sirolimus and Anterior-Wall-Myocardial-Infarction

Very late stent thrombosis is an infrequent yet potentially fatal complication associated with drug-eluting stents. We report the case of an 88-year-old man who sustained an ST-segment-elevation myocardial infarction 11 years after initial sirolimus-eluting stent implantation. Optical coherence tomograms of the lesion showed that the focal incomplete endothelialization of the stent struts was the likely cause; neointimal formation, neoatherosclerosis, and late stent malapposition might also have contributed. To our knowledge, this is the longest reported intervening period between stent insertion and the development of an acute coronary event secondary to very late stent thrombosis. The associated prognostic and therapeutic implications are considerable, because they illuminate the uncertainties surrounding the optimal duration of antiplatelet therapy in patients who have drug-eluting stents. Clinicians face challenges in treating these patients, particularly when competing medical demands necessitate the discontinuation of antiplatelet therapy. In addition to the patient's case, we discuss factors that can contribute to very late stent thrombosis.

Topics: Aged, 80 and over; Anterior Wall Myocardial Infarction; Cardiovascular Agents; Coronary Stenosis; Coronary Thrombosis; Drug-Eluting Stents; Humans; Male; Percutaneous Coronary Intervention; Prosthesis Design; Risk Factors; Sirolimus; Time Factors; Tomography, Optical Coherence; Treatment Outcome

Topics: Anterior Wall Myocardial Infarction; Drug-Eluting Stents; Humans; Immunosuppressive Agents; Paclitaxel; Randomized Controlled Trials as Topic; Sirolimus; Treatment Outcome

A 73-year-old woman was admitted to our hospital with anterior acute myocardial infarction due to subacute thrombosis after coronary stenting with a zotarolimus-eluting stent (ZES), which is a newly developed drug-eluting stent that has been widely used since May 2009 in Japan. Five days before, she underwent implantation with a ZES in the left anterior descending artery due to stable angina pectoris. After stenting, the intravascular ultrasonography showed no malapposition from the proximal to the distal edge of the stent. She received aspirin 100 mg/day and clopidogrel 75 mg/day from 2 weeks before the stent was implanted. When we investigated the single nucleotide polymorphisms of CYP2C19 in this patient, both CYP2C19*2 and CYP2C19*3 were detected, and she was classified as a poor metabolizer. This report is the first to describe subacute stent thrombosis following the implantation of a newly developed ZES in a Japanese patient, which may be related to clopidogrel resistance.

Topics: Aged; Angioplasty, Balloon, Coronary; Anterior Wall Myocardial Infarction; Aryl Hydrocarbon Hydroxylases; Aspirin; Cardiovascular Agents; Clopidogrel; Coronary Angiography; Coronary Artery Disease; Cytochrome P-450 CYP2C19; Drug Resistance; Drug-Eluting Stents; Female; Genotype; Humans; Phenotype; Platelet Aggregation Inhibitors; Polymorphism, Single Nucleotide; Prosthesis Design; Sirolimus; Thrombectomy; Thrombosis; Ticlopidine; Treatment Outcome; Ultrasonography, Interventional

Topics: Angioplasty, Balloon, Coronary; Anterior Wall Myocardial Infarction; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Coronary Restenosis; Drug-Eluting Stents; Humans; Male; Middle Aged; Prosthesis Design; Prosthesis Failure; Sirolimus; Thrombosis; Time Factors; Treatment Outcome