Use Of Thrombus Aspiration Research Articles

“A stratified pathway to stent-free reperfusion: Selecting suitable patients in ST-elevation myocardial infarction”

BackgroundThe DANAMI-3 DEFER study demonstrated that deferring stent implantation in ST-elevation myocardial infarction (STEMI) is safe, although not superior to immediate stenting. It is possible that an individualized revascularization strategy in STEMI, achieved through appropriate patient selection, could be feasible and effective. MethodsThis prospective, non-randomized study included 198 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) between October 2019 and November 2021. Patients were assigned to either the deferred stenting (DS) group (n = 19) or the control group (C) undergoing immediate stenting (n = 179) based on a multimodal approach integrating coronary angiography, intravascular imaging, physiological assessments, and clinical judgment. The primary endpoints included all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). ResultsThe DS group showed a significantly lower rate of stent implantation (10.5 % vs. 97.7 %, p < 0.001) and a higher use of thrombus aspiration (89.5 % vs. 30.7 %, p < 0.001) and glycoprotein IIb/IIIa inhibitors (31.6 % vs. 6.7 %, p < 0.001) compared to the C group. No significant differences were observed between the groups in terms of all-cause mortality (5.3 % vs. 8.9 %, p = 0.59) or MACCE (10.5 % vs. 8.4 %, p = 0.71). ConclusionsThis study demonstrates the feasibility of implementing individualized reperfusion strategies in STEMI within a real-world clinical setting. The findings, while limited by the study design, generate valuable hypotheses that warrant further investigation to refine patient selection criteria and optimize outcomes.

Outcomes, risk factors, and procedural management of acute myocardial infarction caused by stent thrombosis

Coronary stent thrombosis (ST) is a rare but severe complication of percutaneous coronary interventions (PCIs) with significant implications for patient outcomes. Despite advancements in antiplatelet medications and drug-eluting stent (DES) technology, ST remains associated with considerable morbidity and mortality. Notably, ST is an adverse event arising from various factors, including patient characteristics, stent-related issues, and procedural complications. In such a context, intravascular imaging (IVI) plays a pivotal role in assessing the underlying mechanisms and guiding treatment decisions. The use of thrombus aspiration and intracoronary antithrombotic therapies have been debated in the context of de novo acute myocardial infarction, but they could have a remarkable role for ST. However, the optimal management of ST requires individualized approaches tailored to patient-specific factors. This review provides a comprehensive analysis of the current understanding of ST, encompassing its incidence, outcomes, and risk factors, focusing on procedural acute management.

Impact of trial results and guidelines on the practice of Primary PCI over 14 years

Abstract Aim We aimed to present an overview of changes in daily practice of primary PCI in relation to on the growing evidence in device and adjunctive pharmacologic therapy. Methods and results Clinical outcomes, data on treatment as well as characteristics of 19,054 patients prospectively enrolled in a nation-wide registry of primary PCI between 2005 and 2018 were analysed. A year-by-year trend analysis was done to show the dynamic of changes following landmark trial publications and new guideline recommendations. Patient characteristics remained stable except a slight increase of patients needing resuscitation (from 8% to 12%) and treatment delays showed improvements over time. The prescription of new P2Y12 Inhibitors rapidly increased after approval in 2009. Femoral access was predominant in 2011 (over 90%) followed by a steady decrease to under 30% in 2018. The use of thrombus aspiration increased since 2008 with a maximum in 2013 followed by a decrease after publication of two negative randomised trials. Mortality was in average 6%. Conclusion Trial results and guideline recommendations had a strong impact on the practice of PPCI in this national registry. Despite improved treatments, the average in-hospital mortality of 6% indicates the necessity of continuous reassessment of treatment delays and other quality indicators to further improve patient outcome after STEMI.Changes over time

Differences in door-to-balloon time and outcomes in SARS-CoV-2-positive ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: A systematic review and meta-analysis.

The coronavirus disease 2019 infection has significantly impacted the world and placed a heavy strain on the medical system and the public, especially those with cardiovascular diseases. Hoverer, the differences in door-to-balloon time and outcomes in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are not known too much. Web of Science, EMBASE, PubMed, Cochrane Library, Wanfang, VIP, and China's National Knowledge Infrastructure were utilized to perform a systematic literature search until April 30, 2023. We computed the odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) to determine the correlation. A random-effects model was used for the meta-analysis if the study had significant heterogeneity. Meanwhile, sensitivity analysis and Trial sequential analysis were also accomplished using Rveman5.4 and trial sequential analysis 0.9.5.10 Beta software, respectively. A total of 5 eligible studies were explored in our meta-analysis, including 307 cases and 1804 controls. By meta-analysis, the pooled data showed that SARS-CoV-2-positive STEMI patients undergoing percutaneous coronary intervention had a longer door-to-balloon time (OR 6.31, 95% CI 0.99, 11.63, P = .02) than the negative subjects. The glycoprotein IIb/IIIa inhibitor use after SARS-CoV-2 infection (OR 2.71, 95% CI 1.53, 4.81, P = .0006) was relatively frequent compared with controls, and the postoperative Thrombolysis in Myocardial Infarction blood flow (OR 0.48, 95% CI 0.34, 0.67, P < .0001) was worse compared that. The in-hospital mortality (OR 5.16, 95% CI 3.53, 7.53, P < .00001) was higher than non-SARS-CoV-2 infection ones. In addition, we also discovered that age, gender (male), hypertension, diabetes mellitus, hyperlipidemia, smoking, previous myocardial infarction, total ischemia time, and thrombus aspiration use did not have a significant association with the development of STEMI patients with SARS-CoV-2. SARS-CoV-2 positivity is significantly associated with longer door-to-balloon time and higher in-hospital mortality in STEMI patients undergoing primary percutaneous coronary intervention.

In Vitro Comparison of Several Thrombus Removal Tools.

Although the routine use of thrombus aspiration is not recommended, the thrombectomy technique still might be considered for a selected population of patients. Therefore, the assessment of the effectiveness of commercially available thrombectomy devices is still clinically relevant. Here, we present an in vitro comparison of several different types of catheters that can be used for thrombus aspiration or removal. Through the removal of 6 h and 24 h human blood clots in an in vitro model, four catheters were compared: the Launcher, Pronto V4, Vasco+ and the stent-retriever Catchview. The aspiration efficacy was expressed as a percentage of the initial thrombus weight. The effectiveness of the patient's aspiration was dependent on the time of thrombus formation and was significantly higher for a thrombus formed over 24 h (58.5 ± 26.5%) than for one formed over 6 h (48.0 ± 22.5%; p < 0.001). In the presented in vitro model, Pronto V4 and Launcher showed the highest efficiency. Large-bore aspiration catheters were found to be more effective than narrow-bore catheters or stent-retrievers in an in vitro model of thrombus removal. The thrombus aspiration efficacy increases with longer thrombus formation times.

Use of Thrombus Aspiration for Patients With Acute Coronary Syndrome: Insights From the Nationwide J-PCI Registry.

BackgroundThere is significant regional or institutional variation in the use of thrombus aspiration (TA) in patients undergoing percutaneous coronary intervention (PCI). We investigated the temporal trend in TA use and its association with clinical outcomes in acute coronary syndrome using the nationwide J‐PCI (Japanese PCI) registry.Methods and ResultsBetween 2016 and 2018, patients with acute coronary syndrome undergoing PCI (n=282 606; median age, 71.0 years; interquartile range, 62.0–79.0 years; women, 24.7%) at 1124 hospitals were stratified on the basis of whether TA was performed (TA and non‐TA). The patients were subdivided according to clinical presentation (ST‐segment–elevation myocardial infarction, non–ST‐segment–elevation myocardial infarction, and unstable angina). Successful PCI, defined as the achievement of TIMI (Thrombolysis in Myocardial Infarction) 3 flow, and in‐hospital mortality were assessed. During the study period, 83 422 patients (29.5%) underwent TA (52.9%, 23.5%, and 5.2% for ST‐segment–elevation myocardial infarction, non–ST‐segment–elevation myocardial infarction, and unstable angina, respectively), and the TA implementation rate remained relatively stable throughout. Patients treated with TA had higher rate of successful PCI than non‐TA (98.7% versus 97.8%; P<0.001). TA was not associated with in‐hospital death among patients with ST‐segment–elevation myocardial infarction (adjusted odds ratio [aOR], 1.02 [95% CI, 0.94–1.12]). However, TA use was associated with higher rates of in‐hospital death in patients with non–ST‐segment–elevation myocardial infarction ( aOR, 1.51 [95% CI, 1.23–1.86]) or unstable angina ( aOR, 1.95 [95% CI, 1.37–2.79]).ConclusionsIn our retrospective analysis of the nationwide PCI registry, TA use was associated with a higher achievement of successful PCI without impairing in‐hospital mortality among patients with ST‐segment–elevation myocardial infarction. Nevertheless, its use should be cautioned in less‐established indications (eg, non–ST‐segment–elevation myocardial infarction and unstable angina).

Abstract 13716: Significance of Time in Use of Manual Thrombus Aspiration in Patients Undergoing Primary PCI for Achieving TIMI 3 Flow

Background: Primary percutaneous intervention is a life-saving procedure to open the occluded coronary artery. Most of these patients have either total occlusion of artery or have high thrombus burden.Therefore, timely use of thrombus aspiration catheters have a significant importance in terms of morbidity and mortality. Purpose: To assess the effect of timing of manual thrombus aspiration in patients undergoing Primary PCI on post procedure TIMI 3 Flow and in hospital outcomes of a tertiary care hospital. Methods: In this prospective observational study, patients with acute STEMI who underwent primary PCI and have totally occluded coronary artery (TIMI 0 flow) after passing the wire were selected. Time from the onset of chest pain to the use of export catheters (Export time) was calculated in these patients and subsequently in-hospital outcome was monitored. Results: 251 patients were enrolled Cut off value for optimal timing of thrombus aspiration was determined to be 315 minutes with a sensitivity of 68% and specificity of 50%. 117 patients reached in 315 minutes in which Export was used, they achieved post procedure TIMI III flow in 87.2% of patients and 75.4% in which Export was used after 315 minutes. Conclusion: Export time is a significant parameter that achieved better coronary intervention results in terms of post procedure TIMI III flow with the short Export time. Therefore, timely thrombus aspiration should be done for the maximum benefit.

Outcome of manual thrombus aspiration for patients undergoing primary PCI for acute STEMI showing large thrombus burden

BackgroundRoutine thrombus aspiration during primary PCI does not improve clinical outcomes. Although recent guidelines for management of patient presented by ST-elevation myocardial infarction treated by primary PCI does not recommend routine use of thrombus aspiration and ranking it as class III recommendation. However, there is remaining uncertainty about rule of TA in group of patients presented by STEMI and their initial coronary angiogram shows large thrombus burden as there is a logical rationale for greater benefit, and still, there are no clear guidelines for management of this group of patients; the aim of this study is to evaluate the in-hospital and short-term outcome of using manual thrombus aspiration in STEMI patients undergoing primary PCI and showing large thrombus burden.ResultsThe study was prospective observational study included 209 patients referred to coronary care unit (CCU) with diagnosis of STEMI who had undergone primary PCI; their initial coronary angiography show totally occluded infarct-related artery with heavy thrombus burden. Patients were divided into 2 groups: group (B) which included 73 patients, who had undergone PTCA and manual thrombus aspiration followed by stent to culprit lesion, and group (A) which included 136 patients, who had undergone conventional PTCA and stent of culprit lesion within the period from November 2016 till July 2018. Patients had a pre-discharge echo and were followed up for 4 weeks for major adverse cardiac events (MACE) and echo repeated after 1 month of discharge.It was found that thrombus aspiration in heavy thrombus burden cases had improved in-hospital mortality and in-hospital secondary endpoints (TIMI flow, MBG, ST-segment resolution), as well as 30-day MACE and LV systolic function.ConclusionIn patients presented with STEMI and heavy thrombus burden culprit artery, manual thrombus aspiration has great value in reducing index hospitalization and 1 month mortality and improve TIMI flow, MBG, ST-segment resolution, and left ventricular systolic function.

11. Outcomes with selective use of thrombus aspiration in patients with ST-elevation myocardial infarction in a tertiary care hospital

11. Outcomes with selective use of thrombus aspiration in patients with ST-elevation myocardial infarction in a tertiary care hospital

Early Predictors of Left Ventricular Remodeling after Primary Percutaneous Coronary Intervention

AbstractBackground: Successful primary Percutaneous Coronary Intervention (PCI), has reduced the mortality of patients with Acute Myocardial Infarction (AMI). However, the increased survival rate resulted in the increased incidence of Left Ventricular (LV) remodeling. Ventricular remodeling is a predictor of heart failure and for this reason it assumes a negative prognostic value.Aim of the Study: Was to assess the percentage of LV remodeling and to identify at discharge early predictors of LV remodeling after primary PCI.Material and Methods: We included 152 patients diag-nosed as acute STEMI and underwent successful primary PCI. All patients were examined by transthoracic echocardi-ography at discharge and 6 months later. LV remodeling defined as increase in Left Ventricular End Diastolic Volume Index (LVEDVI) >20%. Patients were grouped into two groups: Group I (with LV remodeling) and Group II (without LV remodeling). The following factors affecting LV remodeling were evaluated: Infarct Related Artery (IRA), number of vessels affected, use of thrombus aspiration, type of stent used, post PCI TIMI flow, time to reperfusion, Wall Motion Score Index (WMSI) and cardiovascular risk factors.Results: Patients with an increase in LVEDVI >20% who were considered to have LV remodeling (Group I) were 49 patients (32.2%). Anterior MI was significantly more in GroupI patients (89.8%) vs. (44.7%) in Group II patients (p-value= 0.00). Left Anterior Descending (LAD) artery affection was significantly more in Group I (89.8%) vs. (45.6%) in GroupII (p-value=0.00). Ejection fraction noticed to be significantly greater at baseline in Group II (51±6.81%) vs. (41.4±6.59%) in Group I (p-value=0.00) while Group I patients had signif-icant higher WMSI (1.66±0.19) vs. (1.28±0.17) in Group II (p-value=0.00).Conclusions: LV remodeling occurred in 32.2% of patients. Patients with ECG diagnosis as (anterior MI), WMSI (>1.5), ejection fraction (£45%), and LAD as an IRA were at higher risk for LV remodeling (p 1.5) and LAD as an IRA were the only independent predictors for LV remodeling after primary PCI (relative risk; 3.2 and 2.6 respectively).

Myocardial reperfusion with tirofiban injection via aspiration catheter : Efficacy and safety in STEMI patients with large thrombus burden.

There is no consensus on the use of thrombus aspiration (TA) in primary percutaneous coronary intervention (PPCI), and few studies have focused on the performance of tirofiban via TA catheter after PPCI. Our study investigated the clinical outcome of tirofiban injection through TA in acute ST-segment elevation myocardial infarction (STEMI) patients with large thrombus burden undergoing PPCI treatment. The study comprised 122 STEMI patients who underwent TA during PPCI. Participants were randomly divided into two groups. GroupA received intravenous tirofiban injection and tirofiban injection via aTA catheter to the infarcted coronary artery after aspiration (n = 61). GroupB received intravenous tirofiban injection only (n = 61). Baseline clinical information and follow-up data were collected for both groups. Coronary angiography, electrocardiography, and echocardiography findings as well as major adverse cardiovascular events (MACE) were recorded. There were significant differences in postprocedural Thrombolysis in Myocardial Infarction (TIMI) grade2 and 3 flow between the two groups (p = 0.021, p = 0.006, respectively). The incidence of slow-flow in groupA was significantly lower than that of groupB (p = 0.011). An increased incidence of no ST-segment resolution was observed in groupB (p = 0.011). There were fewer major adverse cardiovascular events in groupA than in groupB, but the difference was not statistically significant. Selective tirofiban injection via TA catheter during PPCI may improve myocardial reperfusion in STEMI patients with large thrombus burden.

Selective use of thrombus aspiration in ST segment elevation myocardial infarction guided by the thr

Selective use of thrombus aspiration in ST segment elevation myocardial infarction guided by the thr

OP-33 - A New Thrombus Classification in Bifurcation Lesions: Coronary Thrombus Classification for Guiding Manual Thrombus Aspiration and Direct Coronary Stenting

Introduction: Although manual thrombus aspiration is losing popularity, the bailout use of thrombus aspiration, not only considering the thrombus load, also based on the localization, and its relationship to the carina and side branches might have a significant periprocedural aspects. We recommended a new thrombus classification in addition to current TIMI thrombus grading. This classification is based on the involvement of side branch ostium and the carina with the thrombus, and the possible thrombus shift from the main vessel to the side branch or vice versa.

Outcome of thrombus aspiration in STEMI patients: a propensity score-adjusted study.

The use of thrombus aspiration (TA) prior to primary percutaneous coronary intervention (PPCI) has undergone a radical change in intervention guidelines. The clinical implications, however, are still under scrutiny. This study investigated the clinical effects and outcome of TA before PPCI in patients with ST-segment elevation myocardial infarction (STEMI). Overall 1027 patients with STEMI were analyzed in this retrospective, propensity score-adjusted, multicenter study. The primary endpoints were in-hospital and long-term mortality. There were 418 patients in the TA group and 609 in the conventional PPCI group. The in-hospital mortality rate was significantly higher in the TA group (8.7 vs. 5.0%; P = 0.03). During long-term follow-up [median follow-up duration 689 days (IQR 405-959)] the mortality rates were similar (TA 14.3%, conventional PPCI 15.0%; P = 0.85). Survival analysis for the complete observation period revealed no significant benefit of TA [hazard ratio (HR) 1.12; 97.5% CI 0.90-0.71; P = 0.63]. There were also no significant differences between the groups in the following secondary endpoints: composite of cardiovascular death and non-fatal reinfarction at discharge (P = 0.39), post-PPCI thrombolysis in myocardial infarction flow-grade-3 (P = 0.14), left ventricular ejection fraction (P = 0.47), and non-fatal reinfarction during follow-up (P = 0.17). Rehospitalization rate (1.82 vs. 10.3%; P < 0.0001) and Canadian Cardiovascular Society (CCS) grading (P = 0.02) during follow-up were significantly lower in the TA group. In our cohort the in-hospital mortality rate was significantly higher for TA patients, but during long-term follow-up the mortality rates did not differ. The incidence of rehospitalization and CCS grading were lower in the TA-treated patients.

Pre-Hospital Ambulance Notification for ST Elevation Myocardial Infarction (STEMI) Leads to Rapid Reperfusion But No Effect on Early Mortality: Insights from the Melbourne Interventional Group (MIG) Registry

Background: Guidelines for acute coronary syndrome management advocate a 12-lead electrocardiogram should be taken en route and transmitted to prenotify the receiving medical facility. The aim is to obtain a door-to-balloon time (DTBT) <90mins. We sought to analyse the benefits of prenotification. Method: Excluding cardiac arrest, consecutive patients undergoing primary PCI for STEMI between 2011-2016 from the MIG registry were included with analysis separated into prenotified and non-prenotified groups. Results: 1134 prenotified (38.6%) and 1806 non-prenotified (61.4%) cases were compared. The prenotified group has a higher proportion of patients >75yo (29.0% vs 22.8%, p = 0.01) and have an eGFR<60 mL/min/1.73m2 (28.2% vs 22.7%, p<0.01), but a similar cardiogenic shock rate (6.7% vs 5.2%, p = 0.12). The prenotified group has a higher thrombus aspiration use (30.2% vs 22.4%, p < 0.001), glycoprotein IIbIIIa inhibitor use (66.6% vs 53.4%, p < 0.001), RCA intervention (47.1% vs 36.5%, p < 0.001) and bare metal stent use (40.5%vs36.0%, p < 0.05) with similar procedural success (95.7% vs 95.2%, p = 0.54). Prenotification leads to a 36 min shorter DTBT (52mins vs 88mins, p < 0.001). Prenotification increases total DTBT < 90mins (88.9% vs 51.3%, p < 0.001), increases in hours DTBT<90mins (93.3% vs 61.6%, p < 0.001) and after hours DTBT < 90mins (85.6 vs 46.0%, p < 0.001). Prenotification has a higher in-hospital (4.6% vs 2.9%, p < 0.05) and 30-day mortality (5.1% vs 3.6%, p < 0.05). Prenotification is not an independent predictor for 30-day mortality (HR 1.37, 95% CI 0.91-2.07). Conclusion: Although prenotification dramatically improves DTBTs (especially after hours) and reduces total ischaemic time, early mortality is not lower. The effect on long term mortality after STEMI is eagerly awaited.

TCT-146 Routine Aspiration thrombectomy is associated with increased stroke rates during primary percutaneous coronary intervention for myocardial infarction

Background: Recent studies have suggested that the routine use of aspiration thrombectomy catheters during primary percutaneous coronary intervention (PCI) do not result in improved mortality and may be associated with an increased stroke rate. This study sought to investigate this hypothesis. Methods: This was an observational study analysing data from a prospective database of 6366 patients undergoing primary PCI between August 2003 and May 2015 at a UK cardiac centre. Patients’ details were collected from the hospital electronic database. Primary outcome was thirty-day stroke rates. Results: 3989 (62.7%) patients underwent PCI alone and 2,377 (37.3%) patients underwent PCI with adjuctive thrombus aspiration. PCI alone group had an older demographic (63 (± 14) years vs 60.7 (± 14)), a lower proportion of male participants 75% vs 79% (P=0.001) and cardiovascular risk factors such as hypertension 22.4% vs 25.3% (P=0.007), hypercholesterolemia 18.5% vs 22.6% (P<0.0001) and a history of smoking 33.5% vs 44.3% (P<0.0001). Thrombus aspiration was associated with a higher 30-day stroke rate [16 (0.7%) vs 11 (0.3%) (HR 2.51; 95% CI 1.03-6.08, P 0.03). Multivariate analysis suggested that this increased risk of stroke was maintained following adjustment for confounders (HR: 1.86; 95% CI 1.02-4.38). There was 379 deaths of which 114 (4.8%) were in the thrombus aspiration cohort vs 265 (6.6%) in PCI only cohort over the follow-up period (60 months). This resulted in a significantly lower rate of all-cause-mortality HR 0.70 (95% CI 0.52-0.94; P 0.02). There was no statistically significant difference in observed myocardial infarction rates HR 0.76 (95% CI 0.47-1.23; P 0.27) and the rates of unscheduled revascularisations HR 0.70 (95% CI 0.43-1.13; P 0.14) between the two groups. Conclusions: Our data series of STEMI patients, suggest that routine thrombus aspiration during primary PCI is associated with a significantly higher stroke, rate however, thrombus aspiration reduced mortality rate. This is consistent with current guidelines which don’t recommend the routine use of thrombus aspiration for primary PCI. A possible mortality reduction in patients with high thrombus grades was seen which may warrant further study.

Patterns of ST segment resolution after guidewire passage and thrombus aspiration in primary percutaneous coronary intervention (PPCI) for acute myocardial infarction

BackgroundST segment elevation allows the rapid identification of patients with acute myocardial infarction who benefit from emergency reperfusion. Primary percutaneous coronary intervention (PPCI) has emerged as the preferred perfusion strategy...

Additional manual thrombus aspiration for ST-segment elevation myocardial infarction during percutaneous coronary intervention: an updated meta-analysis.

BackgroundThe clinical efficacy and safety of adjunctive thrombus aspiration (TA) in patients with ST-segment elevation myocardial infarction (STEMI) during percutaneous coronary intervention (PCI) remain controversial.MethodsTwenty five eligible randomized controlled trials were included to compare the use of thrombus aspiration (TA) with PCI and PCI-only for STEMI. The primary endpoint was all-cause mortality and death. The secondary endpoints were major adverse cardiac events (MACE), recurrent infarction (RI), target vessel revascularization (TVR), stent thrombosis (ST), perfusion surrogate markers and stroke.ResultsTIMI flow grade 3 and MBG 2–3 were significantly increased in the TA plus PCI arm compared with the PCI-only arm [relative risk (RR): 1.05, 95% confidence intervals (CI): 1.02–1.09, P = 0.004] and (RR: 1.68, 95% CI: 1.40–2.00, P < 0.001), respectively. There were no significant differences in all-cause mortality, MACEs, TVR and ST rates between the two groups. The RI rate was lower in the TA plus PCI arm than that in the PCI-only arm with short-term follow-up duration (RR: 0.60, 95% CI: 0.38–0.96, P = 0.03), but there was no significant difference in RI incidence over the medium- or long-term follow-up periods (RR: 1.00, 95% CI: 0.77–1.29, P = 0.98), and (RR: 0.96, 95% CI: 0.81–1.15, P = 0.69), respectively. There were statistically significant differences in the rates of crude stroke and stroke over the medium- or long-term follow-up periods and the crude stroke rate in the TA plus PCI (RR: 1.60, 95% CI: 1.08–2.38, P = 0.02) and (RR: 1.43, 95% CI: 1.03–1.98, P = 0.03), respectively; this was not observed between the two arms during the short-term follow-up period (RR: 1.47, 95% CI: 0.97–2.21, P = 0.07).ConclusionsRoutine TA-assisted PCI in STEMI patients can improve myocardial reperfusion and get limited benefits related to the clinical endpoints, which may be associated with stroke risk.

Thrombus aspiration in acute myocardial infarction.

The success of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is often hampered by incomplete microvascular myocardial reperfusion owing to distal embolization of thrombus resulting in microvascular obstruction. To address this problem, thrombus aspiration devices have been developed that can be used to evacuate coronary thrombus either manually or mechanically. Thrombus aspiration has the potential to reduce the local thrombus load, minimize the need for balloon predilatation, facilitate direct stenting, prevent distal embolization, and ultimately improve myocardial reperfusion. Furthermore, thrombus aspiration has enabled us to study coronary thrombus in vivo, and has facilitated recognition of distinct mechanisms of coronary thrombosis. Clinical trials focusing on manual thrombus aspiration in primary PCI have generally shown improved myocardial reperfusion. However, in two large trials powered for clinical end points, no reduction in 1-year mortality or other adverse clinical events was observed with the use of this strategy. Moreover, one of these trials showed a marginally increased risk of stroke. Consequently, current guidelines do not recommend routine use of thrombus aspiration. Future studies should focus on the identification of subgroups of patients with STEMI who might derive benefit from manual thrombus aspiration, and establish the effect of operator performance on the efficacy and safety of the procedure.

Interventional Cardiology 2015: A Selection of Topical Issues

cyclosporine (2.5 mg/kg body weight) or placebo prior to reperfu- sion of the vessel. The aim was to test the hypothesis that cyclosporine can improve the clinical course and prevent ventricular remodeling in STEMI. The events of the primary end point (a composite of all-cause mortality, heart failure, rehospital- ization, or left ventricular remodeling with an increase in left ventricular end-diastolic volume 15% at 1 year) were recorded in 59.0% and 58.1% of the patients in the cyclosporine and control groups, respectively (odds ratio (OR) = 1.04; 95% confidence interval (95%CI), 0.78-1.39; P = .77). Moreover, treatment with cyclosporine did not reduce the incidence of any of the separate components of the primary end point. The TOTAL trial 4 randomized 10 732 STEMI patients treated with primary PCI to a strategy involving systematic aspiration throm- bectomy vs conventional PCI, to test the hypothesis that manual thromboaspiration could reduce distal embolization and improve microvascular perfusion. The primary outcome was the composite of cardiac death, recurrent myocardial infarction, cardiogenic shock, or severe heart failure at 180 days, and the safety outcome was stroke at 30 days. Primary outcome events were recorded in 6.9% of the patients in the thrombectomy group vs 7.0% of the conventional PCI group (OR = 0.99; 95%CI, 0.85-1.15; P = .86). The rates of cardiac death (thrombectomy vs PCI, 3.1% vs 3.5%; OR = 0.90; 95%CI, 0.73- 1.12; P = .34) and of the primary outcome plus stent thrombosis or revascularization of the target vessel (9.9% vs 9.8%; OR = 1.00; 95%CI, 0.89-1.14; P = .95) were also similar. The rate of stroke within the first 30 days was higher in the aspiration thrombectomy group (0.7% vs 0.3%; OR = 1.13-3.75; P = .02), although the reason for this finding is not clear. Because the same results were obtained in a 1-year follow-up, the investigators in the TOTAL trial do not recommend the systematic use of thrombus aspiration in STEMI, 5 although its role in the cases of certain patients and lesions remains to be defined (Figure 1). The ESTROFA-MI registry, 6 involving patients over 75 years of age, collected retrospective data on the antithrombotic therapy administered to STEMI patients undergoing primary PCI. This registry included 2131 patients: 221 (10.3%) treated with bivalir- udin, 1374 (64.5%) treated with unfractionated heparin only, and 536 (25.2%) treated with abciximab; the mean ages were 81 5, 81.3 4.8, and 79.8 4.0 years, respectively (P 2 according to the BARC (Bleeding Academic Research Consortium) criteria 7 was 0.7%, 1.4%, and 1.0% (P = .8), respectively. On multivariate analysis, none of the strategies proved to be an independent predictor of major cardiac events, although the use of bivalirudin was associated with a lower incidence of cardiac death, without significantly increasing the rate of stent thrombosis. The influence of thrombus aspiration was also analyzed in 2 groups matched for a baseline Thrombolysis In Myocardial Infarction flow grade of 0-1 (560 patients who underwent thrombectomy and 490 who did not), but no significant differences were found in terms of cardiac death, reinfarction, need for repeat revascularization, or stent thrombosis. 6