Clinical Outcomes in Patients Treated With Biodegradable-Polymer Biolimus-Eluting Stents and 6 Months of Dual-Antiplatelet Therapy: The French eBiomatrix 6-Month DAPT Registry

BACKGROUND

Dual-antiplatelet treatment (DAPT) has conventionally been prescribed for 1 year after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Recent evidence suggests that a duration of only 6 months may be equally safe and effective when using contemporary DES options.

OBJECTIVE

The aim of this study was to assess clinical outcomes in patients treated with the BioMatrix biodegradable-polymer coated biolimus-eluting stent (BP-BES; Biosensors International) who received only 6 months of DAPT.

METHODS

This prospective "all-comers" registry enrolled 2038 patients in France. Following PCI, DAPT was started for a recommended period of 6 months. Patients were followed up at 6 and 24 months. The primary endpoint of major adverse cardiac and cerebrovascular event (MACCE) was a composite of all-cause death, cerebrovascular accidents, non-fatal myocardial infarction, or clinically driven target-vessel revascularization. Secondary endpoints included stent thrombosis (ST) and major bleeding (MB).

RESULTS

The mean age of the study population was 67 ± 10.5 years and 77% of patients were male. Follow-up data were available in 96.9% and 95.3% of patients at 6 and 24 months, respectively. At 6 months, the incidences of MACCE, ST, and MB were 3.1%, 0.3%, and 0.4%, respectively. At 24 months, 21.2% of patients were still on DAPT and the cumulative incidences of MACCE, ST, and MB were 9.7%, 0.54%, and 0.79%, respectively.

CONCLUSIONS

In this unselected population of patients undergoing PCI with a BP-BES, a 6-month duration of DAPT after implantation is safe and effective.

Cyclosporine before PCI in Patients with Acute Myocardial Infarction

BACKGROUND

Experimental and clinical evidence suggests that cyclosporine may attenuate reperfusion injury and reduce myocardial infarct size. We aimed to test whether cyclosporine would improve clinical outcomes and prevent adverse left ventricular remodeling.

METHODS

In a multicenter, double-blind, randomized trial, we assigned 970 patients with an acute anterior ST-segment elevation myocardial infarction (STEMI) who were undergoing percutaneous coronary intervention (PCI) within 12 hours after symptom onset and who had complete occlusion of the culprit coronary artery to receive a bolus injection of cyclosporine (administered intravenously at a dose of 2.5 mg per kilogram of body weight) or matching placebo before coronary recanalization. The primary outcome was a composite of death from any cause, worsening of heart failure during the initial hospitalization, rehospitalization for heart failure, or adverse left ventricular remodeling at 1 year. Adverse left ventricular remodeling was defined as an increase of 15% or more in the left ventricular end-diastolic volume.

RESULTS

A total of 395 patients in the cyclosporine group and 396 in the placebo group received the assigned study drug and had data that could be evaluated for the primary outcome at 1 year. The rate of the primary outcome was 59.0% in the cyclosporine group and 58.1% in the control group (odds ratio, 1.04; 95% confidence interval [CI], 0.78 to 1.39; P=0.77). Cyclosporine did not reduce the incidence of the separate clinical components of the primary outcome or other events, including recurrent infarction, unstable angina, and stroke. No significant difference in the safety profile was observed between the two treatment groups.

CONCLUSIONS

In patients with anterior STEMI who had been referred for primary PCI, intravenous cyclosporine did not result in better clinical outcomes than those with placebo and did not prevent adverse left ventricular remodeling at 1 year. (Funded by the French Ministry of Health and NeuroVive Pharmaceutical; CIRCUS ClinicalTrials.gov number, NCT01502774; EudraCT number, 2009-013713-99.).

The long term prognosis of infective endocarditis

Three problems hamper the prognosis of patients who survive the initial phase of infective endocarditis (IE): the rate of IE recurrence is 0.3-2.5/100 patient years, about 60% of patients will have to be operated on at some time, 20-30% during the initial stay, 30-40% during the following 5-8 years; five-year survival after the hospital phase is about 75% in previous reports and 85% in more recent papers. Death is mainly due to heart failure. We looked at the long-term survival of 330 patients with IE who were hospitalized in our institution in 1970-1982, and at the potential influence of 10 factors: age, gender, previous heart disease, microorganism, location of IE, onset of IE, congestive heart failure (CHF) at onset, CHF during the first year, persistent fever, surgery at the acute phase. Global survival was 75% at 6 months, and 57% at 5 years. The only non-significant factor was IE location. The annual instantaneous risk of death was 0.55 at 6 months, 0.18 at 1 year, then 0.03. After one year, the only prognostic factor was age. The relative risk of dying among patients with IE who survived the first year, as compared to the risk of dying among the general population, was 3.27. The IE prognosis is not uniform. Mortality is high during the initial phase, but after one year the risk of dying is low, although still above that of the general population. Part of the risk is probably the direct consequence of IE, but part is due to the course of the underlying heart disease.

Cerebrovascular accidents in infective endocarditis: role of anticoagulation

Anticoagulation is still a matter of debate in infective endocarditis, since it can increase the risk of complications, mostly neurological. In our series of 269 patients with native valve endocarditis studied between 1970 and 1982, 35 were anticoagulated. We observed 14 patients with brain infarcts, of whom five died, and 12 patients with cerebromeningeal or brain haemorrhage of whom six died. In a similar series of 63 patients with prosthetic valve endocarditis, all of whom were on anticoagulation and were studied between 1972 and 1987, we observed five patients with brain infarcts, three of whom died, and two patients with brain haemorrhage, one of whom died. The frequency of cerebrovascular accident (CVA) was similar for both groups (11.1% in prosthetic endocarditis vs 11.5% in native valve endocarditis, P = ns), as was mortality rate (57% vs 48.4%, P = ns). CVA are significantly more frequent among anticoagulated patients (19/94 vs 19/238: P less than 0.01), but the mortality rate in CVA is similar for anticoagulated and non-anticoagulated patients (11/19 vs 8/19: P = ns). The indications for anticoagulation in infective endocarditis remain similar to those in valvular heart disease. In patients with infective endocarditis, anticoagulation with heparin should be maintained whenever a brain infarct is present, unless it is large and/or haemorrhagic.

[Recurrent infective endocarditis]

Between August, 1974 and May, 1987, 486 patients were treated for infective endocarditis. In 16 of these patients (12 men, 4 women, mean age 44.3 +/- 18.0 years at the time of the first episode) the endocarditis recurred: once in 14 patients, twice in 2 patients. The time elapsed between recovery from the first episode and onset of the recurrence varied from 6 to 159 months (mean 54.3 +/- 35.1 months). Among the 18 recurrences, 10 affected native valves (mitral 6, aortic 4) and 8 aortic prostheses. In all but one case the organism isolated during the recurrence (Streptococcus in 14 cases, Staphylococcus in 3 cases, Rickettsia in 1 case) was different from the organism responsible for the previous infection. The 16 patients were followed up for periods of 28 to 203 months (mean 107.0 +/- 58.0 months), counting from the onset of the first episode. Ten patients were treated medically during the second episode: 4 died and 2 had a second recurrence, lethal in one of them (time elapsed between the onset of the first episode and the date of death: 32 to 149 months). Six patients were operated upon (valve replacement in 5 cases, closure of a left aorto-ventricular fistula in 1 case) without deaths. Nine of the 11 survivors are now asymptomatic. The actuarial survival rate in recurrent endocarditis (75 p. 100, 10 years after the onset of the first episode) is not different from that observed in non-recurrent endocarditis.

Infective endocarditis on stenotic aortic valves

Charts were reviewed of 42 adult patients (27 men, 15 women, mean age 55 years, with 17 older than 60) hospitalized and/or autopsied between 1970 and 1986 with diagnosis of definite or highly probable infective endocarditis (IE) on pure aortic stenosis (AS). Ring and/or septal abscesses were found in 18/37 patients who were operated upon and/or autopsied. IE was recognized in 32 patients, undiagnosed in 10 (revealed at autopsy in seven, at operation in three). Infecting organisms were identified in 26 patients (Str. viridans, 16; Str. D, three; Staphylo., four; other, three). Twenty-seven patients were treated in our institution, 14 of them more than four weeks after the beginning of the symptoms. Echocardiograms were recorded in 17, with vegetations in only six. Severe cardiac failure was present in 17 cases. One patient was lost to follow-up. Fourteen patients died (mean delay between IE and death 22.4 months): eight of the 13 non-operated patients (cardiac failure, four; myocardial infarction, two; neurological complications, two) and six of the 14 operated patients (peri-operative death, four; late sudden death, two). Twelve patients are alive (mean follow-up 51.6 months), eight of them in NYHA class 1. IE on pure AS is rare, difficult to recognize echocardiographically, and of poor prognosis. It usually requires rapid aortic valve replacement.

[Prognosis of surgically treated infectious endocarditis]

The prognostic factors in infective endocarditis patients who underwent surgery in the acute stage were evaluated from the records of 189 cases of native valve endocarditis operated upon between 1970 and 1986. Surgery had been performed before June 30, 1982 in 105 patients (group 1) and since July 1, 1982 in 84 patients (group 2). Group 2 only differed from group 1 in that the proportion of negative blood cultures was lower (13.7% vs 35%; p less than 0.01) and that of subjects older than 70 was higher (11.6% vs 5.7%; p less than 0.01). 105 patients (66 in group 1, 39 in group 2) had been operated upon during the first 6 weeks of antibiotic therapy ("early surgery"), while 84 patients (57 in group 1, 27 in group 2) had been operated upon between 7 and 24 weeks from the beginning of antibiotic therapy ("semi-early surgery"). Hospital mortality was 23.6% in group 1 (29/123) as against 10.6% in group 2 (7/66; p less than 0.05). The difference in mortality between the two groups was significant only in early surgery patients (33.3% vs 7.7%; p less than 0.01) and in patients operated upon while the infection was active with presence of pathogens in valve cultures (47.4% vs 7.7%; p less than 0.05). A study of mortality factors showed that the operative prognosis did not depend on the type of valve replacement performed or on the pathogen involved, but solely on the degree of cardiac failure before surgery. The post-hospital course was evaluated in group 1 patients followed up during 61.8 months on average.(ABSTRACT TRUNCATED AT 250 WORDS)

Aorto-coronary artery saphenous vein bypass surgery. A ten-year follow-up

The 10-year follow-up of consecutive series of 126 patients who underwent coronary bypass surgery from January 1970 through December 1972 without associated procedures is reported. There were 112 men and 14 women with a mean age of 50.3 +/- 8.0 years. Indications for operation were stable angina pectoris in 35 cases and unstable angina in 91 cases. Eleven patients had one-vessel disease, 55 patients had two-vessel disease and 60 patients had three-vessel disease. The mean number of grafts per patient was 1.8. Graft patency rate was 78.4% at the time of early angiographic control (from one to 24 months). There were two early deaths and 47 late deaths. One patient was last to follow-up. Twenty-six of the late deaths were cardiac in nature (57.7%). The overall 10-year survival rate was 68.0 +/- 4.1%. The factors most clearly related to survival rate were: age (p less than 0.05) ischaemic ST-segment depressions on resting preoperative electrocardiogram (p less than 0.005), preoperative electrocardiographic evidence of anterior, septal or lateral myocardial infarction (p less than 0.05), ventricular function as assessed by preoperative left ventriculography (p less than 0.05). During the follow-up period 35.1% of survivors had had no recurrence of angina and 64.9% had experienced at least one episode of angina. At the ten-year evaluation 33 surviving patients considered themselves free of angina, 27 patients considered the angina to be less severe than before the operation and four considered it to be the same or more severe. A significant positive correlation was noted between clinical response and completeness of revascularization (p less than 0.05).

Effects of hypothalamic paraventricular lesions on sleep in rats

In 7 rats 45-86% of the hypothalamic paraventricular tissue was destroyed by electrolytic coagulations. During the first 6 post-operative days the mean daily amount of paradoxical sleep was significantly decreased, and the circadian sleep-walking cycles of paradoxical and slow-wave sleep were abolished. The slow-wave sleep rhythm then became normal, but in paradoxical sleep the acrophase was shifted, and in one animal the rhythm was completely inversed. Thus the hypothalamic paraventricular nucleus seems to play a modulating role in the production of paradoxical sleep and in the generation of its rhythm.

[Long-term antithrombotic treatment in patients with valve prostheses. Practical management and complications]

The cumulative annual risk of thrombo-embolic and haemorrhagic complications due to anticoagulants in patients with mechanical prostheses is in the order of 3 to 9 p. cent for mitral prostheses and mitral and aortic prostheses and 2 to 5 p. cent for aortic prostheses. Anticoagulant drugs should be chosen in terms of the type and the site of the implanted prosthesis and the coefficient of the thrombo-embolic and haemorrhagic risk of each subject. In patients with mechanical prostheses, the most effective prevention of the thrombo-embolic risk is ensured by the anti-vitamin K drugs associated with dipyridamole, with a low haemorrhagic risk if the treatment is correctly controlled. In patients with bioprostheses, the anticoagulant treatment (anti-vitamin K or anti-platelet drugs) should be maintained for three to six months after the operation; the anti-vitamin K drugs should not be prolonged indefinitely, except in patients at high risk of thrombo-embolism (atrial fibrillation with a very dilated left auricle, in particular). The management of a pregnant woman with a valve prosthesis and the problems of patients with prostheses undergoing extracardiac or dental operations or invasive investigations are still open to discussion.

Indices of effectiveness of medical and surgical treatment in 40 cases of prosthetic valve endocarditis

Forty patients with prosthetic valve endocarditis (PVE) presenting during a 12-year period at a single hospital were studied. Twenty-six were male and 14 female and ages ranged from 19 to 67 years. During the first six post-operative months, most episodes were caused by staphylococci (38%) and Gram negative bacilli (24%). Between 6 and 11 months no episodes were seen, but thereafter streptococci predominated (50%). The overall mortality was 58% (66% during first six months; 36% thereafter). Nine of 23 patients undergoing re-operation died, most deaths occurring in patients in cardiac failure prior to surgery. Eleven deaths occurred in the 17 patients treated with antibiotics alone. Six of these were pyrexial at death and all but one was infected by a virulent organism. The remaining five were apyrexial at death and all had staphylococcal PVE. Our findings suggest: (1) all cases occurring during the first six months should be initially treated as 'early' PVE; (2) in staphylococcal PVE, apyrexia may not mean cure; (3) the principal guides to prognosis in PVE are the patient's cardiac status and the nature of the infecting organism.

Mitral valve prolapse and infective endocarditis

In a review of 350 consecutive patients with infective endocarditis (IE) 14 patients were found to have mitral valve prolapse (MVP) and mitral IE between 1970 and 1982 in our institution. We first describe the clinical features, laboratory findings and follow up of this group; then we compare it with the data obtained in patients with IE with other types of mitral regurgitation (MR). All patients with MVP had a murmur or a click with a murmur before the acute episode of IE, the most frequent consecutive organism was Streptococcus (nine cases) and the response to antimicrobial therapy was good; only one patient died and three others needed a mitral valve replacement from one month to 12 years later. The comparison with other types of mitral regurgitation with IE was done by sex, age, duration of symptoms before IE diagnosis, frequency of atrial fibrillation, number of congestive heart failures, heart volume on chest X-ray, number of echographic vegetations and echographic left ventricle size, and number of mitral valve replacements and deaths. None of these items differed significantly, but the duration of symptoms before diagnosis was shorter in the group of patients with MVP.

Prognosis of native valve infective endocarditis: a review of 253 cases

Forty years after the first 'recoveries' obtained by antibiotherapy and twenty years after the first success of early valvular replacement, the mortality of infective endocarditis (IE) is still significant. The present study has been undertaken to clarify the factors which influence the prognosis of IE.

[Prognostic significance of electrocardiographic changes observed in the immediate postoperative period of isolated aortic valve replacements]

The predictive value of early postoperative ECG changes was studied in 144 patients: 106 men (mean age 50.6 +/- 12.9 years) and 38 women (mean age 49.7 +/- 15.3 years), undergoing isolated aortic valve replacement (AVR) with a Björk-Shiley prosthesis between January 1973 and December 1976, using an identical protocol of myocardial protection. Eighty four patients had pure or predominant aortic stenosis, 60 had pure or predominant aortic regurgitation. The early postoperative ECGs (first 30 days) were compared with the preoperative recordings to determine the significance of the changes observed in the immediate postoperative period. Changes of ventricular repolarisation (0.2 mV ST depression and/or 0.5 mV or more T wave inversion) were observed in 44% of cases. Isolated T wave inversion--more common in aortic incompetence than in aortic stenosis--had a good prognosis. On the other hand, ST depression was associated with a worse prognosis (mortality rate three times higher). Conduction defects, either atrioventricular or intra-ventricular, were observed in 30% of cases. They had no effects on mortality or long-term outcome. Atrial fibrillation was observed in 16% of cases and had a good prognosis. In conclusion, the only change in the early postoperative ECG of patients undergoing isolated AVR associated with a poor medium or long-term prognosis, was significant ST depression.

[Nutritional status in critically ill patients. Relationship with mortality (author's transl)]

Plasma proteins, triglyceridemia, body composition and delayed hypersensitivity were determined in 154 critically ill patients after admission. Plasma proteins levels were significantly increased in patients that were subsequently discharged vs. those that died: albumin: 33 +/- 6 g/l vs 28 +/- 6 g/l (p < 10(-6)); transferrin 2,18 +/- 0,65 g/l vs. 1,54 +/0 0,55 g/l (p < 10(-7)); prealbumin: 14,32 +/- 7,79 mg/100 ml vs. 7,28 +/-5,36 mg/100 ml (p < 10(-7)) and triglyceridemia was decreased: 1,07 +/- 0,38 g/l vs. 1,66 +/- 1,12 g/l (p not equal to 10(-3)). Body weight, fat weight and lead body mass were not correlated to subsequent mortality. Muscle cell mass was decreased (-17%, p < 10(-2)) and extracellular water was increased (+14%, p < 10(-4)), in patients who subsequently died. Total body water and visceral cell mass did not change. Initial anergy (tested with 3 antigens: candidin, tuberculin, varidase) did correlate with mortality: 35/62 died when delayed hypersensitivity was negative vs. 13/71 when it was positive (p < 10(-4)). Mortality was associated with decreased total lymphocyte count: 884 +/- 1025 vs. 1270 +/- 870 (p < 0,02) and serum iron: 51 +/- 40 micrograms/100 ml vs. 74 +/- 45 micrograms/100 ml (p < 10(-2)). Sepsis correlated with mortality (p < 10(-3)) and could produce these changes. These results suggest that critically ill paients have a protein-calorie malnutrition syndrom marktly different from that observed in simple starvation. Nutritional therapy must be, in this group of patients, adapted to this concept.