The role of manual aspiration thrombectomy in the management of STEMI: a TOTALly different TASTE of TAPAS.

Abstract

In the latest ACC/AHA/SCAI guideline update on primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI), routine use of manual thrombectomy as an adjunct to primary PCI is not recommended (class III: no benefit, level of evidence A) [1]. The guidelines also state that the usefulness of selective and bailout aspiration thrombectomy in patients undergoing primary PCI is not well established (class IIb, level of evidence C). A change in the recommendation occurred following publication of two large randomized studies, the TOTAL trial (a trial of routine aspiration ThrOmbecTomy with PCI versus PCI ALone in Patients with STEMI) (n = 10 732) [2] and the TASTE study (Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia) (n = 7244) [3], which both showed no difference in clinical outcomes between PCI plus thrombectomy versus PCI alone. Previously, the smaller (n = 1071) randomized TAPAS study (Thrombus Aspiration during Percutaneous Coronary Intervention in Acute Myocardial Infarction Study) [4] had shown that manual thrombectomy was associated with better postPCI myocardial perfusion, as measured by the myocardial blush grade (MBG), and a reduction in cardiac mortality, although this study was not powered to detect differ ences in clinical events. However, we believe that there are important observations that should be taken into account when weighing the impact of these trials on everyday practice. In this issue of Advances in Interventional Cardiology, 2 case reports describe successful application of manual thrombectomy beyond the scope of routine STEMI management (a patient with breast cancer and paraneoplastic syndrome, who suffered non-ST-segment myocardial infarction and a patient with bacterial endocarditis of the aortic valve and anterior STEMI caused by embolization of thrombotic material into the left anterior descending (LAD) coronary artery) [5, 6]. Taken together with the recently published data on the lack of clinical benefit of routine manual thrombectomy, the two described reports seem to raise the following question: Has the role of thrombectomy shifted from being considered part of the routine practice of STEMI treatment to being a non-standard therapeutic tool for an exceptional acute MI patient? To attempt an answer to this question, we analyze the results of the main and secondary publications from the TOTAL and the TASTE trials and relate these findings to the knowledge base from earlier clinical studies that seemed to be in favor of the routine use of manual thrombectomy. In the TOTAL trial, patients undergoing manual aspiration thrombectomy as an adjunct to primary PCI had a similar rate of the combined primary endpoint of cardiovascular death, recurrent MI, cardiogenic shock or NYHA IV heart failure at 180 days, as compared with PCI alone (6.9% vs. 7.0%, respectively; HR = 0.99, 95% CI: 0.85–1.15, p = 0.86) [2]. There were no significant differ ences in individual components of the primary endpoint or in the rate of stent thrombosis (1.5% vs. 1.7%, p = 0.42) or target vessel revascularization (4.5% vs. 4.3%, p = 0.77), at 180 days [2]. The crossover rate was 4.6% from thrombectomy to PCI alone and 1.4% from PCI alone to thrombectomy, while the rate of bailout thrombectomy in the PCI-alone group was 7.1% [2]. Nevertheless, the on-treatment analysis that compared patients who received thrombectomy irrespective of randomization (both upfront and bailout) with PCI alone showed no significant difference in the rate of the primary endpoint. At 1 year, the occurrence of the primary composite end