Thrombus Aspiration In ST-Elevation Myocardial Infarction Research Articles

Successful visible thrombus aspiration in ST-segment elevation myocardial infarction: associated factors and the clinical impact.

Thrombus aspiration (TA) has been considered a procedure for controlling distal emboli and improving microvascular perfusion. However, current guidelines classify routine TA as class III recommendation, and it has been reported that the efficacy of TA is limited because of the relatively high incidence of failure in retrieval of thrombotic material. The aim of this study was to explore patient characteristics and procedural factors associated with successful TA in ST-elevation myocardial infarction (STEMI) and to assess the clinical impact of successful TA. This single-center retrospective study enrolled 158 STEMI patients who underwent TA as initial recanalization. Factors associated with successful TA, which was defined as retrieving any visible material by aspiration catheter, were explored, and angiographical and short-term outcomes were assessed. In 146 cases (92.4%), the aspiration catheter reached the culprit lesion. Successful TA was achieved in 72 cases (45.6%). The single angiographical characteristic of successful TA was a higher Thrombolysis in Myocardial Infarction grade before TA. Among the procedural characteristics, the rate of successful TA was higher with a 7-French aspiration catheter compared with the rate with a 6-French catheter (57.1% vs. 29.9%, P = 0.01). Thrombolysis in Myocardial Infarction grade 3 flow was more frequent in patients with successful TA immediately after TA (36.1% vs. 16.3%, P = 0.006) and at final angiography (91.7% vs 79.1%, P = 0.04) compared with the grade in patients without successful TA, respectively. The use of a larger aspiration catheter may be effective in retrieving visible thrombus material, and successful TA led to better angiographical results.

Aspiration thrombectomy in 2015: a TOTAL defeat?

Primary percutaneous coronary intervention (pPCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI), but in a relevant proportion of cases it fails to achieve restoration of perfusion at the level of microcirculation, due to the “no reflow” phenomenon (1). Distal thrombotic embolization has a role among the mechanisms of no reflow, and intracoronary aspiration thrombectomy (AT) was conceived several years ago as an adjunct to pPCI to address this problem (2). Over the last 15 years, AT has been thoroughly investigated in clinical trials, but its clinical value is still debated. In fact, initial studies reported that routine use of AT impacted favourably on surrogate end points such as myocardial blush grade or ST-segment elevation resolution (STR) after pPCI; in addition, the randomized TAPAS trial (Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study), although not powered for clinical endpoints, reported a benefit on 1-year mortality (3,4). Therefore, the 2012 guidelines on STEMI of the European Society of Cardiology (ESC) stated that “routine AT should be considered” (class IIa recommendation) (5). However, the larger TASTE trial (Thrombus Aspiration in STEMI in Scandinavia) failed to prove a significant advantage of routine AT in terms of early and medium-term mortality (6,7), leading to a downgrade of AT to class IIb in 2014 ESC guidelines on myocardial revascularization (8). Most recently, the TOTAL trial (Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI), enrolling 10,732 patients, confirmed the lack of mortality benefit with routine AT (9).

Adjunctive thrombus aspiration versus conventional percutaneous coronary intervention in ST‐elevation myocardial infarction

The objective of this analysis is to determine the effects on mortality of thrombus aspiration during primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) compared with conventional PCI. Adjunctive thrombus aspiration in STEMI improves markers of myocardial reperfusion but evidence for improved survival is limited to the TAPAS trial. We used data of 3,750 consecutive STEMI patients treated with either conventional PCI or thrombus aspiration between August 1, 2001 and January 1, 2009. For each patient, a propensity score was calculated based on clinical and angiographic characteristics, predicting a patient's probability of having been treated with thrombus aspiration. This propensity score was used in several ways to account for differences between patients treated with and without thrombus aspiration. In our primary analysis, patients treated with thrombus aspiration were matched one-to-one with patients treated with conventional PCI on their propensity score (1,391 matched pairs). Kaplan Meier and Cox regression models were used to estimate the influence of treatment on one-year mortality. In total, 1,502 patients (40.1%) were treated with thrombus aspiration. In the propensity matched cohort, after one year 7.2% of patients treated with thrombus aspiration had died compared with 9.3% of patients in the control group. The hazard ratio for one-year mortality in patients treated with thrombus aspiration was 0.76 (95% CI: 0.59-0.99; P = 0.043). The hazard ratio remained materially unaltered and statistically significant in secondary analyses, varying between 0.61 and 0.77. The routine use of thrombus aspiration was associated with reduced one-year mortality in this large real-world patient cohort. These data support the observed survival benefit in the TAPAS trial.