International Journal of Cardiology 113 (2006) e54 – e55 www.elsevier.com/locate/ijcard
Letter to the Editor
Recurrent restenosis in a patient with cardiac allograft vasculopathy: After angioplasty and sirolimus, paclitaxel saves the day Massimo Fineschi a,⁎, Charilaos Tsioulpas, Tommaso Gori, Francesco Di Ciolla, Alessandro Iadanza, Massimo Maccherini, Carlo Pierli a
Department of Cardiology, University and Hospital of Siena, Siena, Italy Received 23 January 2006; accepted 29 April 2006 Available online 6 June 2006
Keywords: Cardiac transplant; Allograft vasculopathy; Stenting; Sirolimus; Paclitaxel
Graft vasculopathy is one of the major and most insidious complications that compromise long-term survival of heart transplant recipients. The mechanism responsible for this accelerated graft vasculopathy is multifactorial and still incompletely understood. A 61-year-old white man underwent orthotopic heart transplantation in January 1999 for end-stage heart failure caused by ischemic heart disease. The heart was explanted from a 40-year-old male, deceased after post-traumatic intracerebral bleeding. No evidence of rejection occurred under triple standard immunosuppression therapy (cyclosporine, azathioprine and prednisone). At the first annual angiographic control, there was no evidence of coronary artery lesions. Two years after transplantation (February 2001), coronary angiography revealed a critical stenosis on the proximal third of the left anterior descending coronary artery (LAD) which was treated with balloon-only angioplasty. In April 2003, repeat follow-up coronary angiography showed 75% restenosis (Fig. 1A). At this time, the lesion was treated with a 2.75–23 mm sirolimus eluting stent (Cordis, Johnson and Johnson) inflated to 16 atm (Fig. 1B).
⁎ Corresponding author. Tel.: +39 577 585719; fax: +39 577 586198. E-mail address:
[email protected] (M. Fineschi). 0167-5273/$ - see front matter © 2006 Published by Elsevier Ireland Ltd. doi:10.1016/j.ijcard.2006.04.033
Double antiplatelet therapy (clopidogrel 75 mg, aspirin 100 mg) was started. Follow-up angiography (February 2004) showed no sign of significant restenosis of the treated vessel. In October 2004, repeat routine angiography showed a 75% focal in-stent restenosis (Fig. 1C). At this point, a paclitaxel eluting stent (Taxus Express 3 × 32 mm, Boston Scientific) was implanted (12 atm inflation) with a good procedural result (Fig. 1D). Another nine months later, angiography and intravascular ultrasound showed no restenosis (Fig. 2A and B), but new coronary lesions were evidenced in the distal LAD and a marginal branch requiring implantation of two more paclitaxel eluting stents. Of note, the patient remained asymptomatic throughout the whole follow-up. Allograft vasculopathy is one of the most insidious complications limiting long-term survival of transplanted patients. The option of using stents eluting different drugs might help in the treatment of this feared condition. To the best of our knowledge, this is the first case of (successful) paclitaxel-on-sirolimus stenting for recurrent restenosis in a patient who had undergone orthotopic cardiac transplantation.
M. Fineschi et al. / International Journal of Cardiology 113 (2006) e54–e55
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Fig. 1. Coronary angiography shows a 75% restenosis on the left anterior descending already treated with angioplasty (white arrow) (A). Implantation of the Sirolimus-eluting stent (white arrow) (B). Restenosis at 1 year follow-up (white arrow) (C). Implantation of the Paclitaxel-eluting stent with an optimal angiographic result (white arrow) (D).
Fig. 2. Patency of the Paclitaxel-eluting stent in the follow-up angiography (white arrow) (A) Absence of neointimal proliferation as shown by intravascular ultrasound imaging.
