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Bianchini E, Lombardi M, Buonpane A, Ricchiuto A, Maino A, Laborante R, Anastasia G, D'Amario D, Aurigemma C, Romagnoli E, Leone AM, D'Ascenzo F, Trani C, Crea F, Porto I, Burzotta F, Vergallo R. Impact of thrombus aspiration on left ventricular remodeling and function in patients with ST-segment elevation myocardial infarction: A meta-analysis of randomized controlled trials. Int J Cardiol 2024; 397:131590. [PMID: 37979785 DOI: 10.1016/j.ijcard.2023.131590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/06/2023] [Accepted: 11/14/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Routine thrombus aspiration (TA) does not improve clinical outcomes in patients with ST-segment-elevation myocardial infarction (STEMI), although data from meta-analyses suggest that patients with high thrombus burden may benefit from it. The impact of TA on left ventricular (LV) functional recovery and remodeling after STEMI remains controversial. We aimed to pool data from randomized controlled trials (RCTs) on the impact of TA on LV function and remodeling after primary percutaneous coronary intervention (pPCI). METHODS PubMed and CENTRAL databases were scanned for eligible studies. Primary outcome measures were: LV ejection fraction (LVEF), LV end diastolic volume (LVEDV), LV end systolic volume (LVESV) and wall motion score index (WMSI). A primary pre-specified subgroup analysis was performed comparing manual TA with mechanical TA. RESULTS A total of 28 studies enrolling 4990 patients were included. WMSI was lower in TA group than in control (mean difference [MD] -0.11, 95% confidence interval [CI] -0.19 to -0.03). A greater LVEF (MD 1.91, 95% CI 0.76 to 3) and a smaller LVESV (MD -6.19, 95% CI -8.7 to -3.6) were observed in manual TA group compared to control. Meta regressions including patients with left anterior descending artery (LAD) involvement showed an association between TA use and the reduction of both LVEDV and LVESV (z = -2.13, p = 0.03; z = -3.7, p < 0.01) and the improvement in myocardial salvage index (z = 2.04, p = 0.04). CONCLUSION TA is associated with improved LV function. TA technique, total ischemic time and LAD involvement appears to influence TA benefit on post-infarction LV remodeling.
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Affiliation(s)
- Emiliano Bianchini
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Marco Lombardi
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Angela Buonpane
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Alfredo Ricchiuto
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Alessandro Maino
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Renzo Laborante
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Gianluca Anastasia
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Genoa, Italy; Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Domenico D'Amario
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy; Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Cristina Aurigemma
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | | | - Carlo Trani
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Genoa, Italy; Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy.
| | - Rocco Vergallo
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Genoa, Italy; Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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Mathews SJ, Parikh SA, Wu W, Metzger DC, Chambers JW, Ghali MG, Sumners MJ, Kolski BC, Pinto DS, Dohad S. Sustained Mechanical Aspiration Thrombectomy for High Thrombus Burden Coronary Vessel Occlusion: The Multicenter CHEETAH Study. Circ Cardiovasc Interv 2023; 16:e012433. [PMID: 36802804 PMCID: PMC9944712 DOI: 10.1161/circinterventions.122.012433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Poor myocardial reperfusion due to distal embolization and microvascular obstruction after percutaneous coronary intervention is associated with increased risk of morbidity and mortality. Prior trials have not shown a clear benefit of routine manual aspiration thrombectomy. Sustained mechanical aspiration may mitigate this risk and improve outcomes. The objective of this study is to evaluate sustained mechanical aspiration thrombectomy before percutaneous coronary intervention in high thrombus burden acute coronary syndrome patients. METHODS This prospective study evaluated the Indigo CAT RX Aspiration System (Penumbra Inc, Alameda CA) for sustained mechanical aspiration thrombectomy before percutaneous coronary intervention at 25 hospitals across the USA. Adults presenting within 12 hours of symptom onset with high thrombus burden and target lesion(s) located in a native coronary artery were eligible. The primary end point was a composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or new or worsening New York Heart Association class IV heart failure within 30 days. Secondary end points included Thrombolysis in Myocardial Infarction thrombus grade, Thrombolysis in Myocardial Infarction flow, myocardial blush grade, stroke, and device-related serious adverse events. RESULTS From August 2019 through December 2020, a total of 400 patients were enrolled (mean age 60.4 years, 76.25% male). The primary composite end point rate was 3.60% (14/389 [95% CI, 2.0-6.0%]). Rate of stroke within 30 days was 0.77%. Final rates of Thrombolysis in Myocardial Infarction thrombus grade 0, Thrombolysis in Myocardial Infarction flow 3, and myocardial blush grade 3 were 99.50%, 97.50%, and 99.75%, respectively. No device-related serious adverse events occurred. CONCLUSIONS Sustained mechanical aspiration before percutaneous coronary intervention in high thrombus burden acute coronary syndrome patients was safe and was associated with high rates of thrombus removal, flow restoration, and normal myocardial perfusion on final angiography.
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Affiliation(s)
- S. Jay Mathews
- Bradenton Cardiology Center, Manatee Memorial Hospital, FL (S.J.M.)
| | - Sahil A. Parikh
- Columbia University Irving Medical Center, New York, NY (S.A.P.)
| | - Willis Wu
- North Carolina Heart and Vascular Research, Raleigh (W.W.)
| | | | | | | | | | | | - Duane S. Pinto
- Beth Israel Deaconess Medical Center, Boston, MA (D.S.P.)
| | - Suhail Dohad
- Cedars-Sinai Medical Center, Los Angeles, CA (S.D.)
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Mathews SJ, Brown CL, Kolski BC, Marques VM, Huynh A, Dohad SY, George JC. Initial experience with a continuous mechanical aspiration system for thrombus removal before percutaneous coronary intervention. Catheter Cardiovasc Interv 2022; 100:950-954. [PMID: 36183400 DOI: 10.1002/ccd.30389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/22/2022] [Accepted: 08/18/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Here we investigate the safety and efficacy of a continuous mechanical aspiration system when used before percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). BACKGROUND Historically, trials of routine manual aspiration thrombectomy in ACS patients have reported mixed results. This may be due to the technical limitations of manual aspiration, which suffers from decreasing vacuum power as aspiration is performed. METHODS This is a retrospective case series of all patients treated with continuous mechanical aspiration (Indigo CAT RX Aspiration System; Penumbra Inc.) before PCI between August 2017 and July 2020 at five centers in the United States. Data regarding angiographic assessments, procedure, and safety were examined. RESULTS Seventy-two patients (mean age 60 ± 12.5 years, 34.7% female) with ST Elevation Myocardial Infarction (STEMI) (80.6%) or Non-ST Elevation Myocardial Infarction (NSTEMI) (19.4%) were included. Target vessels were the right coronary (43.1%), left anterior descending (33.3%), and left circumflex (23.6%). Preprocedure, 94.4% had a high thrombus burden (thrombolysis in myocardial infarction [TIMI] thrombus grade ≥ 3). Median aspiration time was 35 s and median access-to-reperfusion time was 10 min. After CAT RX alone, 86.1% had complete perfusion (TIMI flow grade 3). After the procedure, 94.4% had TIMI thrombus grade <3% and 97.2% had TIMI flow grade 3. There were no cases of ischemic stroke. Cardiovascular mortality at 30 days was 1.4%. CONCLUSIONS In our initial experience, aspirating thrombus from ACS patients using the Indigo CAT RX Aspiration System before PCI was safe and effective for reducing thrombus burden and restoring flow.
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Affiliation(s)
- S Jay Mathews
- Bradenton Cardiology Center, Manatee Memorial Hospital, Bradenton, Florida, USA
| | - Christopher L Brown
- Interventional Cardiology, Scripps Memorial La Jolla, San Diego, California, USA
| | - Brian C Kolski
- Division of Cardiology, Providence St. Joseph Hospital, Orange, California, USA
| | - Vasco M Marques
- Department of Cardiology, Florida Hospital, Tampa, Florida, USA
| | - Andrew Huynh
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Texas Health Science Center at Houston/Memorial Hermann Hospital-Texas Medical Center, Houston, Texas, USA
| | - Suhail Y Dohad
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jon C George
- Division of Interventional Cardiology, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Abstract
Mechanical stress from haemodynamic perturbations or interventional manipulation of epicardial coronary atherosclerotic plaques with inflammatory destabilization can release particulate debris, thrombotic material and soluble substances into the coronary circulation. The physical material obstructs the coronary microcirculation, whereas the soluble substances induce endothelial dysfunction and facilitate vasoconstriction. Coronary microvascular obstruction and dysfunction result in patchy microinfarcts accompanied by an inflammatory reaction, both of which contribute to progressive myocardial contractile dysfunction. In clinical studies, the benefit of protection devices to retrieve atherothrombotic debris during percutaneous coronary interventions has been modest, and the treatment of microembolization has mostly relied on antiplatelet and vasodilator agents. The past 25 years have witnessed a relative proportional increase in non-ST-segment elevation myocardial infarction in the presentation of acute coronary syndromes. An associated increase in the incidence of plaque erosion rather than rupture has also been recognized as a key mechanism in the past decade. We propose that coronary microembolization is a decisive link between plaque erosion at the culprit lesion and the manifestation of non-ST-segment elevation myocardial infarction. In this Review, we characterize the features and mechanisms of coronary microembolization and discuss the clinical trials of drugs and devices for prevention and treatment.
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Affiliation(s)
- Petra Kleinbongard
- grid.5718.b0000 0001 2187 5445Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
| | - Gerd Heusch
- grid.5718.b0000 0001 2187 5445Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
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Taglieri N, Bacchi Reggiani ML, Ghetti G, Saia F, Compagnone M, Lanati G, Di Dio MT, Bruno A, Bruno M, Della Riva D, Corsini A, Narducci R, Rapezzi C. Efficacy and safety of thrombus aspiration in ST-segment elevation myocardial infarction: an updated systematic review and meta-analysis of randomised clinical trials. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:24-38. [PMID: 30160519 DOI: 10.1177/2048872618795512] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND: The role of thrombus aspiration plus primary percutaneous coronary intervention in ST-segment elevation myocardial infarction remains controversial. METHODS: We performed a meta-analysis of 25 randomised controlled trials in which 21,740 ST-segment elevation myocardial infarction patients were randomly assigned to thrombus aspiration plus primary percutaneous coronary intervention or primary percutaneous coronary intervention. Study endpoints were: death, myocardial infarction, stent thrombosis and stroke. RESULTS: On pooled analysis, the risk of death (4.3% vs. 4.8%, odds ratio (OR) 0.90, 95% confidence interval (CI) 0.79-1.03; P=0.123), myocardial infarction (2.4% vs. 2.5%, OR 0.95, 95% CI 0.80-1.13; P=0.57) and stent thrombosis (1.3% vs. 1.6%, OR 0.80, 95% CI 0.63-1.01; P=0.066) was similar between thrombus aspiration plus primary percutaneous coronary intervention and primary percutaneous coronary intervention. The risk of stroke was higher in the thrombus aspiration plus primary percutaneous coronary intervention than the primary percutaneous coronary intervention group (0.84% vs. 0.59%, OR 1.401, 95% CI 1.004-1.954; P=0.047). However, on sensitivity analysis after removing the TOTAL trial, thrombus aspiration plus primary percutaneous coronary intervention was not associated with an increased risk of stroke (OR 1.01, 95% CI 0.58-1.78). The weak association between thrombus aspiration and stroke was also confirmed by the fact that the lower bound of the 95% CI was slightly below unity after removing either the study by Kaltoft or the ITTI trial. There was no interaction between the main study results and follow-up, evidence of coronary thrombus, or study sample size. CONCLUSIONS: In patients with ST-segment elevation myocardial infarction, thrombus aspiration plus primary percutaneous coronary intervention does not reduce the risk of death, myocardial infarction or stent thrombosis. Thrombus aspiration plus primary percutaneous coronary intervention is associated with an increased risk of stroke; however, this latter finding appears weak.
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Affiliation(s)
- Nevio Taglieri
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Maria Letizia Bacchi Reggiani
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Gabriele Ghetti
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Francesco Saia
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Miriam Compagnone
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Gianluca Lanati
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Maria Teresa Di Dio
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Antonio Bruno
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Matteo Bruno
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Diego Della Riva
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Anna Corsini
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Riccardo Narducci
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
| | - Claudio Rapezzi
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Alma Mater Studiorum Università di Bologna, Italy
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Heusch G, Gersh BJ. The pathophysiology of acute myocardial infarction and strategies of protection beyond reperfusion: a continual challenge. Eur Heart J 2018; 38:774-784. [PMID: 27354052 DOI: 10.1093/eurheartj/ehw224] [Citation(s) in RCA: 273] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/12/2016] [Indexed: 12/15/2022] Open
Abstract
The incidence of ST segment elevation myocardial infarction (STEMI) has decreased over the last two decades in developed countries, but mortality from STEMI despite widespread access to reperfusion therapy is still substantial as is the development of heart failure, particularly among an expanding older population. In developing countries, the incidence of STEMI is increasing and interventional reperfusion is often not available. We here review the pathophysiology of acute myocardial infarction and reperfusion, notably the temporal and spatial evolution of ischaemic and reperfusion injury, the different modes of cell death, and the resulting coronary microvascular dysfunction. We then go on to briefly characterize the cardioprotective phenomena of ischaemic preconditioning, ischaemic postconditioning, and remote ischaemic conditioning and their underlying signal transduction pathways. We discuss in detail the attempts to translate conditioning strategies and drug therapy into the clinical setting. Most attempts have failed so far to reduce infarct size and improve clinical outcomes in STEMI patients, and we discuss potential reasons for such failure. Currently, it appears that remote ischaemic conditioning and a few drugs (atrial natriuretic peptide, exenatide, metoprolol, and esmolol) reduce infarct size, but studies with clinical outcome as primary endpoint are still underway.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Hufelandstr. 55, 45122 Essen, Germany
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN, USA
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Abstract
The atherosclerotic coronary vasculature is not only the culprit but also a victim of myocardial ischemia/reperfusion injury. Manifestations of such injury are increased vascular permeability and edema, endothelial dysfunction and impaired vasomotion, microembolization of atherothrombotic debris, stasis with intravascular cell aggregates, and finally, in its most severe form, capillary destruction with hemorrhage. In animal experiments, local and remote ischemic pre- and postconditioning not only reduce infarct size but also these manifestations of coronary vascular injury, as do drugs which recruit signal transduction steps of conditioning. Clinically, no-reflow is frequently seen after interventional reperfusion, and it carries an adverse prognosis. The translation of cardioprotective interventions to clinical practice has been difficult to date. Only 4 drugs (brain natriuretic peptide, exenatide, metoprolol, and esmolol) stand unchallenged to date in reducing infarct size in patients with reperfused acute myocardial infarction; unfortunately, for these drugs, no information on their impact on the ischemic/reperfused coronary circulation is available.
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Affiliation(s)
- Gerd Heusch
- From the Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Essen, Essen, Germany.
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Ghatak A, Singh V, Shantha GPS, Badheka A, Patel N, Alfonso CE, Biswas M, Pancholy SB, Grines C, O'Neill WW, de Marchena E, Cohen MG. Aspiration Thrombectomy in Patients Undergoing Primary Angioplasty for ST Elevation Myocardial Infarction: An Updated Meta-Analysis. J Interv Cardiol 2016; 28:503-13. [PMID: 26642999 DOI: 10.1111/joic.12249] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in patients with STEMI (TOTAL trial) refuted the salutary effect of routine aspiration thrombectomy (AT) in PPCI for patients with ST-elevation myocardial infarction (STEMI). OBJECTIVES We performed an updated meta-analysis to assess clinical outcomes with AT prior to PPCI compared with conventional PPCI alone including the additional trial data. METHODS AND RESULTS Clinical trials (n = 20) that randomized patients (n = 21,281) with STEMI between Routine AT (n = 10,619) and PPCI (n = 10,662) were pooled. There was no difference in all-cause mortality between the 2 groups (RR: 0.89, 95%CI: 0.78-1.01, P = 0.08). Stratifying by follow up at 1-month (RR: 0.87, 95%CI: 0.69-1.10, P = 0.25), up to 6 months (RR: 0.91, 95%CI: 0.74-1.13, P = 0.39 and beyond 6 months (RR: 0.88, 95%CI: 0.74-1.05, P = 0.16) yielded similar results. There was a statistically significant increase risk of stoke rate in the AT arm (RR: 1.51, 95%CI: 1.01-2.25, P = 0.04). The 2 groups were similar with regards to target vessel revascularization (0.94, 95%CI: 0.83-1.06, P = 0.28) recurrent MI (RR: 0.96, 95%CI: 0.80-1.16, P = 0.68, MACE events (RR: 0.91 95%CI: 0.81-1.02, P = 0.11), early (0.59, 95%CI: 0.23-1.50, P = 0.27) and late (RR: 0.91, 95%CI: 0.69-1.18, P = 0.47) stent thrombosis and net clinical benefit (RR 0.99, 95%CI: 0.91-1.07, P = 0.76). CONCLUSION Routine AT prior to PPCI in STEMI is associated with higher risk of stroke. There is no statistical difference in clinical outcome parameters of mortality, major adverse cardiac events, target vessel revascularization, stent thrombosis, and net clinical benefit between AT and PCI alone.
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Affiliation(s)
- Abhijit Ghatak
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, Florida
| | - Vikas Singh
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, Florida
| | - Ghanshyam Palamaner Subash Shantha
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, and University of Iowa Hospitals and Clinics, Iowa City, Iowa.,The Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | | | - Nilesh Patel
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, Florida
| | - Carlos E Alfonso
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, Florida
| | - Monodeep Biswas
- The Wright Center for Graduate Medical Education, Scranton, Pennsylvania
| | | | | | | | - Eduardo de Marchena
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, Florida
| | - Mauricio G Cohen
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, Florida
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Elgendy IY, Huo T, Bhatt DL, Bavry AA. Is Aspiration Thrombectomy Beneficial in Patients Undergoing Primary Percutaneous Coronary Intervention? Meta-Analysis of Randomized Trials. Circ Cardiovasc Interv 2016; 8:e002258. [PMID: 26175531 DOI: 10.1161/circinterventions.114.002258] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND It is unclear whether intravenous glycoprotein IIb/IIIa inhibitors or ischemic time might modify any clinical benefits observed with aspiration thrombectomy before primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction. METHODS AND RESULTS Electronic databases were searched for trials that randomized ST-segment-elevation myocardial infarction patients to aspiration thrombectomy before PCI versus conventional PCI. Summary estimates were constructed using a DerSimonian-Laird model. Seventeen trials with 20 960 patients were available for analysis. When compared with conventional PCI, aspiration thrombectomy was not associated with a significant reduction in the risk of mortality 2.8% versus 3.2% (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.76-1.04; P=0.13), reinfarction 1.3% versus 1.4% (RR, 0.93; 95% CI, 0.73-1.17; P=0.52), the combined outcome of mortality or reinfarction 4.1% versus 4.6% (RR, 0.90; 95% CI, 0.79-1.02; P=0.11), or stent thrombosis 0.9% versus 1.2% (RR, 0.82; 95% CI, 0.62-1.08; P=0.15). Aspiration thrombectomy was associated with a nonsignificant increase in the risk of stroke 0.6% versus 0.4% (RR, 1.45; 95% CI, 0.96-2.21; P=0.08). Meta-regression analysis did not identify a difference for the log RR of mortality, reinfarction, and the combined outcome of mortality or reinfarction with intravenous glycoprotein IIb/IIIa inhibitors (P=0.17, 0.70, and 0.50, respectively) or with ischemic time (P=0.29, 0.66, and 0.58, respectively). CONCLUSIONS Aspiration thrombectomy before primary PCI is not associated with any benefit on clinical end points and might increase the risk of stroke. Concomitant administration of intravenous glycoprotein IIb/IIIa inhibitors and ischemic time did not seem to influence any potential benefits observed with aspiration thrombectomy.
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Affiliation(s)
- Islam Y Elgendy
- From the Department of Medicine, University of Florida, Gainesville (I.Y.E., T.H., A.A.B.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Medicine Service, North Florida/South Georgia Veterans Health System, Gainesville (A.A.B.)
| | - Tianyao Huo
- From the Department of Medicine, University of Florida, Gainesville (I.Y.E., T.H., A.A.B.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Medicine Service, North Florida/South Georgia Veterans Health System, Gainesville (A.A.B.)
| | - Deepak L Bhatt
- From the Department of Medicine, University of Florida, Gainesville (I.Y.E., T.H., A.A.B.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Medicine Service, North Florida/South Georgia Veterans Health System, Gainesville (A.A.B.)
| | - Anthony A Bavry
- From the Department of Medicine, University of Florida, Gainesville (I.Y.E., T.H., A.A.B.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Medicine Service, North Florida/South Georgia Veterans Health System, Gainesville (A.A.B.).
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Stiermaier T, de Waha S, Fürnau G, Eitel I, Thiele H, Desch S. Thrombusaspiration bei Patienten mit akutem Myokardinfarkt. Herz 2016; 41:591-598. [DOI: 10.1007/s00059-016-4412-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 01/24/2016] [Indexed: 10/22/2022]
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12
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Impact of routine manual aspiration thrombectomy on outcomes of patients undergoing primary percutaneous coronary intervention for acute myocardial infarction: A meta-analysis. Int J Cardiol 2016; 204:189-95. [DOI: 10.1016/j.ijcard.2015.11.135] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 11/17/2015] [Accepted: 11/22/2015] [Indexed: 11/17/2022]
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Manual Thrombus Aspiration Is Not Associated With Reduced Mortality in Patients Treated With Primary Percutaneous Coronary Intervention: An Observational Study of 10,929 Patients With ST-Segment Elevation Myocardial Infarction From the London Heart Attack Group. JACC Cardiovasc Interv 2016; 8:575-84. [PMID: 25907084 DOI: 10.1016/j.jcin.2014.11.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/07/2014] [Accepted: 11/20/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVES This study aimed to assess the impact of thrombus aspiration on mortality in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI). BACKGROUND The clinical effect of routine intracoronary thrombus aspiration before primary PCI in patients with ST-segment elevation myocardial infarction is uncertain. METHODS We undertook an observational cohort study of 10,929 ST-segment elevation myocardial infarction patients from January 2005 to July 2011 at 8 centers across London, United Kingdom. Patients' details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society PCI dataset. Primary outcome was all-cause mortality at a median follow-up of 3.0 years (interquartile range: 1.2 to 4.6 years). RESULTS In our cohort, 3,572 patients (32.7%) underwent thrombus aspiration during primary PCI. Patients who had thrombus aspiration were younger, had lower rates of previous myocardial infarction but were more likely to have poor left ventricular function. Procedural success rates were higher (90.9% vs. 89.2%; p=0.005) and in-hospital major adverse cardiac event rates were lower (4.4% vs. 5.5%; p=0.012) in patients undergoing thrombus aspiration. However, Kaplan-Meier analysis demonstrated no significant difference in mortality rates between patients with and without thrombus aspiration (14.8% aspiration vs. 15.3% PCI only; p=0.737) during the follow-up period. After multivariate Cox analysis (hazard ratio [HR]: 0.89, 95% confidence interval [CI]: 0.65 to 1.23) and the addition of propensity matching (HR: 0.85 95% CI: 0.60 to 1.20) thrombus aspiration was still not associated with decreased mortality. CONCLUSIONS In this cohort of nearly 11,000 patients, routine thrombus aspiration was not associated with a reduction in long-term mortality in patients undergoing primary PCI, although procedural success and in-hospital major adverse cardiac event rates were improved.
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Thrombus aspiration in acute myocardial infarction: concepts, clinical trials, and current guidelines. Coron Artery Dis 2016; 27:233-43. [PMID: 26751424 DOI: 10.1097/mca.0000000000000335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The pathogenesis that underlies acute myocardial infarction is complex and multifactorial. One of the most important components, however, is the role of thrombus formation following atherosclerotic plaque rupture, leading to sudden coronary occlusion and subsequent ischemia and infarction. Thrombus aspiration provides the opportunity of intracoronary clot extraction with the aim to improve coronary and myocardial perfusion, by reducing the risk of no-reflow secondary to distal embolization of thrombus. The utility of thrombus aspiration during primary percutaneous coronary intervention has been assessed in an increasing number of observational and randomized studies. This article reviews the contemporary data and provides insights into the validity of thrombus aspiration in the setting of acute myocardial infarction.
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Jolly SS, Cairns JA, Yusuf S, Rokoss MJ, Gao P, Meeks B, Kedev S, Stankovic G, Moreno R, Gershlick A, Chowdhary S, Lavi S, Niemela K, Bernat I, Cantor WJ, Cheema AN, Steg PG, Welsh RC, Sheth T, Bertrand OF, Avezum A, Bhindi R, Natarajan MK, Horak D, Leung RCM, Kassam S, Rao SV, El-Omar M, Mehta SR, Velianou JL, Pancholy S, Džavík V. Outcomes after thrombus aspiration for ST elevation myocardial infarction: 1-year follow-up of the prospective randomised TOTAL trial. Lancet 2016; 387:127-35. [PMID: 26474811 PMCID: PMC5007127 DOI: 10.1016/s0140-6736(15)00448-1] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Two large trials have reported contradictory results at 1 year after thrombus aspiration in ST elevation myocardial infarction (STEMI). In a 1-year follow-up of the largest randomised trial of thrombus aspiration, we aimed to clarify the longer-term benefits, to help guide clinical practice. METHODS The trial of routine aspiration ThrOmbecTomy with PCI versus PCI ALone in Patients with STEMI (TOTAL) was a prospective, randomised, investigator-initiated trial of routine manual thrombectomy versus percutaneous coronary intervention (PCI) alone in 10,732 patients with STEMI. Eligible adult patients (aged ≥18 years) from 87 hospitals in 20 countries were enrolled and randomly assigned (1:1) within 12 h of symptom onset to receive routine manual thrombectomy with PCI or PCI alone. Permuted block randomisation (with variable block size) was done by a 24 h computerised central system, and was stratified by centre. Participants and investigators were not masked to treatment assignment. The trial did not show a difference at 180 days in the primary outcome of cardiovascular death, myocardial infarction, cardiogenic shock, or heart failure. However, the results showed improvements in the surrogate outcomes of ST segment resolution and distal embolisation, but whether or not this finding would translate into a longer term benefit remained unclear. In this longer-term follow-up of the TOTAL study, we report the results on the primary outcome (cardiovascular death, myocardial infarction, cardiogenic shock, or heart failure) and secondary outcomes at 1 year. Analyses of the primary outcome were by modified intention to treat and only included patients who underwent index PCI. This trial is registered with ClinicalTrials.gov, number NCT01149044. FINDINGS Between Aug 5, 2010, and July 25, 2014, 10,732 eligible patients were enrolled and randomly assigned to thrombectomy followed by PCI (n=5372) or to PCI alone (n=5360). After exclusions of patients who did not undergo PCI in each group (337 in the PCI and thrombectomy group and 331 in the PCI alone group), the final study population comprised 10,064 patients (5035 thrombectomy and 5029 PCI alone). The primary outcome at 1 year occurred in 395 (8%) of 5035 patients in the thrombectomy group compared with 394 (8%) of 5029 in the PCI alone group (hazard ratio [HR] 1·00 [95% CI 0·87-1·15], p=0·99). Cardiovascular death within 1 year occurred in 179 (4%) of the thrombectomy group and in 192 (4%) of 5029 in the PCI alone group (HR 0·93 [95% CI 0·76-1·14], p=0·48). The key safety outcome, stroke within 1 year, occurred in 60 patients (1·2%) in the thrombectomy group compared with 36 (0·7%) in the PCI alone group (HR 1·66 [95% CI 1·10-2·51], p=0·015). INTERPRETATION Routine thrombus aspiration during PCI for STEMI did not reduce longer-term clinical outcomes and might be associated with an increase in stroke. As a result, thrombus aspiration can no longer be recommended as a routine strategy in STEMI. FUNDING Canadian Institutes of Health Research, Canadian Network and Centre for Trials Internationally, and Medtronic Inc.
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Affiliation(s)
- Sanjit S Jolly
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada.
| | - John A Cairns
- University of British Columbia, Vancouver, BC, Canada
| | - Salim Yusuf
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Michael J Rokoss
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Peggy Gao
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Brandi Meeks
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sasko Kedev
- University Clinic of Cardiology, Sts. Cyril and Methodius University, Skopje, Macedonia
| | - Goran Stankovic
- Clinical Center of Serbia and Department of Cardiology, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | | | - Anthony Gershlick
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS Trust, Glenfield Hospital, Leicester, UK
| | - Saqib Chowdhary
- University Hospitals South Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Shahar Lavi
- London Health Sciences Centre, Department of Medicine, London, ON, Canada
| | - Kari Niemela
- Heart Center, Tampere University Hospital, Tampere, Finland
| | - Ivo Bernat
- University Hospital and Faculty of Medicine Pilsen, Pilsen, Czech Republic
| | | | | | - Philippe Gabriel Steg
- Université Paris-Diderot, Sorbonne Paris-Cité, INSERM Unité 1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, Department of Medicine, Edmonton, AB, Canada
| | - Tej Sheth
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology, University of Santo Amaro, Sao Paulo, Brazil
| | | | - Madhu K Natarajan
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - David Horak
- Krajská Nemocnice Liberec, Liberec, Czech Republic
| | | | | | - Sunil V Rao
- Duke Clinical Research Institute, Durham, NC, USA
| | - Magdi El-Omar
- Central Manchester Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Shamir R Mehta
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - James L Velianou
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
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The Oculothrombotic Reflex. JACC Cardiovasc Interv 2016; 9:123-5. [DOI: 10.1016/j.jcin.2015.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 10/28/2015] [Accepted: 10/28/2015] [Indexed: 11/22/2022]
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Trombectomía por aspiración para el tratamiento del infarto agudo de miocardio con elevación del segmento ST: un metanálisis de 26 ensayos aleatorizados con 11.943 pacientes. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2015.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Briasoulis A, Palla M, Afonso L. Clinical Outcomes of Manual Aspiration Thrombectomy in Patients with Acute Myocardial Infarction: An Updated Meta-Analysis. Cardiology 2015; 132:124-130. [DOI: 10.1159/000433418] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/19/2015] [Indexed: 11/19/2022]
Abstract
Background: Recent trials on manual aspiration thrombectomy (AT) in patients with ST-elevation myocardial infarction did not show any significant benefits of AT. Aims: The present meta-analysis was designed to systematically evaluate prospective randomized trials and assess the effects of AT on all-cause mortality, major cardiovascular events (MACE), target vessel revascularization, myocardial reinfarction, stroke and surrogate myocardial perfusion markers. Methods and Results: We conducted an EMBASE and MEDLINE search for studies in which patients were randomized to treatment with AT plus primary percutaneous coronary intervention (PCI) versus PCI. We identified 16 prospective randomized trials which enrolled 10,437 controls that underwent conventional PCI and 10,385 patients who underwent PCI with AT with an average follow-up duration of 5.8 months. A significant reduction in MACE with AT was noted (OR 0.91; 95% CI 0.82-0.99; p = 0.04). In spite of improved TIMI 3 and myocardial blush grade 3 rates, AT did not significantly reduce all-cause mortality, target-vessel revascularization and myocardial infarction. Stroke rates were increased with AT. Conclusion: The results of this large meta-analysis of 20,822 patients suggest that adjunctive AT to PCI may be associated with improved myocardial reperfusion but limited benefits related to the clinical end-points.
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Spitzer E, Heg D, Stefanini GG, Stortecky S, Rutjes AWS, Räber L, Blöchlinger S, Pilgrim T, Jüni P, Windecker S. Aspiration Thrombectomy for Treatment of ST-segment Elevation Myocardial Infarction: a Meta-analysis of 26 Randomized Trials in 11,943 Patients. ACTA ACUST UNITED AC 2015; 68:746-52. [PMID: 25979551 DOI: 10.1016/j.rec.2015.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 01/27/2015] [Indexed: 12/15/2022]
Abstract
INTRODUCTION AND OBJECTIVES There is continued debate about the routine use of aspiration thrombectomy in patients with ST-segment elevation myocardial infarction. Our aim was to evaluate clinical and procedural outcomes of aspiration thrombectomy-assisted primary percutaneous coronary intervention compared with conventional primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction. METHODS We performed a meta-analysis of 26 randomized controlled trials with a total of 11 943 patients. Clinical outcomes were extracted up to maximum follow-up and random effect models were used to assess differences in outcomes. RESULTS We observed no difference in the risk of all-cause death (pooled risk ratio = 0.88; 95% confidence interval, 0.74-1.04; P = .124), reinfarction (pooled risk ratio = 0.85; 95% confidence interval, 0.67-1.08; P = .176), target vessel revascularization (pooled risk ratio = 0.86; 95% confidence interval, 0.73-1.00; P = .052), or definite stent thrombosis (pooled risk ratio = 0.76; 95% confidence interval, 0.49-1.16; P = .202) between the 2 groups at a mean weighted follow-up time of 10.4 months. There were significant reductions in failure to reach Thrombolysis In Myocardial Infarction 3 flow (pooled risk ratio = 0.70; 95% confidence interval, 0.60-0.81; P < .001) or myocardial blush grade 3 (pooled risk ratio = 0.76; 95% confidence interval, 0.65-0.89; P = .001), incomplete ST-segment resolution (pooled risk ratio = 0.72; 95% confidence interval, 0.62-0.84; P < .001), and evidence of distal embolization (pooled risk ratio = 0.61; 95% confidence interval, 0.46-0.81; P = .001) with aspiration thrombectomy but estimates were heterogeneous between trials. CONCLUSIONS Among unselected patients with ST-segment elevation myocardial infarction, aspiration thrombectomy-assisted primary percutaneous coronary intervention does not improve clinical outcomes, despite improved epicardial and myocardial parameters of reperfusion.
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Affiliation(s)
- Ernest Spitzer
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Dik Heg
- Clinical Trials Unit, University of Bern, Bern, Switzerland; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Anne W S Rutjes
- Clinical Trials Unit, University of Bern, Bern, Switzerland; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | | | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Peter Jüni
- Clinical Trials Unit, University of Bern, Bern, Switzerland; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland.
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Tanboğa İH, Topçu S, Aksakal E, Kurt M, Kaya A, Oduncu V, Sevimli S. Thrombus aspiration in patients with ST elevation myocardial infarction: meta-analysis of 16 randomized trials. Anatol J Cardiol 2015; 15:175-87. [PMID: 25880174 PMCID: PMC5337052 DOI: 10.5152/akd.2015.6114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2015] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE The mortality rate is high in some patients undergoing primary percutaneous coronary intervention (PPCI) because of ineffective epicardial and myocardial perfusion. The use of thrombus aspiration (TA) might be beneficial in this group but there is contradictory evidence in current trials. Therefore, using PRISMA statement, we performed a meta-analysis that compares PPCI+TA with PPCI alone. METHODS Sixteen studies in which PPCI (n=5262) versus PPCI+TA (n=5256) were performed, were included in this meta-analysis. We calculated the risk ratio (RR) for epicardial and myocardial perfusion, such as the Thrombolysis In myocardial Infarction (TIMI) flow, myocardial blush grade (MBG) and stent thrombosis (ST) resolution (STR), and clinical outcomes, such as all-cause death, recurrent infarction (Re-MI), target vessel revascularization/target lesion revascularization (TVR/TLR), stent thrombosis (ST), and stroke. RESULTS Postprocedural TIMI-III flow frequency, postprocedural MBG II-III flow frequency, and postprocedural STR were significantly high in TA+PPCI compared with the PPCI alone group. However, neither all-cause mortality [6.6% vs. 7.4%, RR=0.903, 95% confidence interval (CI): 0.785-1.038, p=0.149] nor Re-MI (2.3% vs. 2.6%, RR=0.884, 95% CI: 0.693-1.127, p=0.319), TVR/TLR (8.2% vs. 8.0%, RR=1.028, 95% CI: 0.900-1.174, p=0.687), ST (0.93% vs. 0.90%, RR=1.029, 95% CI: 0.668-1.583, p=0.898), and stroke (0.5% vs. 0.5%, RR=1.073, 95% CI: 0.588-1.959, p=0.819) rates were comparable between the groups. CONCLUSION This meta-analysis is the first updated analysis after publishing the 1-year result of the "Thrombus Aspiration during ST-Segment Elevation Myocardial Infarction" trial, and it showed that TA did not reduce the rate of all-cause mortality, Re-MI, TVR/TLR, ST, and stroke.
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Adjunctive manual thrombus aspiration during ST-segment elevation myocardial infarction: a meta-analysis of randomized controlled trials. PLoS One 2014; 9:e113481. [PMID: 25405874 PMCID: PMC4236171 DOI: 10.1371/journal.pone.0113481] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 10/25/2014] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The aim of this study was to synthesize evidence by examining the effects of manual thrombus aspiration on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS A total of 26 randomized controlled trials (RCTs), enrolling 11,780 patients, with 5,869 patients randomized to manual thrombus aspiration and 5,911 patients randomized to conventional percutaneous coronary intervention (PCI), were included in the meta-analysis. Separate clinical outcome analyses were based on different follow-up periods. There were no statistically reductions in the incidences of mortality (risk ratio [RR], 0.86 [95% confidence interval [CI]: 0.73 to 1.02]), reinfarction (RR, 0.62 [CI, 0.31 to 1.32]) or target vessel revascularization (RR, 0.89 [CI, 0.75 to 1.05]) in the manual thrombus aspiration arm at 12 to 24 months of follow-up. The composite major adverse cardiac events (MACEs) outcomes were significantly lower in the manual thrombus aspiration arm over the long-term follow-up (RR, 0.76 [CI, 0.63 to 0.91]). A lower incidence of reinfarction was observed in the hospital to 30 days (RR, 0.59 [CI, 0.37 to 0.92]). CONCLUSION The present meta-analysis suggested that there was no evidence that using manual thrombus aspiration in patients with STEMI could provide distinct benefits in long-term clinical outcomes.
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Kumbhani DJ, Bavry AA, Desai MY, Bangalore S, Byrne RA, Jneid H, Bhatt DL. Aspiration thrombectomy in patients undergoing primary angioplasty: totality of data to 2013. Catheter Cardiovasc Interv 2014; 84:973-7. [PMID: 24782350 DOI: 10.1002/ccd.25532] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/11/2014] [Accepted: 04/27/2014] [Indexed: 01/28/2023]
Abstract
OBJECTIVES We sought to update our meta-analysis on clinical outcomes with aspiration thrombectomy prior to primary percutaneous coronary intervention (PPCI) compared with conventional PPCI alone due to the availability of additional trial data. BACKGROUND The clinical efficacy of adjunctive aspiration thrombectomy in ST-elevation myocardial infarction (STEMI) patients undergoing PPCI remains controversial. A recent large-scale randomized trial showed no benefit in terms of mortality at 30 days. METHODS Clinical trials that randomized STEMI patients to aspiration thrombectomy prior to PPCI compared with conventional PPCI alone were included. RESULTS A total of 11,321 patients from 20 randomized controlled trials were included. The composite major adverse cardiac event (MACE) endpoint was lower in the aspiration thrombectomy arm compared with conventional PPCI alone (risk ratio [RR] = 0.81, 95% CI 0.70-0.94; P = 0.006). Although all-cause mortality was similar between the adjunctive aspiration thrombectomy arm and PPCI arms (RR = 0.83, 95% CI 0.67-1.01; P = 0.06), late mortality (6-12 months) was significantly reduced (RR = 0.64; 95% CI 0.44-0.92; P = 0.016). Reinfarction (RR = 0.64, 95% CI 0.44-0.92; P = 0.017) and stent thrombosis (RR = 0.54; 95% CI 0.32-0.91; P = 0.021) were similarly lower. Differences in target vessel revascularization were of borderline significance (RR = 0.83, 95% CI 0.68-1.01; P = 0.06). CONCLUSIONS Our meta-analysis including all randomized controlled trials on aspiration thrombectomy to date demonstrates a significant reduction in adverse clinical outcomes including stent thrombosis compared with conventional PCI alone.
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Affiliation(s)
- Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
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23
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Angiographic and Clinical Impact of Successful Manual Thrombus Aspiration in Diabetic Patients Undergoing Primary PCI. Int J Vasc Med 2014; 2014:263926. [PMID: 24804102 PMCID: PMC3996962 DOI: 10.1155/2014/263926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 03/04/2014] [Indexed: 01/14/2023] Open
Abstract
Background. Diabetes mellitus is associated with worse angiographic and clinical outcomes after percutaneous coronary intervention (PCI). Aim. To investigate the impact of manual thrombus aspiration on in-stent restenosis (ISR) and clinical outcome in patients treated by bare-metal stent (BMS) implantation for ST-segment elevation myocardial infarction (STEMI). Methods. 100 diabetic patients were prospectively enrolled. They were randomly assigned to undergo either standard primary PCI (group A, 50 patients) or PCI with thrombus aspiration using Export catheter (group B, 50 patients). The primary endpoint was the rate of eight-month ISR. The secondary endpoint included follow-up for major adverse cardiac events (MACE). Results. Mean age of the study cohort was 59.86 ± 8.3 years, with 64 (64%) being males. Baseline characteristics did not differ between both groups. Eight-month angiogram showed that group B patients had significantly less late lumen loss (0.17 ± 0.35 versus 0.60 ± 0.42 mm, P < 0.001), with lower incidence of ISR (4% versus 16.6%, P < 0.001). There was a trend towards lower rate of MACE in the same group of patients. Conclusion. In diabetic patients undergoing primary PCI, manual thrombus aspiration (compared with standard PCI) was associated with better ISR rate after BMS implantation.
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Rathod KS, Hamshere SM, Choudhury TR, Jones DA, Mathur A. Use of Thrombectomy Devices in Primary Percutaneous Interventions for ST-elevation Myocardial Infarction - An Update. Interv Cardiol 2014; 9:102-107. [PMID: 29588786 DOI: 10.15420/icr.2011.9.2.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion modality in patients with ST-elevation myocardial infarction (STEMI). While PPCI is highly effective in achieving epicardial coronary reperfusion, a significant proportion of patients fail to achieve adequate myocardial reperfusion. This is in part due to the distal microembolisation of thrombus and plaque debris during PCI. Recognition of this has led to the development of a number of devices with different mechanisms of action that aim to reduce such distal embolisation and therefore improve end myocardial perfusion. Study results of thrombectomy devices however have been largely inconsistent, especially about clinical outcome data, and several meta-analyses have been carried out as a result. This review aims to critically analyse the literature data on thrombectomy during PPCI, taking into account the most recent studies and the latest meta-analyses looking to see whether thrombectomy use is associated with improved outcomes.
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Affiliation(s)
- Krishnaraj S Rathod
- Department of Cardiology, Barts Health NHS Trust.,Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University, London.,NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London
| | - Stephen M Hamshere
- Department of Cardiology, Barts Health NHS Trust.,NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London
| | - Tawfiq R Choudhury
- Department of Cardiology, Barts Health NHS Trust.,NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London
| | - Daniel A Jones
- Department of Cardiology, Barts Health NHS Trust.,Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University, London.,NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London
| | - Anthony Mathur
- Department of Cardiology, Barts Health NHS Trust.,Department of Clinical Pharmacology, William Harvey Research Institute, Queen Mary University, London.,NIHR Cardiovascular Biomedical Research Unit, London Chest Hospital, London
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Abstract
There is continued interest in the concept of limiting myocardial infarct size with adjunctive agents administered along with reperfusion injury; however, there remains considerable controversy in the literature. The purpose of this article is to review the medical literature on clinical trials performed during the past 3 years that have attempted to reduce myocardial infarct size by administration of adjunctive therapies along with reperfusion therapy. A PubMed-driven literature search revealed a host of clinical trials focusing on the following prominent types of therapies: endogenous conditioning (postconditioning and remote ischemic conditioning); rapid cooling; pharmacological therapy (cyclosporine, abciximab, clopidogrel, tirofiban, erythropoietin, thrombus aspiration, adenosine, glucose-insulin-potassium, statins, antidiabetic agents, FX06, iron chelation, and ranolazine). Although there remains some controversy, quite a few of these studies showed that adjunctive therapy further reduced myocardial infarct size when coupled with reperfusion. Antiplatelet agents are emerging as some of the newest agents that seem to have cardioprotective capabilities. Postconditioning has become a bit more controversial in the clinical literature; remote conditioning, early and rapid cooling, adenosine, and ranolazine are intriguing therapies deserving of larger studies. Certain agents and maneuvers, such as erythropoietin, protein kinase C δ inhibitors, iron chelation, and intra-aortic balloon counterpulsation, perhaps should be retired. The correct adjunctive therapy administered along with reperfusion has the capability of further reducing myocardial injury during ST-segment-elevation myocardial infarction.
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Affiliation(s)
- Robert A Kloner
- Division of Cardiovascular Medicine, Department of Medicine, Heart Institute, Good Samaritan Hospital, Los Angeles, CA 90017, USA.
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Role of Aspiration and Mechanical Thrombectomy in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty. J Am Coll Cardiol 2013; 62:1409-18. [DOI: 10.1016/j.jacc.2013.04.025] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 04/01/2013] [Accepted: 04/08/2013] [Indexed: 02/06/2023]
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Gollop ND, Murray PJ. Should the practicing interventionalist use manual aspiration systematically in all patients or only in selected patients with an angiographically obvious thrombotic burden? Interact Cardiovasc Thorac Surg 2013; 17:731-5. [PMID: 23825162 DOI: 10.1093/icvts/ivt295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A best-evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, should the practicing interventionalist use manual aspiration systematically in all patients undergoing percutaneous coronary intervention (PCI) or only in selected patients with an angiographically obvious thrombotic burden? Altogether, 198 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the evidence demonstrates that clinical and angiographic outcomes with respect to manual thrombectomy are similar and encouraging for patients with both angiographic evidence of thrombus burden and those in whom it is used routinely. In addition, there is no significant increase in major adverse cardiac events when routine use of manual aspiration is adopted as opposed to reserving its use for those patients with angiographic evidence of thrombus. In summary, the evidence supports the use of routine systematic manual aspiration in all patients undergoing primary PCI for ST-elevation myocardial infarction.
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Horne A, Chacko M. Thrombectomy Devices in Coronary Intervention. Interv Cardiol Clin 2013; 2:347-359. [PMID: 28582141 DOI: 10.1016/j.iccl.2012.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Primary percutaneous coronary intervention is the favored mode of reperfusion therapy for ST-elevation myocardial infarction (STEMI) when able to be performed in a timely fashion in appropriately selected patients. However, controversy about the role of coronary thrombectomy in the management of STEMI persists because of a paucity of favorable historical data. After the TAPAS trial thrombectomy has gained favor in recent years. The results of the TOTAL, TASTE, and SMART percutaneous coronary intervention trials will provide further insight into the use of thrombectomy in STEMI. This article examines the relevant trial evidence regarding how to best manage and apply thrombectomy in clinical practice.
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Affiliation(s)
- Aaron Horne
- Division of Cardiology, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Matthews Chacko
- Division of Cardiology, Johns Hopkins Hospital, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA.
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Costopoulos C, Gorog DA, Di Mario C, Kukreja N. Use of thrombectomy devices in primary percutaneous coronary intervention: A systematic review and meta-analysis. Int J Cardiol 2013; 163:229-241. [DOI: 10.1016/j.ijcard.2011.11.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 10/30/2011] [Accepted: 11/04/2011] [Indexed: 12/23/2022]
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Mehta S, Kostela JC, Oliveros E, Flores AI, Pena C, Cohen S, Rowen R, Treto K. Compulsive Thrombus Management in STEMI Interventions. Interv Cardiol Clin 2012; 1:485-505. [PMID: 28581966 DOI: 10.1016/j.iccl.2012.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Thrombus is a fundamental concept in the pathophysiology of ST-elevated myocardial infarction (STEMI). Distal embolization and no reflow are associated with less angiographic success, reduced myocardial blush, less ST resolution after primary percutaneous coronary intervention, larger enzymatic infarct size, lower left ventricular ejection fraction at discharge, and higher long-term mortality. We believe that with the use of thrombectomy devices, these shortcomings can be minimized. Based on our experience from the Single Individual Community Experience Registry (SINCERE) database, we formulated a selective thrombus burden management strategy (the Mehta classification) for thrombus management.
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Affiliation(s)
- Sameer Mehta
- Miller School of Medicine, University of Miami, 1400 Northwest 12th Avenue, Miami, FL 33136, USA; Mercy Medical Center, 3663 South Miami Avenue, FL 33133, USA; Lumen Foundation, 55 Pinta Road, Miami, FL 33133, USA.
| | - Jennifer C Kostela
- Internal Medicine, New York Hospital Queens, 56-45 Main Street, Flushing, NY 11355, USA; Ross University School of Medicine, 630 US Highway 1, North Brunswick, NJ 08902, USA
| | | | | | - Camilo Pena
- Lumen Foundation, 55 Pinta Road, Miami, FL 33133, USA
| | - Salomon Cohen
- Departamento de Neurocirugia, Instituto Mexicano del Seguro Social, Avenida Club de Golf #3 Torre A Dep. 1501, Lomas Country, Huixquilucan Edo de Mexico, 52779, Mexico
| | - Rebecca Rowen
- Ross University School of Medicine, 630 US Highway 1, North Brunswick, NJ 08902, USA
| | - Kevin Treto
- Ross University School of Medicine, 786 Seneca Meadows Road, Winter Springs, FL 32708, USA
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