Stopping or continuing clopidogrel 12 months after drug-eluting stent placement: the OPTIDUAL randomized trial

AIM

This open-label, randomized, and multicentre trial tested the hypothesis that, on a background of aspirin, continuing clopidogrel would be superior to stopping clopidogrel at 12 months following drug-eluting stent (DES) implantation.

METHODS AND RESULTS

Patients (N = 1799) who had undergone placement of ≥1 DES for stable coronary artery disease or acute coronary syndrome were included in 58 French sites (January 2009-January 2013). Patients (N = 1385) free of major cardiovascular/cerebrovascular events or major bleeding and on aspirin and clopidogrel 12 months after stenting were eligible for randomization (1:1) between continuing clopidogrel 75 mg daily (extended-dual antiplatelet therapy, DAPT, group) or discontinuing clopidogrel (aspirin group). The primary outcome was net adverse clinical events defined as the composite of death, myocardial infarction, stroke, or major bleeding. Follow-up was planned from a minimum of 6 to a maximum of 36 months after randomization. Owing to slow recruitment, the study was stopped after enrolment of 1385 of a planned 1966 patients. Median follow-up after stenting was 33.4 months. The primary outcome occurred in 40 patients (5.8%) in the extended-DAPT group and 52 in the aspirin group (7.5%; hazard ratio 0.75, 95% confidence interval 0.50-1.28; P = 0.17). Rates of death were 2.3% in the extended-DAPT group and 3.5% in the aspirin group (HR 0.65, 95% CI 0.34-1.22; P = 0.18). Rates of major bleeding were identical (2.0%, P = 0.95).

CONCLUSIONS

Extended DAPT did not achieve superiority in reducing net adverse clinical events compared to 12 months of DAPT after DES placement. The power of the OPTIDUAL trial was however low and reduced by premature termination of enrolment.

CLINICALTRIALSGOV NUMBER

NCT00822536.

[Paradoxical embolism and thrombosis trapped in the foramen ovale. Role of transesophageal echocardiography]

The authors report a case of paradoxical embolism presenting with syncope and a transient cerebrovascular accident. A large thrombus was observed entrapped in the foramen ovale during transthoracic echocardiography and confirmed at transoesophageal echocardiography. Despite the recent cerebrovascular event surgery was successfully performed. This clinical situation, and a review of the literature illustrate the diagnostic value of transoesophageal echocardiography, the finding of an intra-atrial thrombus being a possible surgical indication when the clinical context is favourable.

[Transesophageal echography and systemic ischemic incidences: 235 cases]

From the first of June 90 to the thirty first of January 94, transesophageal echocardiography was performed in 235 consecutive patients (mean age 56+/-16 years), presenting either with cerebral ischemic event (n = 202) or a peripheral arterial embolism (n = 33). All patients had normal echocardiographic and Doppler examinations of the carotid arteries, and transthoracic echocardiography did not show any possible cardiac origin for stroke. Ninety seven patients (41.2%) had documented cardiac disease and/or atrial fibrillation (group 1); 138 patients (58.8%) had no previous cardiovascular history (group 2). Transesophageal echocardiography revealed a possible embolic source in 65.9% of cases (group 1) compared with 29.7% of cases in group 2 (p < 0.001). Intracavitary thrombus and spontaneous contrast in the left atrium were detected only in group 1 (21.6% vs 0%, p < 0.001 and 24.7% vs 0%, p < 0.001 respectively). Patent foramen ovale was more frequent in group 2: 14.5% of cases vs 4.1% of cases, p < 0.01. There was no significant difference between atheromatous aortic plaques and interatrial septam aneurysm incidence in the two groups. Patent foramen ovale and interatrial septal aneurysm were more frequent in group 2: 85% of cases vs 10% of cases in group 1. Transesophageal echocardiography contributes more in patients with a history of cardiac disease. In patients without cardiac disease, patient with foramen ovale and interatrial septal aneurysm were mainly detected: their association represented a risk factor of cerebral ischemic event. Therefore transesophageal echocardiography should be performed in young patients or in case of recurrent event.

[Influence of the valve position on the complications related to pericardial Carpentier-Edwards valve after 8 years]

Between July 1984 and December 1991, 541 Carpentier-Edwards pericardial prostheses were implanted in 536 patients (420 aortic and 121 mitral prostheses). The operative mortality was 2.9% for aortic and 3.3% for mitral valve replacement. All but 8 patients were followed up for an average of 3.9 years, making a total follow-up of 1930 patient-years. There were 61 deaths during follow-up (41 AVR, 20 MVR). The actuarial 8 year survival was 80 +/- 6% for AVR and 74 +/- 10% for MVR. There were 15 deaths related to the prostheses. The probability of absence of valve-related mortality was 97 +/- 3% for AVR and 92 +/- 6% for MVR (NS). The valve-related complications included 15 thromboembolic events (AVR: 12; MVR: 3), 10 endocarditis (AVR: 7; MVR: 3), 8 anticoagulant-related haemorrhages (AVR: 4; MVR: 4), 4 degeneration (AVR: 2; MVR: 2). There were no cases of cusp tear. The probability of absence of thromboembolic events at 8 years was 96 +/- 3% for AVR and 96 +/- 4% for MVR (NS), of absence of endocarditis 97 +/- 2% for AVR and 97 +/- 3% for MVR (NS) and of absence of valve degeneration 99 +/- 1% for AVR and 99 +/- 2% for MVR (NS). These results show that the position of the bioprosthesis had no influence on valve-related morbidity and that pericardium is a satisfactory tissue for the manufacture of mitral bioprostheses.

[Surgery of valve replacement with pericardial prosthesis]

The ideal artificial heart valve still does not exist among the various cardiac valves available to the clinician. Morbidity and mortality are directly related to the valve itself. Despite the promising hemodynamic results obtained in the 70s with pericardial prosthesis, these valves were progressively abandoned due to their poor long-term resistance. Based on an analysis of the causes of failures, modifications were made in the manufacturing method and current results with pericardial valves has greatly improved, inciting new interest in their clinical use. Today, the pericardium is recognized as a valid substitution material for bioprostheses. Results of long-term series should confirm current studies. Research is under way to determine how to improve pericardium longevity since tissue deterioration remains the limiting factor.

New procedure to replace the aortic valve with autologous pericardium: a clinical case

Primary tissue failure is a major problem with pericardial or porcine heterografts, and the causes of calcification of the tissue are not yet known. The deterioration of bioprostheses may be due in part to immunologic response. Using autologous tissue is a current approach of research. We present a case of replacement of the aortic valve using an original procedure with autologous pericardium.

The Carpentier-Edwards pericardial aortic valve: intermediate results in 420 patients

From July 1984 to December 1991, 420 patients underwent isolated aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis in our Institution. Of the patients 71.5% were male, the mean age was 66.9 +/- 11.9 years and 48% were in NYHA clinical stage III or IV. The operative mortality rate was 2.9% (12/420). All patients but six were followed up for an average of 3.9 years after their operation and total follow-up was 1444 patient-years. At this time of the study, over 80% of the patients are in NYHA class I or II, 6% are in atrial fibrillation and 7% receive anticoagulation treatment. There were 41 late deaths. After 8 years the actuarial survival rate is 80% +/- 6%. Nine patients died of valve-related causes (three endocarditis, three thromboembolic complication, one structural failure, and two sudden deaths). The actuarial rate of freedom from valve-related death was 97% +/- 3% at 8 years. Valve-related complications included 12 thromboembolic episodes (0.8% patient-year), 7 endocarditis (0.5% patient-year), 4 anticoagulant-related complications (0.2% patient-year), 6 reoperations (0.4% patient-year) and 2 structural valve failures (0.1% patient-year). After 8 years, freedom from thromboembolic complication was 96% +/- 3%, from endocarditis 97% +/- 2%, from reoperation 98% +/- 2% and from valve failure 99% +/- 1%. There were only two structural deteriorations (calcification and stenosis) and one explanation. No leaflet tear was observed. We conclude that these intermediate results are better than those obtained with previous pericardial bioprostheses.

[Complete cusp rupture of Hancock pericardial bioprosthesis with systemic embolism. Apropos of a case]

The authors report the case of a systemic embolism of a cusp of a Hancock pericardial aortic bioprosthesis. This rare complication has not been previously reported to the authors' knowledge, and should lead to immediate valve replacement.

[Angioplasty after failure of thrombolysis in myocardial infarction. Hospital results apropos of 40 consecutive patients]

Intravenous thrombolysis during the acute phase of myocardial infarction is successful in restoring perfusion in 60 to 80% of cases. When it is unsuccessful, there is disagreement about the best approach to adopt. The article reports the results obtained in 40 consecutive patients treated by angioplasty after thrombolysis had been unsuccessful. Reperfusion was achieved in 92.5% of cases, with a hospital mortality rate of 7.5% (2.5% if patients admitted in a stage of cardiogenic shock are excluded). There was no mortality related to the procedure itself and an emergency aorto-coronary by-pass was not required in any case. Since it is accepted that the subsequent prognosis depends on coronary patency, coronary artery assessment after thrombolysis, followed by angioplasty if the occlusion persists seems to be a logical strategy if the myocardial territory is compromised.