Sonothrombolysis in the ambulance for ST-elevation myocardial infarction: rationale and protocol.

S El Kadi,A C Van Rossum,O Kamp,T R Porter

doi:10.1007/s12471-020-01516-9

Abstract

BackgroundTreatment of ST-elevation myocardial infarction (STEMI) has improved over the years. Current challenges in the management of STEMI are achievement of early reperfusion and the prevention of microvascular injury. Sonothrombolysis has emerged as a potential treatment for acute myocardial infarction, both for epicardial recanalisation as well as improving microvascular perfusion. This study aims to determine safety and feasibility of sonothrombolysis application in STEMI patients in the ambulance.MethodsTen patients with STEMI will be included and treated with sonothrombolysis in the ambulance during transfer to the PCI centre. Safety will be assessed by the occurrence of ventricular arrhythmias and shock during sonothrombolysis intervention. Feasibility will be assessed by the extent of protocol completion and myocardial visibility. Efficacy will be determined by angiographic patency rate, ST-elevation resolution, infarct size and left ventricular volumes, and function measured with cardiovascular magnetic resonance imaging, and contrast and strain echocardiography. A comparison will be made with matched controls using an existing STEMI database.DiscussionSonothrombolysis is a novel technique for the treatment of cardiovascular thromboembolic disease. The first clinical trials on its use for STEMI have demonstrated promising results. This study will be the first to examine the feasibility of in-ambulance sonothrombolysis for STEMI.Trial registrationEU Clinical Trials Register (identifier: 2019-001883-31), registered 2020-02-25.

Highlights

Background Treatment ofST-elevation myocardial infarction (STEMI) has improved over the years
Primary percutaneous coronary intervention (PCI) with concomitant dual antiplatelet therapy and periprocedural anticoagulation constitutes the treatment of choice in STEMI patients [1]
Safety will be assessed by the occurrence of ventricular arrhythmias defined as sustained ventricular tachycardia and/or ventricular fibrillation and the occurrence of shock defined as a systolic blood pressure

Summary

Introduction

Background Treatment ofST-elevation myocardial infarction (STEMI) has improved over the years. Sonothrombolysis has emerged as a potential treatment for acute myocardial infarction, both for epicardial recanalisation as well as improving microvascular perfusion. The optimal treatment strategy for ST-elevation myocardial infarction (STEMI) is immediate restoration of epicardial coronary blood flow. In addition to prolonged ischaemia and subsequent infarct size, microvascular injury due to ischaemic and reperfusion processes is a major determinant of adverse left ventricular remodelling and poor prognosis [4] and occurs in up to 50% of the patients [5]. By minimising infarct size and microvascular injury, left ventricular function may be preserved with improved long-term prognosis. No or only small beneficial effects in a selected patient population have been demonstrated Other interventions such as thrombus aspiration to reduce distal embolisation [12] and remote ischaemic

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