Thrombectomy In Acute Myocardial Infarction Research Articles

Emergent Coronary Thrombectomy for Acute Myocardial Infarction Immediately Following Craniotomy with Tumor Resection.

The management of perioperative acute myocardial infarction (AMI) following oncologic neurosurgery requires balancing competing risks of myocardial ischemia and postoperative bleeding. There are limited human data to establish the safest timing of antiplatelet or anticoagulation therapy following neurosurgical procedures. For patients with malignancy experiencing AMI in the acute postoperative period, staged percutaneous coronary intervention (PCI) with upfront coronary aspiration thrombectomy followed by delayed completion PCI may offer an opportunity for myocardial salvage while minimizing postoperative bleeding risks. CYP2C19 genotyping and platelet aggregation studies can help confirm adequate platelet inhibition once antiplatelet therapy is resumed.

Abstract 14990: A Propensity Score Analysis of Five-Year Outcomes After Coronary Thrombus Aspiration in Acute Myocardial Infarction: Insights From the FAST-MI Real-Life Registry

Introduction: Though previous trials and registries have shown no short-term benefit of thrombectomy in acute myocardial infarction (AMI), data on long-term outcomes are lacking. Hypothesis: Use of coronary thrombectomy in real-life conditions does not affect 5-year outcome. Methods: FAST-MI program consists of 3 nationwide French surveys (2005, 2010, 2015), including consecutive AMI patients over a 1-month period. This analysis focused on patients undergoing percutaneous coronary intervention (PCI, N=9,731). Five-year follow-up is >96%. Results: Thrombectomy was used in 1,781 patients (18%; 2005: 7%, 2010: 27%, 2015: 18%), 87% of them had STEMI. They were younger (61±13 vs 65±14 yo), mostly men (81% vs 74%, p<0.001), with less multivessel coronary artery disease (47% vs 55%, P<0.001) and a culprit lesion mostly on the right coronary artery (40% vs 31%, P<0.001). Crude in-hospital death was higher with thrombectomy (3.1% vs 2.0%, P=0.005) but 5-year death lower (13% vs 17%, P<0.001; crude HR 0.74 [95%CI 0.66-0.82]). After adjustment on the propensity score (PS) for getting thrombectomy, OR for in-hospital death was 1.24[95%CI 0.82-1.87] and HR for 5-year death: 0.95 [95%CI 0.79-1.14], P=0.58. In hospital survivors, Cox multivariate adjustment including discharge medications yielded similar results (HR 0.96, 95%CI 0.76-1.21, P=0.73). After PS matching, the two cohorts (N=1,430 each) had even distributions for all baseline characteristics and medications. In-hospital death was similar (2.7% vs 2.6%, P=0.91) but stroke was numerically higher (0.8% vs 0.3%, P=0.13) with thrombectomy. Five-year survival was similar in the 2 cohorts: HR 0.93, 95%CI 0.75-1.14, P=0.46. (Figure) Conclusions: These real-world data show that the use of thrombectomy has increased until 2010 and declined thereafter, in keeping with international guidelines, and suggest that thrombectomy has no beneficial nor detrimental effect on long-term survival compared to PCI alone.

TCT-145 Rheolytic Thrombectomy for Acute Myocardial Infarction Complicated by Cardiogenic Shock

TCT-145 Rheolytic Thrombectomy for Acute Myocardial Infarction Complicated by Cardiogenic Shock

Current Considerations of Thrombectomy for Acute Myocardial Infarction

Management of thrombus in coronary lesions remains a challenge that is frequently encountered during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) and is usually associated with poor clinical outcomes. At the same time, the optimum management of such lesions remains a dilemma. Multiple thrombus removal procedures have emerged with the short-term aim of improving myocardial perfusion and a longer-term aim of decreasing the incidence of both major adverse cardiac events (MACE) and all-cause mortality. In this review, we will highlight the main procedures utilized for thrombus removal during primary PCI for STEMI, with particular emphasis on aspiration thrombectomy. We will also approach possible theories that might explain the apparent lack of clinical benefit recently shown with such procedures.

Thrombectomy in Acute Myocardial Infarction

Two large randomized controlled trials have demonstrated that routine manual thrombectomy is not beneficial in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI) and was associated with an elevated stroke rate within 30 days ( N Engl J Med 2013; 369:1587 and N Engl J Med 2015; 372:1389). Although thrombectomy significantly improved early surrogate …

Rheolityc thrombectomy in acute myocardial infarction: Effect on microvascular obstruction, infarct size, and left ventricular remodeling

We sought to analyze whether rheolytic thrombectomy (RT) in comparison with manual thrombus aspiration (MTA) may reduce microvascular obstruction (MVO), infarct size (IS), and left ventricular (LV) remodeling in ST-elevation myocardial infarction (STEMI). Conflicting results have been reported as to whether MTA reduces MVO and IS. Eighty STEMI reperfused by primary angioplasty and abciximab were randomly allocated (1:1) to RT or MTA. Cardiac magnetic resonance imaging (MRI) was performed in 37 patients (19 RT) and after 1 year in 19 (9 RT); baseline, 1- and 6-month 2D-echo was performed in all patients. MVO and IS were measured 8 min after gadolinium injection with late enhancement sequences and were analyzed quantitatively at a core laboratory blinded to randomization. At baseline TIMI thrombus grade were similar (RT: 4.47 ± 0.84 vs. MTA: 4.67 ± 0.76, P = 0.453). After thrombectomy, thrombus grade decreased to 1.11 ± 1.04 in RT vs. 2.17 ± 1.29 in MTA arm (P = 0.009). RT compared with MTA did not reduced significantly myocardial IS [12.2% (6.4-22.1) vs. 19.0% (7-28.5), P = 0.224] as well as the extent of MVO [0.0% (0.0-0.17) vs. 0.6% (0.0-1.4), P = 0.117], but a trend toward a lower incidence of MVO (16% vs. 44%, P = 0.056) and a less LV remodeling rate were found in RT arm (11% vs. 24%, P < 0.140). RT in comparison with MTA was more effective in thrombus removal, but it did not reduced significantly the IS and the extent of MVO. However, a trend toward a lower incidence of MVO and a better preservation of LV volumes were found in RT arm. © 2015 Wiley Periodicals, Inc.

Manual Aspiration Thrombectomy in Acute Myocardial Infarction: A Clinical Experience

Multiple clinical studies have failed to establish the role of routine use of thrombectomy in ST-elevation myocardial infarction (STEMI) patients. There is a paucity of data on the impact of thrombectomy in unselected STEMI patients outside clinical trials. We sought to evaluate the clinical variables and outcomes associated with the performance of thrombectomy in STEMI patients. We retrospectively examined the clinical outcomes in all STEMI patients who underwent successful percutaneous intervention (PCI) at our center. Patients were divided into two groups, one with patients who underwent conventional PCI and another with patients who had thrombus aspiration in addition to conventional PCI. We compared the baseline clinical characteristics, laboratory investigations, re-infarction rates, and all-cause mortality. Total 477 consecutive STEMI patients were identified. Overall, 29% (139) of the patients underwent conventional PCI and 71% (338) of the patients were treated with aspiration thrombectomy and PCI. In addition to the presence of thrombus, patients with nonanterior infarction, and patients with hemodynamic instability requiring intra-aortic balloon pump support were more likely to undergo thrombectomy. Thrombectomy was associated with higher enzymatic infarction (creatine kinase: 2,796 [2,575] vs. 1,716 [1,662]; p < 0.0001; CK-MB: 210.6 [156.0] vs. 142.0 [121.9], p < 0.0001). However, thrombectomy was not associated with any difference in 30 day reinfarction rate (3.3 vs. 2.9%, p = 0.83), mortality (5.0 vs. 7.2%, p = 0.35), or composite of death and 30 day reinfarction (7.7 vs. 9.4%, p = 0.55). We observed that STEMI patients with anterior infarction and hemodynamic instability were more likely to undergo thrombectomy during primary PCI.

Comparing benefits expected in the design of randomized trials with the results of mature meta-analysis: An analysis on aspiration thrombectomy in acute myocardial infarction

Comparing benefits expected in the design of randomized trials with the results of mature meta-analysis: An analysis on aspiration thrombectomy in acute myocardial infarction

TCTAP C-032 Unexpectedly Migration of Giant Thrombus in Left Anterior Descending Artery into Left Circumflex Artery During Primary Coronary Intervention with Aspiration Thrombectomy in Acute Myocardial Infarction

### Patient initials or identifier number 59/M, JCB Unit number: 746706 ### Relevant clinical history and physical exam Fifty-nine years old male presented to our emergency room with severe chest pain of 3 hours’ duration. He was an ex-smoker and accumulated a 10 pack years smoking history.

TCT-247 Effects on Infarct Size, Microvascular Obstruction, Left Ventricular Volumes and Function of Manual Thrombus Aspiration and Rheolytic Thrombectomy in Acute Myocardial Infarction: 1-year SMART-MRI substudy

TCT-247 Effects on Infarct Size, Microvascular Obstruction, Left Ventricular Volumes and Function of Manual Thrombus Aspiration and Rheolytic Thrombectomy in Acute Myocardial Infarction: 1-year SMART-MRI substudy

Comparison of Manual Thrombus Aspiration With Rheolytic Thrombectomy in Acute Myocardial Infarction

Manual thrombus aspiration (MTA) is completely ineffective in 30% of cases, and the high profiles of the catheters prevent their use in tortuous and calcified vessels. The rheolytic thrombectomy (RT) device has the potential for improved thrombus removal in acute myocardial infarction as compared with MTA. No data exist on the comparison between the 2 techniques. Randomized study, including 80 acute myocardial infarction patients allocated to RT or MTA before infarct artery stenting. Primary end point of this study is residual thrombus burden by optical coherence tomography. Secondary end points are (1) residual thrombolysis in myocardial infarction thrombus grade; (2) postintervention thrombolysis in myocardial infarction flow and myocardial blush; (3) early ST-segment resolution; (4) percentage of malapposed stent struts at 6 months; (5) 6-month restenosis; and (6) 6-month major adverse cardiovascular events. All but 1 patient had residual thrombus after manual aspiration thrombectomy or RT. The number of optical coherence tomography quadrants containing thrombus in MTA arm was higher than in the RT arm, but this difference did not reach significance (median value 65 and 53, respectively; P=0.083). Large residual thrombus was more frequently revealed in the manual aspiration thrombectomy arm (patients with number of quadrants above the median value 60% in the manual aspiration thrombectomy arm and 37% in the RT arm, P=0.039). All markers of reperfusion were better in the RT arm. At 6 months, the percentage of malapposed stent struts in the MTA arm was higher than in the RT arm (2.7±4.5% and 0.8±1.6%, respectively; P=0.019). MTA or RT allows only incomplete removal of thrombus in patients with acute myocardial infarction. The primary end point of the study was not met. However, RT as compared with MTA seems to be more effective in thrombus removal and myocardial reperfusion. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01281033.

症例 大量の冠動脈血栓像を伴う急性心筋梗塞に対して,冠動脈内血栓吸引療法を施行した1例

症例 大量の冠動脈血栓像を伴う急性心筋梗塞に対して,冠動脈内血栓吸引療法を施行した1例

Role of Aspiration and Mechanical Thrombectomy in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty: An Updated Meta-Analysis of Randomized Trials

This meta-analysis was designed to update data on clinical outcomes with aspiration thrombectomy or mechanical thrombectomy before primary percutaneous coronary intervention (PCI) compared with conventional primary PCI alone. The clinical efficacy of thrombectomy in acute myocardial infarction (AMI) remains uncertain. Clinical trials that randomized AMI patients to aspiration (18 trials, n = 3,936) or mechanical thrombectomy (7 trials, n = 1,598) before PCI compared with conventional PCI alone were included. The weighted mean duration of clinical follow-up was 6 months. Aspiration thrombectomy vs. conventional primary PCI (18 trials, n=3,936): Major adverse cardiac events (MACE) (risk ratio [RR]: 0.76; 95% confidence interval [CI]: 0.63 to 0.92; p = 0.006) and all-cause mortality (RR: 0.71; 95% CI: 0.51 to 0.99; p = 0.049) were significantly reduced with aspiration thrombectomy. Beneficial trends were noted for recurrent MI (p = 0.11) and target vessel revascularization (p = 0.06). Final infarct size (p = 0.64) and ejection fraction (p = 0.32) at 1 month were similar. ST-segment resolution (STR) at 60 min (RR: 1.31; 95% CI: 1.16 to 1.48; p < 0.0001) and Thrombolysis In Myocardial Infarction blush grade (TBG) 3 post-procedure (RR: 1.37; 95% CI: 1.19 to 1.59; p < 0.0001) were both improved with aspiration thrombectomy. Mechanical thrombectomy vs. conventional primary PCI (7 trials, n = 1,598): there was no difference between the mechanical thrombectomy and conventional primary PCI arms in the incidence of MACE (RR: 1.10; 95% CI: 0.59 to 2.05; p = 0.77), mortality (p = 0.57), recurrent MI (p = 0.32), target vessel revascularization (p = 0.19), or final infarct size (p = 0.47). A benefit in STR at 60 min (RR: 1.25; 95% CI: 1.06 to 1.47; p = 0.007), but not TBG 3 (RR: 1.09; 95% CI: 0.86 to 1.38; p = 0.48) was noted. Thrombectomy during AMI by manual catheter aspiration, but not mechanically, is beneficial in reducing MACE, including mortality, at 6 to 12 months compared with conventional primary PCI alone.

Rheolytic thrombectomy in acute myocardial infarction — first Croatian experiences

Rheolytic thrombectomy in acute myocardial infarction — first Croatian experiences

TCT-60 Comparison Of Manual Aspiration With Rheolytic Thrombectomy In Acute Myocardial Infarction: The Final 6-Month Results Of The SMART Primary PCI Trial

TCT-60 Comparison Of Manual Aspiration With Rheolytic Thrombectomy In Acute Myocardial Infarction: The Final 6-Month Results Of The SMART Primary PCI Trial

Trombectomia adjunta em intervenção percutânea primária para infarto agudo do miocárdio

Primary percutaneous coronary intervention (PCI) has become the favored reperfusion strategy in acute ST-segment elevation myocardial infarction. Lower post-PCI myocardial perfusion grade, no-reflow and even drug-eluting stent thrombosis have been related to the presence of intracoronary thrombus. Adjunctive thrombectomy refers to procedures and devices that remove thrombotic material from the infarction-related artery, in theory, before distal embolization can occur. There is substantial variability between randomized controlled trials of thrombectomy in primary PCI with regards to tested devices, procedural characteristics, adjuvant medical regimen and examined outcomes. As a general statement, improvements in myocardial perfusion endpoints do not translate into reductions in clinical outcomes. Yet, an increasing number of trials with a longer follow-up reported benefits arising late after the index myocardial infarction. Simple aspiration catheters may also produce better outcomes than devices that fragment the thrombus before aspirating debris. Clinical or angiographic variables which best predict benefits from the use of thrombectomy remain to be defined. The aim of this review is to provide perspective on the conclusions of available trials and meta-analysis of adjunctive thrombectomy in acute myocardial infarction. Targets for future studies are discussed.

Aspiration coronary thrombectomy for acute myocardial infarction increases myocardial salvage

The aim of the study was to assess if aspiration thrombectomy in high risk patients with STEMI and angiographic evidence of thrombus may improve myocardial salvage. It is unclear if thrombus aspiration before percutaneous intervention (PCI) improves myocardial salvage. The trial was a prospective randomized study. The inclusion criteria were: first STEMI within 12 hr from symptoms onset, culprit lesion in left anterior descending or right coronary artery, culprit artery TIMI flow ≤ 2 and angiographic evidence of thrombus. The primary endpoint was myocardial salvage index (MSI) as assessed by (99m) Tc-sestamibi SPECT imaging. We randomized 137 patients (98 male, mean age 64.1 ± 12.5 years) either to aspiration thrombectomy followed by standard PCI with stent implantation (n = 67) or to standard primary PCI (n = 70). Index perfusion defect was similar in both study groups: 34.2% ± 13.1% in thrombectomy group versus 37.1% ± 12.0% in primary PCI group (P = 0.2). MSI was larger in aspiration thrombectomy group than in control patients [25.4% (IQR 13.5-44) vs. 18.5% (IQR 7.7-30.3) respectively, P = 0.02]. The final infarct size was smaller in patients treated with aspiration thrombectomy (23.1% ± 13.3% vs. 28.9% ± 10.2% in the control group, P = 0.002). Aspiration thrombectomy improves myocardial salvage in high risk STEMI patients with angiographic evidence of thrombus.

Letter by Lozano et al Regarding Article, “Adjunctive Thrombectomy for Acute Myocardial Infarction: A Bayesian Meta-Analysis”

To the Editor: We have read with interest the article by Mongeon et al1 related to thrombectomy in acute myocardial infarction. Since the introduction of the first device in the interventional arena a decade ago, we have used a long list of different designs with varying clinical results, frequently disappointing in comparison with the expectations. Although the hypothesis of thrombus elimination may look attractive, …

Response to Letter Regarding Article, “Adjunctive Thrombectomy for Acute Myocardial Infarction: A Bayesian Meta-Analysis”

Response: Angiographically visible thrombus was required in only 5 of the 21 trials1,–,5; therefore, a subanalysis limited …

Long‐term outcome after thrombectomy in acute myocardial infarction

Current data appear in favour of thrombectomy for ST-elevation myocardial infarction (STEMI). However, information on long-term outcome after thrombectomy is limited. We performed a retrospective long-term study to assess the risk of cardiac re-hospitalizations and survival after discharge from the index hospitalization for STEMI. Patients originally randomized to percutaneous coronary intervention (PCI) with thrombectomy vs. standard PCI were included in a retrospective long-term observational study. The primary study endpoint was the combined risk for all-cause death or cardiac re-hospitalization after index discharge under optimal medical therapy. The cumulative number of cardiac hospitalization days and ventricular remodelling assessed by echocardiography and plasma biomarkers were secondary endpoints. Of 94 STEMI patients who had been randomized between 11/2000 and 03/2003, 89 patients consented to long-term follow-up. A total of 43 patients had been allocated to thrombectomy and 46 to standard primary PCI. The minimum follow-up time was 1115 days. There was a significantly lower risk for death or cardiac re-hospitalization for patients of the thrombectomy group (hazard ratio = 0.69, 95% CI: 0.49-0.98, P = 0.036). The incidence of recurrent myocardial infarction was not different (P = 0.343). No differences in cardiac remodelling were detected by echocardiography, with the exception that heart-type fatty acid binding protein at 53.2 +/- 17 months was lower in the thrombectomy group (P = 0.045). Thrombectomy in STEMI may decrease the long-term risk for death or cardiac re-hospitalization.