, Nova Scotia Medical Examiner Service, 51 Garland Ave, Dartmouth, NS B3B 0A6, Nova Scotia, Canada
| | - Dipti Surve
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Maria E Romero
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Frank D Kolodgie
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Renu Virmani
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
| | - Aloke V Finn
- Department of Cardiovascular Pathology, CVPath Institute, 19 Firstfield Road, Gaithersburg, MD 20878, USA
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201, USA
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