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KARJALAINEN PP et al.
ORIGINAL ARTICLE
Circulation Journal
Oicial Journal of the Japanese Circulation Society
http://www.j-circ.or.jp
Cardiovascular Intervention
Early Neointimal Coverage and Vasodilator Response
Following Biodegradable Polymer Sirolimus-Eluting
vs. Durable Polymer Zotarolimus-Eluting Stents
in Patients With Acute Coronary Syndrome
– HATTRICK-OCT Trial –
Pasi P. Karjalainen, MD, PhD; Ville Varho, MD; Wail Nammas, MD, PhD; Jussi Mikkelsson, MD, PhD;
Mikko Pietilä, MD, PhD; Antti Ylitalo, MD, PhD; Juhani K.E. Airaksinen, MD, PhD; Jussi Sia, MD, PhD;
Kai Nyman, MD, PhD; Fausto Biancari, MD, PhD; Tuomas Kiviniemi, MD, PhD
Background: Patients at high bleeding risk would benefit from a shorter dual antiplatelet therapy after PCI. Compared to first-generation devices, the design of newer generation drug-eluting stents may facilitate more rapid anatomical and functional healing of stented vessel based on thinner stent platforms, biodegradable/biocompatible
polymers and rapid drug elution.
Methods and Results: Forty-four non-diabetic patients with acute coronary syndrome (ACS) and culprit lesion in
the LAD were randomized to receive either biodegradable polymer sirolimus-eluting stent (BP-SES) or durable
polymer zotarolimus-eluting stent (DP-ZES). Neointimal strut coverage was examined using optical coherence tomography, and vasodilator response on invasive thermodilution-derived coronary flow reserve (CFR) at 3-month
follow-up. The primary endpoints were percent uncovered struts and CFR. A total of 425 cross-sections (4,897 struts)
were analyzed in the BP-SES group, and 425 cross-sections (5,467 struts) in the DP-ZES group. The percent uncovered struts was lower in the BP-SES group compared with the DP-ZES group, both at strut level (3.9% vs. 8.9%,
respectively, P<0.001), and stent level (3.9±3.2% vs. 8.9±6.9%, respectively, P=0.019). No significant difference
was found between the 2 groups regarding CFR (3.0±1.3 vs. 3.2±1.0, respectively, P>0.05).
Conclusions: In non-diabetic patients with ACS, BP-SES provided slightly better stent strut coverage at 3 months
compared with DP-ZES, but neither stent was fully covered. No difference in vasodilator response was seen.
(Circ J 2015; 79: 360 – 367)
Key Words: Biodegradable polymer; Coronary flow reserve; Optical coherence tomography; Sirolimus-eluting stent;
Zotarolimus-eluting stent
ecent reports suggest a paradigm shift in the occurrence
of stent thrombosis (ST) as evidenced by lower event
rates in patients treated with newer generation drugeluting stents (DES) compared to bare metal stents (BMS) or
irst-generation DES.1 Incomplete neointimal coverage over
stent struts has been suggested as a potential substrate for late
ST in histopathological studies,2 as well as in an observational
case-control setting using optical coherence tomography (OCT)
in vivo.3 Durable polymer is a possible stimulus for vessel wall
R
inlammatory and hypersensitivity reaction leading to incomplete endothelialization following DES implantation. Localized
hypersensitivity reaction has been demonstrated in the vessel
wall at autopsy, and in thrombus aspirates, from patients with
very late ST following irst-generation DES.4,5
Newer generation DES have thinner stent platforms, biodegradable/biocompatible polymers and rapid drug elution compared to irst-generation devices. The frequency of uncovered
struts was reported lower with biodegradable polymer biolim-
Received September 10, 2014; revised manuscript received November 3, 2014; accepted November 12, 2014; released online December
15, 2014 Time for primary review: 22 days
Heart Center, Satakunta Central Hospital, Pori (P.P.K., J.M., A.Y.); Heart Center, Turku University Hospital and University of Turku, Turku
(V.V., W.N., M.P., J.K.E.A., T.K.); Department of Cardiology, Central Ostrobothnia Central Hospital, Kokkola (J.S.); Department of
Medicine, Central Finland Central Hospital, Jyväskylä (K.N.); and Department of Surgery, Oulu University Hospital, Oulu (F.B.), Finland
The irst two authors contributed equally (P.P.K., V.V.).
Mailing address: Pasi P. Karjalainen, MD, PhD, Department of Cardiology, Satakunta Central Hospital, Sairaalantie 3, FIN-28100, Pori,
Finland. E-mail: pasi.karjalainen@satshp.i
ISSN-1346-9843 doi: 10.1253/circj.CJ-14-1000
All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp
Circulation Journal Vol.79, February 2015
HATTRICK-OCT Trial
361
Figure 1. Flow chart of the HATTRICK-OCT trial.
us-eluting stents compared with durable polymer sirolimuseluting stents (SES), as demonstrated on OCT at 9-month
follow-up,6 but not compared with durable polymer everolimus-eluting stents (DP-EES).7 In a bench-top study, the biocompatible BioLinx polymer did not induce activated monocyte
adhesion.8 BioLinx polymer-coated zotarolimus-eluting stent
(ZES) was associated with low rates of uncovered and malapposed struts on OCT at 13 months.9 Earlier reports have also
raised concerns about local epicardial vasomotor dysfunction
associated with DES 6 months or later after implantation.10,11
In this prospective randomized trial, we combined the anatomical and functional healing assessment by exploring neointimal strut coverage and vasodilator response 3 months following biodegradable polymer SES (BP-SES) vs. BioLinx
durable polymer ZES (DP-ZES) implantation in non-diabetic
patients presenting with acute coronary syndrome (ACS).
Methods
Patient Selection and Study Design
The Healing AT ThRee months after percutaneous coronary
Intervention for ACS (HATTRICK-OCT) trial was a prospective
multicenter single-blinded randomized controlled trial, with the
chief aim of comparing neointimal coverage and vasodilator
response 3 months following the implantation of BP-SES vs.
DP-ZES in non-diabetic patients presenting with ACS. From
June 2011 to July 2012, we enrolled 46 patients aged >18 years,
presenting with ACS, with a signiicant (≥50% diameter ste-
nosis) de novo lesion in the left anterior descending coronary
artery. Consort low chart is presented in Figure 1. The main
exclusion criteria were diabetes mellitus (presumed microcirculatory dysfunction), unprotected left main disease, ostial or
bifurcation lesion, multi-vessel disease, a second de novo stenosis ≥50% in the stented vessel, intolerance to the study medications, planned surgery within 12 months of the index procedure, and life expectancy <12 months. The HATTRICK-OCT
trial was conducted in 4 referral centers. Patients were randomly assigned (1:1) to receive either BP-SES or DP-ZES.
Computer-generated randomization was implemented using a
closed-envelope system stratiied by center. Study investigators were by necessity aware of treatment allocation, but patients and those who performed data management and analysis
were blinded.
Devices
The BP-SES (Orsiro; Biotronik, Bülach, Switzerland) has a
stent platform based on the Pro-Kinetic Energy BMS with a
helicoidal design coated with passive and active coating layers. It is a tubular thin-strut balloon-expandable stent, made of
L-605 cobalt-chromium alloy. The stent surface is completely
coated with a layer of silicon carbide (PROBIO®) that acts as
a diffusion barrier reducing ion release. The active coating
layer (BIOlute) consists of high-molecular-weight poly-l-lactic
acid that completely disintegrates into carbon dioxide and water.
It covers the whole stent surface with an abluminal thickness
of 7.5 µm, and a luminal thickness of 3.5 µm. The sirolimus
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362
KARJALAINEN PP et al.
concentration is 1.4 µg/mm2 of the stent surface area, designed
to achieve complete drug release in approximately 100 days.
The thickness of the coated strut is 71 µm for stents with a
nominal diameter ≤3 mm, and 91 µm for larger sizes. DP-ZES
(Resolute Integrity; Medtronic Cardiovascular, Santa Rosa,
CA, USA) is a DES that contains zotarolimus at a dose of
1.6 µg/mm2 of stent surface area; 85% of the drug is eluted in
the irst 60 days; the drug is completely eluted at 180 days. It
is coated with BioLinx polymer, composed of 3 different polymers: the hydrophobic C10 acts as a drug reservoir for slow
and sustained release; the hydrophilic polyvinyl-pyrrolidinone
serves biocompatibility; and C19 contains both hydrophilic
and hydrophobic components. The thickness of the coated
strut is 97 µm.
Pharmacological Interventions
Patients already maintained on aspirin received no additional
aspirin loading. Aspirin-naïve patients received a loading dose
of 250 mg orally or 250–500 mg i.v., and continued at a daily
dose of 75–150 mg indeinitely. Oral clopidogrel was initiated
at a loading dose of at least 300 mg before or immediately after
the procedure, and continued at a daily dose of 75 mg. As per
protocol, patients in either group were prescribed oral clopidogrel for a minimum of 6 months, and thereafter, for extended
periods (maximum 12 months) at the operator’s discretion.
During the procedure, low-molecular-weight heparin or unfractionated heparin was administered i.v. in the standard dosage.
Use of peri-procedural glycoprotein IIb/IIIa inhibitors or bivalirudin was at the operator’s discretion.
Ethics
This study is part of a wider protocol in progress to assess
thrombotic and bleeding complications of cardiac procedures
in Finland.12–17 The study was initiated and designed by the
investigators and conducted according to the ethics guidelines
of the 1964 Declaration of Helsinki, as revised in 2002. No
industry representatives were involved in the study execution,
analysis or reporting. Informed written consent was obtained
from every patient after explanation of the study protocol. The
protocol was approved by the Ethics Committees of the coordinating center, Turku University Hospital, and the other participating hospitals. The HATTRICK-OCT trial is registered
with ClinicalTrials.gov, number NCT01391871.
OCT
Image Acquisition OCT images were obtained 3 months
after the index procedure, immediately after follow-up angiography, with the C7Xr frequency-domain system (LightLab
Imaging, Westford, MA, USA), using the non-occlusive technique via radial or femoral approach. A 0.014-inch guidewire
was introduced into the vessel using a 6-F guiding catheter.
An imaging catheter (Dragonly; LightLab Imaging) was positioned distal to the stent, and automated motorized pullback
was performed at 20 mm/s during lush of 4–6 ml/s iso-osmolar
contrast. A segment length of 54 mm was visualized, and images were stored digitally for subsequent analysis.
Image Analysis Ofline OCT analysis was performed independently by 2 investigators blinded to patient characteristics
and to the stent used. Proprietary software (LightLab Imaging)
was used to analyze cross-sections at 1-mm intervals (every 5
frames) within the stented segment. In each cross-section, the
number of struts was counted. Struts were classiied as uncovered if any part of the strut was visibly exposed to the lumen,
or covered if a layer of tissue was visible all over the relecting
surfaces. The percent uncovered struts was calculated as the
number of uncovered struts as a percentage of all analyzed
struts. In covered struts, neointimal hyperplasia (NIH) thickness was measured from the strut marker to the endoluminal
edge of the tissue coverage, following a straight line connecting the strut marker with the center of gravity of the vessel.14
Stent cross-sectional area (CSA) and lumen CSA were traced
semi-automatically. NIH area was calculated by subtracting
lumen CSA from stent CSA. Percent NIH area was calculated
by dividing the NIH area by the stent CSA, multiplied by 100.
Apposition was assessed by measuring the distance between
the strut marker and the lumen contour following a straight line
connecting this marker with the center of gravity of the vessel.
A margin of 18 µm was added as a correction for half the blooming. Struts with distance to lumen contour greater than the sum
of strut thickness+polymer thickness+18 µm were considered
malapposed. Given a coated strut thickness of 71 µm, we adopted
a malapposition threshold of 90 µm for the BP-SES (110 µm
for stents >3.0 mm in diameter). Similarly, given a coated strut
thickness of 97 µm for the DP-ZES, we adopted a threshold of
115 µm. Struts located at the ostium of a side branch were excluded from the analysis. Thrombus was deined as an irregular high- or low-backscattering (red or white thrombus) mass
protruding into the lumen discontinuous from the surface.
Hemodynamic Measurements
Patients were instructed to avoid heavy meals, caffeine, alcohol and tobacco for 12 h before the study. Coronary low reserve (CFR), fractional low reserve (FFR) and index of microcirculatory resistance (IMR) were measured as follows. A
bolus of i.c. nitroglycerin (0.2 mg) was administered at the
onset of the procedure, and repeated before baseline and hyperemia assessments. A coronary 0.014-inch pressure wire
(Certus®; St. Jude Medical, MN, USA) was used. After calibration, the pressure wire was advanced to the tip of the guiding
catheter for equalization of pressure and temperature signals, and
then positioned distal to the stent approximately at two-thirds
of the length of the artery. Care was taken to maintain the guiding catheter and sensor in position throughout all measurements.
The sensor was used to obtain thermodilution curves and distal
coronary pressure. The resting mean transit time was determined
by 3 injections of 3 ml room-temperature saline.18 Hyperemia
was induced by i.v. infusion of adenosine (140 μg · kg–1 · min–1).
Steady-state maximum hyperemia was conirmed by minor drop
of the aortic pressure and subjective sensation of adenosine
effects. Measurements were obtained after at least 1 min from
the onset of infusion. The hyperemic mean transit time was assessed using 3 injections of 3 ml room-temperature saline. In the
case of large luctuation (>20% variation) of hyperemic or basal
mean transit time, measurement was repeated. CFR was calculated as a ratio of baseline to hyperemic mean transit time.
Simultaneous measurement of the mean aortic pressure (Pa)
and the mean distal coronary pressure (Pd) were also performed
at maximum hyperemia to calculate FFR. IMR was calculated
as the distal coronary pressure at maximum hyperemia divided
by the inverse of the hyperemic mean transit time.
Statistical Analysis
The primary endpoint was the percent of uncovered struts in
BP-SES compared with DP-ZES at 3-month follow-up. Sample size was calculated using 2 methods. We assumed that an
average of 150 struts per patient would be analyzed, and therefore we estimated that inclusion of 22 patients in each group
would show 5% difference in the percent uncovered struts
between BP-SES and DP-ZES (power of 80%, 2-sided type I
error of 0.05). We also calculated a sample size of 22 patients/
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HATTRICK-OCT Trial
363
Table 1. Baseline Subject Characteristics
BP-SES group
(n=22)
DP-ZES group
(n=22)
P-value
Age (years)
62.5±9.7
62.0±12.1
0.87
Male
18 (81.1)
17 (77.3)
0.72
Hypertension
8 (36.4)
6 (27.3)
0.75
Hypercholesterolemia
7 (31.8)
4 (18.2)
0.49
Current smoking
5 (22.7)
8 (36.4)
0.51
Prior myocardial infarction
1 (4.5)
1 (4.5)
1.0
Prior PCI/CABG
1 (4.5)
0
1.0
Variable
Risk factors
Medical history
Medications at discharge
Aspirin
22 (100)
22 (100)
1.0
Clopidogrel
22 (100)
22 (100)†
1.0
ACEI/ARB
18 (81.8)
15 (68.2)
0.49
β-blockers
21 (95.5)
22 (100)
1.0
1 (4.5)
0
1.0
22 (100)
22 (100)
1.0
VKA
Statins
Indication for PCI
Unstable angina
1 (4.5)
3 (13.6)
0.61
NSTEMI
9 (40.9)
8 (36.4)
1.0
STEMI
12 (54.5)
Stent diameter (mm)
11 (50)
1.0
3.2±0.3
3.2±0.3
0.71
18.0±3.4
17.5±3.2
0.65
2 (9.1)
1 (4.5)
1.0
A
3 (15.8)
2 (11.1)
B1
10 (52.6)
12 (66.7)
B2
6 (31.6)
3 (16.7)
C
0
1 (5.6)
Pre-procedural TIMI flow grade
1.7±1.4
1.9±1.2
0.73
Culprit lesion related thrombus
12 (60.0)
6 (30.0)
0.111
9 (42.9)
6 (27.3)
0.347
Pre-dilatation
17 (77.3)
19 (82.6)
0.722
Post-dilatation
9 (40.9)
18 (78.3)
0.016
13.2±2.6
13.1±3.3
0.953
3.0±0.0
3.0±0.2
0.15
Stent length (mm)
Two overlapping stents
Lesion type
0.50
Aspiration thrombectomy
Maximal expansion pressure
Post-procedural TIMI flow grade
Data given as mean ± SD or n (%). †One patient treated with prasugrel. ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; BP-SES, biodegradable polymer sirolimus-eluting stent; CABG, coronary
artery bypass grafting; DP-ZES, durable polymer zotarolimus-eluting stent; NSTEMI, non-ST-elevation myocardial
infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; TIMI, Thrombolysis
In Myocardial Infarction; VKA, vitamin K antagonist.
group using an effect size of 5% and expected SD of 5% in
stent-level analysis (power of 80%, 2-sided type I error of 0.05).19
Co-primary endpoint was CFR at 3-month follow-up. Continuous variables were tested for normality with KolmogorovSmirnov and Shapiro-Wilk tests and reported as mean ± SD or
as median and interquartile range (IQR) where appropriate.
Fisher exact test, independent samples t-test, Mann-Whitney
U-test and Spearman’s test were used for univariate analysis.
Inter-observer variability was assessed by evaluating 50 random cross-sections by 2 independent investigators.
Pooled analysis of measurements was performed in order to
account for clustering, in view of the large number of measurements obtained on OCT, and hence to get a better estimation
of the proportion of uncovered struts, malapposed struts, and
NIH thickness. Because heterogeneity was anticipated and conirmed among observational studies, pooled analysis was per-
formed using a random effects model (DerSimonian-Laird).
Meta-regression was used to estimate the difference between
the study groups. All statistical analysis was 2-sided at the 5%
signiicance level using SPSS v. 16.0.1 (SPSS, Chicago, IL,
USA) and Open Meta-analyst (http://www.cebm.brown.edu/
open_meta).
Results
Baseline Characteristics
Forty-six non-diabetic patients with ACS were enrolled: 23 received BP-SES, and 23 received DP-ZES. Two patients withdrew consent (1 in each group), thus 22 patients in either group
were available for analysis. Angiography was performed at median follow-up of 93 days (IQR, 23 days) following the index
procedure in the BP-SES group, vs. 98 days (IQR, 20 days) in
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KARJALAINEN PP et al.
Table 2. Optical Coherence Tomography
Variable
BP-SES group
(n=22)
DP-ZES group
(n=22)
P-value
Cross-sectional analysis
No. cross-sections analyzed
Struts per cross-section
425
425
1.0
11.5±0.66
12.9±1.2
<0.001
Stent area (mm2)
6.8±1.6
7.5±1.7
0.09
Lumen area (mm2)
6.5 [2.2]
7.1 [2.6]
0.06
NIH area (μm2)
380 [410]
460 [550]
0.11
% NIH area
5.7 [5.9]
5.7 [7.6]
0.69
0.13
Strut-level analysis
Total no. struts analyzed
4,897
5,467
NIH thickness (μm)
69.1±58.2
76.5±82.9
0.15
Uncovered struts
189 (3.9)
495 (8.9)
<0.001
Malapposed struts
101 (2.1)
292 (5.3)
<0.001
3.9±3.2
8.9±6.9
0.019
Stent-level analysis
% Uncovered struts
Stents with >5% uncovered struts
% Malapposed struts
Intra-stent thrombus
7 (31.8)
14 (63.6)
0.069
2.2±3.7
4.3±9.5
0.33
2 (9.1)
1 (4.5)
1.0
Data given as mean ± SD, median [IQR], or n (%). NIH, neointimal hyperplasia. Other abbreviations as in Table 1.
Figure 2. Evaluation of the study stents on optical coherence tomography at 3-month follow-up. (A,B) stent struts well covered
with neointima (arrows). (C,D) uncovered struts.
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365
Table 3. Invasive Hemodynamics
BP-SES group
(n=18)
DP-ZES group
(n=16)
P-value
Fractional flow reserve
0.87±0.07
0.87±0.06
0.93
Coronary flow reserve
3.0±1.3
3.2±1.0
0.56
Coronary flow reserve <2.5
8 (44.4)
2 (12.5)
0.06
19.2±8.1
22.7±13.0
0.32
Variable
Index of microcirculatory resistance
Data given as mean ± SD or n (%). Abbreviations as in Table 1.
the DP-ZES group (P=0.65). Clinical and procedural characteristics (Table 1) were balanced between the 2 groups (P>0.05
for all), apart from occurrence of post-dilation: 9 (40.9%) vs.
18 (78.3%) in BP-SES and DP-ZES, respectively (P=0.016).
Culprit lesion-related thrombus was seen initially in 12 (54.5%)
vs. 6 (27.3%), in the BP-SES vs. DP-ZES groups, respectively
(P=0.11).
OCT Measurements
OCT image acquisition was successful in all patients, and no
OCT procedure-related complications were observed. We analyzed 4,897 struts in 425 cross-sections of BP-SES and 5,467
struts in 425 cross-sections of DP-ZES (Table 2). The percent
of uncovered struts was signiicantly lower in the BP-SES
compared with the DP-ZES group, both at strut level (3.9% vs.
8.9%, respectively, P<0.001), and at stent level (3.9±3.2% vs.
8.9±6.9%, respectively, P=0.019; Figure 2). Moreover, the
frequency of malapposed struts was signiicantly lower in the
BP-SES group at strut level (2.1% vs. 5.3%, respectively,
P<0.001), but not at stent level (2.2±3.7% vs. 4.3±9.5%, respectively, P=0.33). Mean NIH thickness, NIH area, and percent
NIH area, however, were similar between the 2 groups (P>0.05
for all). Thrombi were detected in 2 stents in the BP-SES
group vs. 1 stent in the DP-ZES group (P=1.0). Inter-observer
variability for measurement of NIH thickness was 6±9 µm. In
addition, the measurements of strut apposition and coverage
were highly reproducible.
Pooled analysis showed that the proportion of uncovered
struts in the overall series was 5.6% (95% CI: 4.6–6.5%), with
signiicant heterogeneity between the evaluated struts (I2=93%).
The pooled proportion of uncovered struts was 3.3% (95% CI:
2.3–4.2%, I2=82%) for BP-SES, and 8.2% (95% CI: 6.4–9.9%,
I2=95%) for DP-ZES (P<0.0001). The pooled proportion of
malapposed struts was 1.5% (95% CI: 0.9–2.0%, I2=82%) for
BP-SES, and 2.5% (95% CI: 1.7–3.3%, I2=95%) for DP-ZES,
(P=0.479). The pooled mean NIH thickness was 68.2 µm (95%
CI: 59.6–76.9%, I2=98%) for BP-SES, and 74.2 µm (95% CI:
62.7–85.7, I2=98%) for DP-ZES, (P=0.465).
Hemodynamic Measurements
Patients with FFR<0.8 were excluded from the CFR data analysis (4 and 3 patients in the BP-SES and DP-ZES groups, respectively). No statistically signiicant differences were found
between the 2 groups regarding CFR, FFR and IMR (P>0.05
for all; Table 3). Left ventricular ejection fraction was similar
between the groups (65.4±8.0% vs. 62.0±12.2% for BP-SES
and DP-ZES, respectively).
Discussion
The current HATTRICK-OCT trial has shown that in nondiabetic patients presenting with ACS, the percent of uncovered
stent struts on OCT was slightly lower for BP-SES compared
with DP-ZES at 3-month follow-up. Neither of the stents, however, was fully covered at 3 month follow-up. Vasodilator response assessed using CFR, FFR and IMR was similar between
the 2 groups.
This is the irst study to use a combination of OCT-derived
anatomical as well as pressure wire-based functional healing
assessment after stent implantation. Rationale for the early
3-month time frame was to gather up-to-date information on
newer generation DES healing properties in patients treated
for ACS: a condition often associated with delayed healing pattern. This information is important especially when shorter dual
antiplatelet therapy (DAPT) needs to be considered for patients
at high risk for bleeding complications. HATTRICK-OCT provides evidence that vascular healing was not complete at 3
months follow-up with these new-generation stent devices, as
evidenced by the minor proportion of uncovered stent struts and
abnormal vasodilator function in some patients. It is currently
not known what would be the suficient OCT-derived level of
strut coverage (and lack of malapposition) to be able to safely
discontinue DAPT without risk of ST. Nevertheless, recent
clinical data suggest that patients who interrupt or discontinue
DAPT medication between 1 and 12 months after DP-ZES implantation are considered at low risk and showed no increased
risk for ST compared with those on continuous DAPT until 12
months.20 On this basis, it seems that BP-SES could have at
least as low as or lower ST risk compared with DP-ZES, but
this needs to be veriied in prospective clinical trial.
BP-SES: Clinical Perspective
Previously, SES demonstrated evidence of greater eficacy for
reduction of restenosis and late lumen loss (LLL), compared
with other irst-generation DES.21 In one of the early attempts
to use BP-SES, TIVOLI stent (Essen Technology, Beijing,
China) was compared with a DP-ZES (Endeavor’ Medtronic
Cardiovascular, USA) in a non-randomized fashion.22 In-stent
LLL and binary restenosis at 8-month follow-up were signiicantly lower with the BP-SES compared with the DP-ZES; at
2-year follow-up, target lesion revascularization was signiicantly lower with the BP-SES.22 Another non-randomized study
showed similar in-stent LLL in patients who received BP-SES
(EXCELLTM; JW Medical, Shandong, China) and DP-SES
(0.14 vs. 0.12 mm, respectively, P=0.629) at 9-month followup.23 An angioscopy study on DP-ZES reported struts fully
embedded in neointima at 4 months.24 A irst-in-man report of
a novel BP-SES with L-605 cobalt-chromium stent platform
(FIREHAWK®; MicroPort Medical, Shanghai, China) implanted in single de novo coronary lesions demonstrated an in-stent
LLL of 0.13 mm at 4-month follow-up.25 And, similar to the
present study, on OCT at 4 months, a frequency of uncovered
struts of 3.8% was noted (3.9% in the present study), but the
prevalence of malapposed struts was much lower (0.1% vs.
2.6% in the present study).25 The exclusive enrolment of patients with ACS in the present study may partly explain the
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KARJALAINEN PP et al.
higher prevalence of malapposed struts at a similar time point.
The frequent use of balloon post-dilation in that study (52.4%)
does not account for the difference in malapposition, because
the rates of post-dilation in the present study were 40.9% and
78.3% between BP-SES and DP-ZES, respectively. Interestingly, malapposition was more frequent in DP-ZES, despite a
higher rate of post-dilatation. The malapposition at 3 months
might be explained by positive remodelling of the vessel wall
as a response to the drug polymer in DP-ZES, which is also
supported by the statistically insigniicant trend towards larger
lumen CSA in DP-ZES despite equal baseline lumen diameters.
Unfortunately, the absence of baseline OCT assessment limits
the discrimination between persistent acute malapposition and
late acquired malapposition. Finally, the BIOFLOW-I was a
irst-in-man study evaluating the eficacy and safety of the
Orsiro BP-SES in 30 patients with single de novo native coronary lesions.26 Angiographic in-stent LLL was 0.05±0.22 mm
at 9-month follow-up; at 12 months, the cumulative incidence
of device-oriented major adverse cardiovascular events was
10%; no ST was observed. The current study in non-diabetic
patients with ACS demonstrated better OCT-detected neointimal strut coverage associated with the Orsiro BP-SES compared with DP-ZES at 3 months.
Vasodilator Function
Impaired vasodilator response has been reported after DES
implantation using i.c. acetylcholine infusion, rapid atrial pacing, physical exercise, and adenosine, as vasodilator stimuli.8,9,27
CFR was adopted as an indicator of functional healing because
it was recently shown to predict outcome when added to standard evaluation, in unselected patient populations, as well as
in patients with ACS.14,28,29 We used a coronary pressure wire
(Certus®) for the functional healing assessment because it allows simultaneous measurement of CFR, IMR and FFR. Whereas FFR measures the pressure drop across an epicardial vessel
and IMR the vasodilator capacity of the microcirculation, CFR
relects coronary low through both the epicardial arteries and
the microcirculation. Reduced CFR can be due to either stenosis in epicardial arteries or combined dysfunction of the coronary microcirculation and vascular endothelium.30 Previously,
lower CFR was detected in patients with DP-EES compared
with titanium-nitride-oxide-coated stents at 10-month followup, indicating persistent vasodilator dysfunction after DES implantation.14 In the HATTRICK-OCT study, we found no differences between the 2 stent groups regarding CFR, IMR and
FFR. Nevertheless, the proportion of patients with abnormal
CFR <2.5 was 44.4% vs. 12.5% for the BP-SES vs. DP-ZES
groups, respectively (P=0.06). The high rates may imply that
the vasodilator function had not recovered completely with
either stent, although signiicant difference between the stent
groups was not seen. The higher occurrence of culprit lesion
thrombus and aspiration thrombectomy in BP-SES as a factor
predisposing to distal embolization is another possible cause of
impaired CFR at 3 months. Whether this translates into adverse clinical outcome remains to be addressed in larger prospective studies.
Study Limitations
The current trial had a relatively small sample size, and therefore its results should be interpreted with caution. Moreover, the
current OCT technology cannot detect tissue coverage <10 µm
and thus, cannot identify very thin layers of endothelial coverage. Additionally, the absence of baseline OCT and vasodilator
response data immediately after the index procedure prevents
comprehensive interpretation of data. It cannot be conirmed
whether malapposed struts are due to persistent acute or late
acquired malapposition. The fact that no independent core lab
was involved in data analysis is another potential limitation.
Finally, the trial was underpowered to correlate clinical endpoints with OCT indings, and decision on the length of DAPT
cannot be made based on these OCT results only. Therefore,
larger prospective studies are needed.
Conclusions
In non-diabetic patients with ACS, neither of these newer generation stent devices was fully covered at 3 months follow-up.
The percent of uncovered stent struts on OCT was lower for
BP-SES compared with DP-ZES at 3-month follow-up, but CFR
and IMR were similar between the groups.
Acknowledgments
The authors thank RN Minna Ampio, RN Kristiina Lahtola and RN Tuija
Vasankari for their excellent technical assistance.
Disclosures
Conlicts of Interest: This study was supported by a scholarship for research within the area of ACS from the Finnish Cardiac Society (T.K.);
by grants from the Finnish Foundation for Cardiovascular Research,
Helsinki, Finland (T.K., J.K.E.A.); and by Turku University Hospital
Research Foundation. The authors report no other relationships that could
be construed as a conlict of interest.
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