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Rebuttal: Reply to letter to the editor written by Fernandez‐Pereira et al

We reply with interest to the Letter to the Editor written by Fernandez-Pereira et al. [1], which was in response to our article comparing drug-eluting stents (DES) versus bare metal stents (BMS) in the treatment of transplant coronary artery disease (TCAD) [2]. Our study retrospectively compared 105 orthotopic heart transplant (OHT) patients who underwent percutaneous coronary intervention (PCI) for the treatment of TCAD. At 5 years, both DES and BMS were associated with similar rates of major adverse cardiac events (40.8% vs. 59.6%), death (31.8% vs. 40.4%), myocardial infarction (12.2% vs. 11.3%), target vessel revascularization (25.5% vs. 26.5%), and time to repeat OHT (2.27 years vs. 3.22 years). The data on the clinical superiority of DES when compared to BMS for TCAD patients are lacking and controversial. There is some evidence that DES is more effective than BMS in preventing restenosis in TCAD patients [3–6] possibly by slowing the progression of immune-mediated intimal thickening. However, these studies were non-randomized, small in size, and other published studies show some conflicting results [7,8]. Our study did not yield a significant difference in clinical outcomes in the two groups of patients undergoing PCI. Possible reasons for these results include lack of randomization leading to significant baseline characteristic differences between the two groups and the lack of power to detect a true difference [2]. However, Fernanadez-Pereira and coworkers mention that a confounding factor affecting outcomes may be due to oral immunosuppressive (OI) therapies (such as prednisone and rapamycin) for the purpose of anti-rejection maintenance in patients receiving PCI for TCAD. Although data exist supporting the role of OI therapies in preventing restenosis after PCI of native coronary artery disease [9], this has not been studied in comparison with DES and BMS in a randomized fashion. In addition, the theory that OI therapies prevent restenosis in native vessel PCI has not been studied extensively and is not accepted in routine practice. Therefore, to apply this theory to TCAD patients may be a bit premature. In our study, patients in the BMS and DES groups received OI therapies whereas in the ORAR III trial [9], only the BMS group received rapamycin, making that data even less relevant to our study. It is certainly possible that with more studies, OI therapies can show a significant impact in preventing restenosis in both PCI of native vessels and TCAD patients. However, current data are lacking to strongly support a role for OI therapies in PCI patients. Randomized studies and larger studies looking at both OI and comparing BMS with DES will be important in defining the best treatment strategy for patients with TCAD.