Abstract
Background: Angiographic detection of thrombus in STEMI is associated with adverse outcomes. However, routine thrombus aspiration failed to demonstrate the anticipated benefit. Hence, management of high coronary thrombus burden remains challenging. We sought to assess for the first time extracted thrombotic material characteristics utilizing micro-computed tomography (micro-CT).Methods: One hundred thirteen STEMI patients undergoing thrombus aspiration were enrolled. Micro-CT was undertaken to quantify retrieved thrombus volume, surface, and density. Correlation of these indices with angiographic and electrocardiographic outcomes was performed.Results: Mean aspirated thrombus volume, surface, and density (±standard deviation) were 15.71 ± 20.10 mm3, 302.89 ± 692.54 mm2, and 3139.04 ± 901.88 Hounsfield units, respectively. Aspirated volume and surface were significantly higher (p < 0.001) in patients with higher angiographic thrombus burden. After multivariable analysis, independent predictors for thrombus volume were reference vessel diameter (RVD) (p = 0.011), right coronary artery (RCA) (p = 0.039), and smoking (p = 0.027), whereas RVD (p = 0.018) and RCA (p = 0.019) were predictive for thrombus surface. Thrombus volume and surface were independently associated with distal embolization (p = 0.007 and p = 0.028, respectively), no-reflow phenomenon (p = 0.002 and p = 0.006, respectively), and angiographically evident residual thrombus (p = 0.007 and p = 0.002, respectively). Higher thrombus density was correlated with worse pre-procedural TIMI flow (p < 0.001). Patients with higher aspirated volume and surface developed less ST resolution (p = 0.042 and p = 0.023, respectively).Conclusions: Angiographic outcomes linked with worse prognosis were more frequent among patients with larger extracted thrombus. Despite retrieving larger thrombus load in these patients, current thrombectomy devices fail to deal with thrombotic material adequately. Further studies of novel thrombus aspiration technologies are warranted to improve patient outcomes.Clinical Trial Registration: QUEST-STEMI trial ClinicalTrials.gov number: NCT03429608 Date of registration: February 12, 2018. The study was prospectively registered.
Highlights
Despite the tremendous progress in cardiovascular medicine over the last decades, ST-segment elevation myocardial infarction (STEMI) still remains one of the leading causes of mortality worldwide [1]
Residual thrombus was angiographically evident in 14 patients (12.4%), whereas Myocardial Blush Grade (MBG) was equal to 0 or 1 in 36 (31.86%) of patients
The main findings of our study (Figure 4) were as follows: [1] thrombus analysis by micro-CT is feasible, reliable, and reproducible; [2] larger thrombus was extracted in patients with high intracoronary Thrombus burden (TB) under angiographic imaging; [3] higher aspirated thrombus volume and surface were associated with adverse angiographic outcomes, including distal embolization and no-reflow phenomenon; [4] angiographically evident residual thrombus was more frequent among patients with larger retrieved thrombus; [5] a non-significant trend (p = 0.073) toward worse myocardial blush grade in patients with larger extracted thrombus volume was observed; [6] aspirated thrombus volume and surface were significantly higher in smokers; and [7] worse pre-procedural Thrombolysis In Myocardial Infarction (TIMI) flow was observed in thrombi with higher density
Summary
Despite the tremendous progress in cardiovascular medicine over the last decades, ST-segment elevation myocardial infarction (STEMI) still remains one of the leading causes of mortality worldwide [1]. Thrombus burden (TB) is an important prognostic determinant [2], as it has been associated with an increase in the rate of major adverse cardiac and cerebrovascular events (MACCE) [3]. The optimal therapy for STEMI is timely performed primary percutaneous coronary intervention (pPCI) [4]. Large randomized controlled trials (RCTs) and meta-analyses failed to demonstrate the theoretically anticipated benefit for routine MATh, suggesting lack of synergy between MATh and pPCI with a subsequent increase in the risk of stroke [8,9,10,11]. Routine thrombus aspiration failed to demonstrate the anticipated benefit. We sought to assess for the first time extracted thrombotic material characteristics utilizing micro-computed tomography (micro-CT)
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