Thrombus aspiration during primary percutaneous coronary intervention improves myocardial reperfusion and reduces infarct size: the EXPIRA (thrombectomy with export catheter in infarct-related artery during primary percutaneous coronary intervention) prospective, randomized trial

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

The enigma of the 'smoker's paradox': Results from a single-center registry of patients with STEMI undergoing primary percutaneous coronary intervention

BACKGROUND

Smoker's paradox usually refers to the observation of a favorable outcome of smoking patients in acute myocardial infarction.

METHODS

From April 2006 to December 2018 a population of 2456 patients with ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI) were prospectively enrolled in the MATRIX registry. Ischemic time, clinical, demographics, angiographic data, and 1-year follow-up were collected.

RESULTS

Among 2546 patients admitted with STEMI, 1007 (41 %) were current smokers. Smokers were 10 years younger and had lower crude in-hospital and 1-year mortality (1.5 % vs 6 %, p < 0.0001 and 5 % vs 11 %, p < 0.0001), shorter ischemic time (203 [147-299] vs 220 [154-334] minutes, p = 0.002) and shorter decision time (60 [30-135] vs 70 [36-170] minutes, p = 0.0063). Smoking habit [OR:0.37(95 % CI:0.18-0.75)-p < 0.01], younger age [OR 1.06 (95%CI:1.04-1.09)-p < 0.001] and shorter ischemic time [OR:1.01(95%CI:1.01-1.02)-p < 0.05] were associated to lower in-hospital mortality. Only smoking habit [HR:0.65(95 % CI: 0.44-0.9)-p = 0.03] and younger age [HR:1.08 (95%CI:1.06-1.09)-p < 0.001] were also independently associated to lower all-cause death at 1-year follow-up. After propensity matching, age, cardiogenic shock and TIMI flow <3 were associated with in-hospital mortality, while smoking habit was still associated with reduced mortality. Smoking was also associated with reduced mortality at 1-year follow-up (HR 0.54, 95 % CI [0.37-0.78]; p < 0.001).

CONCLUSIONS

Smoking patients show better outcome after PCI for STEMI at 1-year follow-up. Although "Smoking paradox" could be explained by younger age of patients, other factors may have a role in the explanation of the phenomenon.

Initial experience with a novel stent-based mechanical thrombectomy device for management of acute myocardial infarction cases with large thrombus burden

BACKGROUND

Patients with acute myocardial infarction (AMI) and large thrombus burden (LTB) still represent a challenge. Afflicted patients have a high morbidity and mortality. Aspiration thrombectomy is often ineffective in those cases. Mechanical thrombectomy devices (MTDs), which are effective for management of ischemic strokes, were recently CE-approved for treatment of thrombotic coronary lesions. Real-world data about their performance in AMI cases with LTB are scarce. This study sought to summarize our early experience with a novel MTD device in this context.

METHODS

We analyzed consecutive patients from the prospective OPTIMISER registry (NCT04988672), who have been managed with the NeVa™ MTD (Vesalio, USA) for AMI with LTB at a tertiary cardiology facility. Outcomes of interest included, among others, periprocedural complications, target lesion failure (TLF), target lesion revascularization (TLR) and target vessel myocardial infarction (TV-MI).

RESULTS

Overall, 15 patients underwent thrombectomy with the NeVa™ device. Thrombectomy was successfully performed in 14 (93%) patients. Final TIMI 3 flow was achieved in 13 (87%) patients, while 2 (13%) patients had TIMI 2 flow. We encountered no relevant periprocedural complications, especially no stroke, stent thrombosis or vessel closure. After a mean follow-up time of 26 ± 2.9 months, 1 (7%) patient presented with TLR due to stent thrombosis (10 months after treatment with the MTD and stenting).

CONCLUSIONS

In AMI patients with LTB, the deployment of the novel NeVa™ MTD seems efficient and safe. Further randomized trials are warranted to assess whether the use of the NeVa™ device in cases with LTB improves procedural and clinical outcomes.

The Use of Thrombectomy during Primary Percutaneous Coronary Intervention: Resurrecting an Old Concept in Contemporary Practice

Optimal myocardial reperfusion during primary percutaneous coronary intervention (pPCI) is increasingly recognized to be beyond restoring epicardial coronary flow. Both invasive and non-invasive tools have highlighted the limitation of using this metric, and more efforts are focused towards achieving optimal reperfusion at the level of the microcirculation. Recent data highlighted the close relationship between thrombus burden and impaired microcirculation in patients presenting with ST-segment elevation myocardial infarction (STEMI). Moreover, distal embolization was an independent predictor of mortality in patients with STEMI. Likewise, the development of no-reflow phenomenon has been directly linked with worse clinical outcomes. Adjunctive thrombus aspiration during pPCI is intuitively intended to remove atherothrombotic material to mitigate the risk of distal embolization and the no-reflow phenomenon (NRP). However, prior trials on the use of thrombectomy during pPCI did not support its routine use, with comparable clinical endpoints to patients who underwent PCI alone. This article aims to review the existing literature highlighting the limitation on the use of thrombectomy and provide future insights into trials investigating the role of thrombectomy in contemporary pPCI.

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

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.

The impact of primary percutaneous coronary intervention strategies during ST-elevation myocardial infarction on the prevalence of coronary microvascular dysfunction

Coronary microvascular dysfunction (CMD) is a common complication of ST-segment elevation myocardial infarction (STEMI) and can lead to adverse cardiovascular events. This is a non-randomized, observational, prospective study of STEMI patients with multivessel disease who underwent primary PCI, grouped based on whether they underwent balloon pre-dilatation stenting or direct stenting of the culprit lesion. Coronary physiology measurements were performed 3 months post-PCI including coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) measurements at the culprit vessel. The primary endpoint was the prevalence of CMD at 3 months, defined as IMR ≥ 25 or CFR < 2.0 with a normal fractional flow reserve. Secondary endpoints included major adverse cardiovascular events (MACE) at 12 months. Two hundred ten patients were enrolled; most were men, 125 (59.5%), with a median age of 65 years. One hundred twelve (53.2%) underwent balloon pre-dilatation before stenting, and 98 (46.7%) underwent direct stenting. The prevalence of CMD at 3 months was lower in the direct stenting group than in the balloon pre-dilatation stenting group (12.24% vs. 40.18%; p < 0.001). Aspiration thrombectomy and administration of intracoronary glycoprotein IIb/IIIa inhibitors were associated with lower odds of CMD (OR = 0.175, p = 0.001 and OR = 0.113, p = 0.001, respectively). Notably, MACE in patients who underwent direct stenting was lower than in those who underwent balloon pre-dilatation before stenting (14.29% vs. 26.79%; p = 0.040). In STEMI patients with multivessel disease, direct stenting of the culprit lesion, aspiration thrombectomy and administration of intracoronary glycoprotein IIb/IIIa inhibitors were associated with a lower prevalence of CMD at 3 months and lower incidence of MACE at 12 months compared with balloon pre-dilatation stenting.This trial is registered at https://ichgcp.net/clinical-trials-registry/NCT05406297 .

Thrombus architecture is influenced by the antiplatelet loading treatment in patients with acute myocardial infarction

BACKGROUND

Intracoronary thrombus formation is a main cause of acute myocardial infarction triggered by platelet activation. However, there are no data on the impact of different treatment strategies with antiplatelet agents before percutaneous coronary intervention (PCI) on histological characteristics of thrombus formation.

OBJECTIVE

In this study, we investigate the impact of preinterventional administration of the P2Y12-inhibitors clopidogrel and prasugrel on thrombus composition, highlighting significant changes associated with the antiplatelet pre-treatment.

METHODS

We prospectively enrolled 104 consecutive patients with ST-segment elevation myocardial infarction (STEMI) undergoing immediate PCI and thrombus aspiration by immunohistochemical staining along with RNA-sequencing employing Nanostring analysis. Fifty-two patients were treated with either prasugrel loading (60 mg) or clopidogrel loading (600 mg) prior to PCI, respectively.

RESULTS

In Patients with STEMI, intracoronary thrombus architecture was significantly altered between patients pre-treated with prasugrel when compared to clopidogrel. Fibrin content of thrombi was significantly decreased (41.8 % versus 66.7 %, p = 0.009) after pre-treatment with prasugrel compared to clopidogrel. Furthermore, levels of MPO positive cells in intracoronary thrombi were significantly decreased in patients with prasugrel pre-treatment (90.5 versus 201.1, p = 0.014) indicating an association of antiplatelet pre-treatment and the inflammatory responses during thrombus formation. Most strikingly, we observed significant differences among both pre-treatment groups regarding altered RNA expression and signaling pathways of thrombo-inflammatory processes within the thrombotic material, which were independently associated with antiplatelet strategies.

CONCLUSIONS

Our study elucidates the impact of antiplatelet pre-treatment on thrombus remodeling and architecture, thereby lowering the risk of recurrent adverse cardiovascular events in prasugrel-treated patients.

Manual Thrombus Aspiration in Patients With ST-Elevation Myocardial Infarction With High Thrombus Burden and a Total Ischemic Time Greater or Equal Than 3 Hours: Mini Review

Manual Thrombus Aspiration (MTA) reduces thrombus burden and improves myocardial reperfusion markers in patients with ST-segment elevation myocardial infarction (STEMI), however its clinical benefit is controversial due to conflicting results from randomized clinical trials, which is why the benefit of its application during primary angioplasty (PA) remains uncertain. Reports such as that of Doo Sun Sim, et al. suggest that the impact of MTA may become clinically relevant in patients with a longer total ischemia time.1 We present the case of an adult male, with multiple risk factors for coronary disease, with lower STEMI, due to occlusion of the right coronary artery with a heavy thrombus load and an ischemia time of 10 hours. It was successfully treated by MTA, removing abundant intracoronary thrombus and obtaining a TIMI III flow, without requiring stent implantation. The case, the evolution and the current knowledge regarding the use of AT are discussed. Our case report and review of five cases with similar characteristics in the literature illustrate the use of MTA in patients with STEMI, high thrombus burden, and prolonged ischemia time.

Efficacy of thrombus aspiration in cardiogenic shock complicating acute myocardial infarction and high thrombus burden

INTRODUCTION AND OBJECTIVES

Current guidelines do not recommend routine thrombus aspiration in acute myocardial infarction (AMI) because no benefits were observed in previous randomized trials. However, there are limited data in cardiogenic shock (CS) complicating AMI.

METHODS

We included 575 patients with AMI complicated by CS. The participants were stratified into the TA and no-TA groups based on use of TA. The primary outcome was a composite of 6-month all-cause death or heart failure rehospitalization. The efficacy of TA was additionally assessed based on thrombus burden (grade I-IV vs V).

RESULTS

No significant difference was found in in-hospital death (28.9% vs 33.5%; P=.28), or 6-month death, or heart failure rehospitalization (32.4% vs 39.4%; HRadj: 0.80; 95%CI, 0.59-1.09; P=.16) between the TA and no-TA groups. However, in 368 patients with a higher thrombus burden (grade V), the TA group had a significantly lower risk of 6-month all-cause death or heart failure rehospitalization than the no-TA group (33.4% vs 46.3%; HRadj: 0.59; 95%CI, 0.41-0.85; P=.004), with significant interaction between thrombus burden and use of TA for primary outcome (adjusted Pint=.03).

CONCLUSIONS

Routine use of TA did not reduce short- and mid-term adverse clinical outcomes in patients with AMI complicated by CS. However, in select patients with a high thrombus burden, the use of TA might be associated with improved clinical outcomes. The study was registered at ClinicalTrials.gov (Identifier: NCT02985008).

Thrombus containing lesions strategies during primary percutaneous coronary interventions in ST-segment elevation myocardial infarction: insights from ORPKI National Registry

In the era of potent P2Y₁₂ inhibitors, according to current guidelines, treatment with glycoprotein IIb/IIIa inhibitors (GPIs) should be limited to bail-out and/or highly thrombotic situations. Similarly, the recommendation for aspiration thrombectomy (AT) is downgraded to very selective use. We examine the prevalence, and predictors of GPI and AT use in STEMI patients referred to primary percutaneous coronary intervention (PCI). Data on 116,873 consecutive STEMI patients referred to primary PCI in Poland between 2015 and 2020 were analyzed. GPIs were administered in 29.3%, AT was used in 11.6%, and combined treatment with both in 6.1%. There was a mild trend toward a decrease in GPI and AT usage during the analyzed years. On the contrary, there was a rapid growth of the ticagrelor/prasugrel usage rate from 6.5 to 48.1%. Occluded infarct-related artery at baseline and no-reflow during PCI were the strongest predictors of GPI administration (OR 2.3; 95% CI 2.22-2.38 and OR 3.47; 95% CI 3.13-3.84, respectively) and combined usage of GPI and AT (OR 4.4; 95% CI 4.08-4.8 and OR 3.49; 95% CI 3.08-3.95 respectively) in a multivariate logistic regression model. Similarly, the administration of ticagrelor/prasugrel was an independent predictor of both adjunctive treatment strategies. In STEMI patients in Poland, GPIs are selectively used in one in four patients during primary PCI, and the combined usage of GPI and AT is marginal. Despite the rapid growth in potent P2Y₁₂ inhibitors usage in recent years, GPIs are selectively used at a stable rate during PCI in highly thrombotic lesions.

Sustained Mechanical Aspiration Thrombectomy for High Thrombus Burden Coronary Vessel Occlusion: The Multicenter CHEETAH Study

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.

Predilation Ballooning in High Thrombus Laden STEMIs: An Independent Predictor of Slow Flow/No-Reflow in Patients Undergoing Emergent Percutaneous Coronary Revascularization

Background

Distal embolization due to microthrombus fragments formed during predilation ballooning is considered one of the possible mechanisms of slow flow/no-reflow (SF/NR). Therefore, this study aimed to compare the incidence of intraprocedure SF/NR during the primary percutaneous coronary intervention (PCI) in patients with high thrombus burden (≥4 grade) with and without predilation ballooning for culprit lesion preparation. Methodology. This prospective descriptive cross-sectional study included patients with a high thrombus burden (≥4 grades) who underwent primary PCI. Propensity-matched cohorts of patients with and without predilation ballooning in a 1 : 1 ratio were compared for the incidence of intraprocedure SF/NR.

Results

A total of 765 patients with high thrombus burden undergoing primary PCI were included in this study. The mean age was 55.75 ± 11.54 years, and 78.6% (601) were males. Predilation ballooning was conducted in 346 (45.2%) patients. The incidence of intraprocedure SF/NR was significantly higher (41.3% vs. 27.4%; p < 0.001) in patients with predilation ballooning than in those without preballooning, respectively. The incidence of intraprocedure SF/NR also remained significantly higher for the predilation ballooning cohort with an incidence rate of 41.3% as against 30.1% (p=0.002) for the propensity-matched cohort of patients without predilation ballooning with a relative risk of 1.64 (95% CI: 1.20 to 2.24). Moreover, the in-hospital mortality rate remained higher but insignificant, among patients with and without predilation ballooning (8.1% vs. 4.9%; p=0.090).

Conclusion

In conclusion, predilation ballooning can be associated with an increased risk of incidence of intraprocedure SF/NR during primary PCI in patients with high thrombus burden.

Cardiac Magnetic Resonance Shows Improved Outcomes in Patients with an ST-Segment Elevation Myocardial Infarction and a High Thrombus Burden Treated with Adjuvant Aspiration Thrombectomy

There is a discrepancy between epicardial vessel patency and microcirculation perfusion in a third of patients treated with percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Optimization with aspiration thrombectomy (AT) may reduce distal embolization and microvascular obstruction. The effect of AT in the treatment of STEMI is debatable. The purpose of this study was to use cardiac magnetic resonance (CMR) to determine whether AT influences microvascular obstruction (MVO), infarct size and left ventricular (LV) remodelling in STEMI patients. Sixty STEMI patients with a thrombus-occluded coronary artery were randomized in a 2:1 fashion to receive PCI proceeded by AT (AT + PCI group), or PCI only. MVO, myocardial infarct size and LV remodelling were assessed by CMR during the index hospitalization and 6 months thereafter. The majority of patients had a large thrombus burden (TIMI thrombus grade 5 in over 70% of patients). PCI and AT were effective in all cases. There were no periprocedural strokes. CMR showed that the addition of AT to standard PCI was associated with lesser MVO when indexed to the infarct size and larger infarct size reduction. There were less patients with left ventricle remodelling in the AT + PCI vs. the PCI only group. To conclude, in STEMI patients with a high thrombus burden, AT added to PCI is effective in reducing infarct size, MVO and LV remodelling.

Benchmarking Observational Analyses Before Using Them to Address Questions Trials Do Not Answer: An Application to Coronary Thrombus Aspiration

To increase confidence in the use of observational analyses when addressing effectiveness questions beyond those addressed by randomized trials, one can first benchmark the observational analyses against existing trial results. We used Swedish registry data to emulate a target trial similar to the Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia (TASTE) randomized trial, which found no difference in the risk of death or myocardial infarction by 1 year with or without thrombus aspiration among individuals with ST-elevation myocardial infarction. We benchmarked the emulation against the trial at 1 year and then extended the emulation's follow-up to 3 years and estimated effects in subpopulations underrepresented in the trial. As in the TASTE trial, the observational analysis found no differences in risk of outcomes by 1 year between groups (risk difference = 0.7 (confidence interval, -0.7, 2.0) and -0.2 (confidence interval, -1.3, 1.0) for death and myocardial infarction, respectively), so benchmarking was considered successful. We additionally showed no difference in risk of death or myocardial infarction by 3 years, or within subpopulations by 1 year. Benchmarking against an index trial before using observational analyses to answer questions beyond those the trial could address allowed us to explore whether the observational data can be trusted to deliver valid estimates of treatment effects.

Intracoronary pharmacological therapy versus aspiration thrombectomy in STEMI (IPAT-STEMI): A systematic review and meta-analysis of randomized trials

BACKGROUND

Thrombus load in STEMI patients remains a challenge in practice. It aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Various strategies have been advocated to reduce thrombus burden.

OBJECTIVES

This meta-analysis aimed to evaluate the effectiveness of intracoronary-administered thrombolytics or glycoprotein IIb/IIIa inhibitors (GPI) in comparison with aspiration thrombectomy (AT) as an adjunct to percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI).

METHODS

A comprehensive literature search for randomized trials that compared intracoronary-administered thrombolytics or GPI with AT in STEMI patients who underwent PCI, was conducted using various databases (e.g., MEDLINE, EMBASE, CENTRALE). Primary outcome was procedural measures (e.g., TIMI flow grade 3, TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR)).

RESULTS

Twelve randomized trials enrolled 1,466 patients: 696 were randomized to intracoronary-administered pharmacological interventions and 553 to AT. Patients randomized to PCI alone were excluded. Thrombolytics significantly improved TIMI flow grade 3 (odds ratio = 3.71, 95% CI: 1.85-7.45), complete STR (odds ratio = 3.64, 95% CI: 1.60-8.26), and TMPG 3 (odds ratio = 5.31, 95% CI: 2.48-11.36). Thrombolytics significantly reduced major adverse cardiovascular events (MACE) (odds ratio = 0.29, 95% CI: 0.13-0.65) without increasing bleeding risk. Trial sequential analysis assessment confirmed the superiority of thrombolytics for the primary outcome. Intracoronary GPI, either alone or combined with AT, did not improve procedural or clinical outcomes.

CONCLUSIONS

Compared with AT, intracoronary-administered thrombolytics significantly improved myocardial perfusion and MACE in STEMI patients.

Impact of Stress Hyperglycemia on No-Reflow Phenomenon in Patients with ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background:

Stress hyperglycemia is a common finding during acute myocardial infarction and associated with poor prognosis. To reduce the occurrence of no-reflow, prognostic factors must be identified before primary percutaneous coronary intervention (PPCI). Our objective was to investigate the impact of stress hyperglycemia in non-diabetic and diabetic patients on no-reflow phenomenon after PPCI.

Methods:

The study comprised 480 patients with ST elevation myocardial infarction (STEMI) who were managed by PPCI. Patients were classified into two groups according to thrombolysis in myocardial infarction (TIMI) flow grade: Group I (Patients with normal flow, TIMI 3 flow) and Group II (Patients with no-reflow, TIMI 0-2 flow). Patients were analyzed for clinical outcomes including mortality and major adverse cardiac events.

Results:

Incidence of stress hyperglycemia was 14.8% in non-diabetic patients and 22.2% in diabetic patients; the incidence of no-reflow phenomenon was 13.5% and no-reflow was significantly higher in patients with stress hyperglycemia. Multivariate regression analysis identified the independent predictors of no-reflow phenomenon: stress hyperglycemia OR 3.247 (CI95% 1.656–6.368, P = 0.001), Killip class >1 OR 1.893 (CI95% 1.004–3.570, P = 0.049) and cardiogenic shock OR 3.778 (CI95% 1.458–9.790, P = 0.006).

Conclusion:

Stress hyperglycemia was associated with higher incidence of no-reflow phenomenon. The independent predictors of no-reflow were stress hyperglycemia, Killip class >1 and cardiogenic shock.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

A fresh look at coronary microembolization

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.

Manual Thrombus Aspiration and its Procedural Stroke Risk in Myocardial Infarction

Background

The previous large‐scale randomized controlled trial showed that routine thrombus aspiration (TA) during percutaneous coronary intervention (PCI) was associated with an increased risk of stroke. However, real‐world clinical evidence is still limited.

Methods and Results

We investigated the association between manual TA and stroke risk during primary PCI in the OACIS (Osaka Acute Coronary Insufficiency Study) database (N=12 093). The OACIS is a prospective, multicenter registry of myocardial infarction. The primary end point of the present study is stroke at 7 days. A total of 9147 patients who underwent primary PCI within 24 hours of hospitalization were finally analyzed (TA group, n=4448, versus non‐TA group, n=4699 patients). TA was independently associated with risk of stroke at 7 days (odds ratio [OR], 1.92 [95% CI, 1.19‒3.12]; P=0.008) in the simple logistic regression model, while the multilevel random effects logistic regression model with hospital treated as a random effect showed that manual TA was not associated with incremental risk of stroke at 7 days (OR, 0.91 [95% CI, 0.71‒1.16]; P=0.435). The 7‐day stroke risk of manual TA was significantly heterogeneous in different institutions (P_{for interaction}=0.007).

Conclusions

Manual TA during primary PCI for patients with acute myocardial infarction was independently associated with the overall increased risk of periprocedural stroke. However, this result was substantially skewed because of institution specific risk variation, suggesting that the periprocedural stroke may be preventable by prudent PCI procedure or appropriate periprocedural management.

Registration

URL: https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000005464. Unique identifier: UMIN000004575.

Remote Ischemic Conditioning in Ischemic Stroke and Myocardial Infarction: Similarities and Differences

Acute myocardial infarction and ischemic stroke are leading causes of morbidity and mortality worldwide. Although reperfusion therapies have greatly improved the outcomes of patients with these conditions, many patients die or are severely disabled despite complete reperfusion. It is therefore important to identify interventions that can prevent progression to ischemic necrosis and limit ischemia-reperfusion injury. A possible strategy is ischemic conditioning, which consists of inducing ischemia – either in the ischemic organ or in another body site [i.e., remote ischemic conditioning (RIC), e.g., by inflating a cuff around the patient's arm or leg]. The effects of ischemic conditioning have been studied, alone or in combination with revascularization techniques. Based on the timing (before, during, or after ischemia), RIC is classified as pre-, per-/peri-, or post-conditioning, respectively. In this review, we first highlight some pathophysiological and clinical similarities and differences between cardiac and cerebral ischemia. We report evidence that RIC reduces circulating biomarkers of myocardial necrosis, infarct size, and edema, although this effect appears not to translate into a better prognosis. We then review cutting-edge applications of RIC for the treatment of ischemic stroke. We also highlight that, although RIC is a safe procedure that can easily be implemented in hospital and pre-hospital settings, its efficacy in patients with ischemic stroke remains to be proven. We then discuss possible methodological issues of previous studies. We finish by highlighting some perspectives for future research, aimed at increasing the efficacy of ischemic conditioning for improving tissue protection and clinical outcomes, and stratifying myocardial infarction and brain ischemia patients to enhance treatment feasibility.

Clinical Impact of Thrombus Aspiration and Interaction With D-Dimer Levels in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Objectives: To evaluate the effect of thrombus aspiration (TA) strategy on the outcomes and its interaction with D-dimer levels in patients with ST-segment elevation myocardial infarction (STEMI) during primary percutaneous coronary intervention (PCI) in "real-world" settings. Materials and Methods: This study included 1,295 patients with STEMI who had undergone primary PCI with or without TA between January 2013 and June 2017. Patients were first divided into a TA+PCI group and a PCI-only group, and the baseline characteristics and long-term mortality between the two groups were analyzed. Furthermore, we studied the effect of TA on the clinical outcomes of patients grouped according to quartiles of respective D-dimer levels. The primary outcome was all-cause mortality, and the secondary outcomes were new-onset heart failure (HF), rehospitalization, re-PCI, and stroke. Results: In the original cohort, there were no significant differences in all-cause mortality between the TA+PCI and PCI-only groups (hazard ratio, 0.789; 95% confidence interval, 0.556-1.120; p = 0.185). After a mean follow-up of 2.5 years, the all-cause mortality rates of patients in the TA + PCI and PCI-only groups were 8.5 and 16.2%, respectively. Additionally, differences between the two groups in terms of the risk of HF, re-PCI, rehospitalization, and stroke were non-significant. However, after dividing into quartiles, as the D-dimer levels increased, the all-cause mortality rate in the PCI group gradually increased (4.3 vs. 6.0 vs. 7.0 vs. 14.7%, p < 0.001), while the death rate in the TA+PCI group did not significantly differ (4.6 vs. 5.0 vs. 4.0 vs. 3.75%, p = 0.85). Besides, in the quartile 3 (Q3) and quartile 4 (Q4) groups, the PCI-only group was associated with a higher risk of all-cause mortality than that of the TA+PCI group (Q3: 4.0 vs. 7.0%, p = 0.029; Q4: 3.75 vs. 14.7%, p < 0.001). Moreover, the multivariate logistic regression analysis demonstrated that TA is inversely associated with the primary outcome in the Q4 group [odds ratio (OR), 0.395; 95% CI, 0.164-0.949; p = 0.038]. Conclusions: The findings of our real-world study express that routine manual TA during PCI in STEMI did not improve clinical outcomes overall. However, patients with STEMI with a higher concentration of D-dimer might benefit from the use of TA during primary PCI. Large-scale studies are recommended to confirm the efficacy of TA.

Laser Vaporization of Intracoronary Thrombus and Identifying Plaque Morphology in ST-Segment Elevation Myocardial Infarction as Assessed by Optical Coherence Tomography

Objectives

We evaluated the thrombus-vaporizing effect of excimer laser coronary angioplasty (ELCA) in patients with ST-segment elevation myocardial infarction (STEMI) by optical coherence tomography (OCT).

Background

Larger intracoronary thrombus elevates the risk of interventional treatment and mortality in patients with STEMI.

Methods

A total of 92 patients with STEMI who presented within 24 hours from the onset and underwent ELCA following manual aspiration thrombectomy (MT) were analyzed.

Results

The mean baseline thrombolysis in myocardial infarction flow grade was 0.4 ± 0.6, which subsequently improved to 2.3 ± 0.7 after MT (p < 0.0001) and 2.7 ± 0.5 after ELCA (p=0.0001). The median residual thrombus volume after MT was 65.7 mm³, which significantly reduced to 47.5 mm³ after ELCA (p < 0.0001). Plaque rupture was identified by OCT in only 22 cases (23.9%) after MT, but was distinguishable in 36 additional cases after ELCA (total: 58 cases; 63.0%). Ruptured lesions contained a higher proportion of red thrombus than nonruptured lesions (75.9% vs. 43.3%, p=0.001). Significantly larger thrombus burden after MT (69.6 mm³ vs. 56.3 mm³, p < 0.05) and greater thrombus reduction by ELCA (21.2 mm³ vs. 11.8 mm³, p < 0.01) were observed in ruptured lesions than nonruptured lesions.

Conclusions

ELCA effectively vaporized intracoronary thrombus in patients with STEMI even after MT. Lesions with plaque rupture contained larger thrombus burden that was frequently characterized by red thrombus and more effectively reduced by ELCA.

Mechanical aspiration thrombectomy using the penumbra CAT RX system for patients presenting with acute coronary syndrome

Patient undergoing PCI can have distal embolization and microvascular obstruction despite normalization of epicardial blood flow. Aspiration thrombectomy has been studied previously to reduce infarct size, but prior methods of aspiration thrombectomy were associated with increased risk of stroke and is currently recommended as a bailout strategy. Penumbra CAT RX has been recently approved for aspiration thrombectomy, we evaluated the catheter's use in an academic cardiac catheterization lab. Patients undergoing cardiac catherization at an academic medical center who had deployment of the Penumbra CAT RX from 2017 through 2020 were included in the case series. TIMI flow pre and post procedure were determined by individual operator. Endpoints included 30-day cardiovascular death and post-procedural stroke. The Penumbra CAT RX catheter was used in a total of 34 patients, with 71% STEMI, 23% NSTEMI, 3% UA, and 3% new onset heart failure. TIMI 3 flow was achieved in 88% of cases. There were no cases of 30-day cardiovascular death or post procedural stroke. Aspiration thrombectomy continues to have clinical benefit in modern cardiac catherization laboratories with use in select cases. The Penumbra CAT RX appears to be safe and highly effective at thrombus removal in the acute setting without increased stroke risk as seen with manual aspiration thrombectomy.

Reducing Cardiac Injury during ST-Elevation Myocardial Infarction: A Reasoned Approach to a Multitarget Therapeutic Strategy

The significant reduction in ‘ischemic time’ through capillary diffusion of primary percutaneous intervention (pPCI) has rendered myocardial-ischemia reperfusion injury (MIRI) prevention a major issue in order to improve the prognosis of ST elevation myocardial infarction (STEMI) patients. In fact, while the ischemic damage increases with the severity and the duration of blood flow reduction, reperfusion injury reaches its maximum with a moderate amount of ischemic injury. MIRI leads to the development of post-STEMI left ventricular remodeling (post-STEMI LVR), thereby increasing the risk of arrhythmias and heart failure. Single pharmacological and mechanical interventions have shown some benefits, but have not satisfactorily reduced mortality. Therefore, a multitarget therapeutic strategy is needed, but no univocal indications have come from the clinical trials performed so far. On the basis of the results of the consistent clinical studies analyzed in this review, we try to design a randomized clinical trial aimed at evaluating the effects of a reasoned multitarget therapeutic strategy on the prevention of post-STEMI LVR. In fact, we believe that the correct timing of pharmacological and mechanical intervention application, according to their specific ability to interfere with survival pathways, may significantly reduce the incidence of post-STEMI LVR and thus improve patient prognosis.

Impact of manual thrombectomy on microvascular obstruction in STEMI patients

OBJECTIVE

To assess the effect of manual thrombectomy (MT) on microvascular obstruction (MVO) using cardiac magnetic resonance (CMR) in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Three hundred and eighty-three patients admitted for STEMI and undergoing CMR fulfilled the inclusion criteria and were categorized into two groups (did or did not undergo MT). The two primary endpoints were the occurrence and extent of MVO, analyzed as a categorical variable and as a semicontinuous variable. Among the 383 patients, 49.1% exhibited MVO. Both the incidence of MVO and the median number of segments presenting with MVO were significantly higher in the MT group than in the no-MT group, (59.5 vs. 38.9%, p < .001) and (1.5 [0;4] vs. 0 [0;2], p < .001). Analysis stratified on coronary thrombus grade showed similar results, only in patients with a high thrombus burden (60.7 vs. 43.5%, p = .004, and 2 [0;4] vs. 0 [0;3], p = .001. When adjusting for baseline differences, MT remained a determinant of MVO occurrence and extent (odds ratio, OR 1.802 [95% confidence interval, CI 1.080-3.009], p = .024) and β = .137, p = .024) in patients with a high thrombus grade.

CONCLUSION

In STEMI patients, MT was associated with the occurrence and extent of MVO, on CMR, especially in patients with a high thrombus burden.

Multicenter and all-comers validation of a score to select patients for manual thrombectomy, the DDTA score

BACKGROUND

Routine manual thrombectomy (MT) is not recommended in primary percutaneous coronary intervention (P-PCI) but it is performed in many procedures. The objective of our study was validating the DDTA score, designed for selecting patients who benefit most from MT.

METHODS

Observational and multicenter study of all consecutive patients undergoing P-PCI in five institutions. Results were compared with the design cohort and the performance of the DDTA was analyzed in all patients. Primary end-point of the analyses was TIMI 3 after MT; secondary endpoints were final TIMI 3, no-reflow incidence, in-hospital mortality and in-hospital major cardiovascular events (MACE). In-hospital prognosis was assessed by the Zwolle risk score.

RESULTS

Three hundred forty patients were included in the validation cohort and no differences were observed as compared to the design cohort (618 patients) except for lower use of MT and higher IIb/IIIa inhibitors or drug-eluting stents. The probability of TIMI 3 after MT decreased as delay to P-PCI was higher. If DDTA score, MT was associated to TIMI 3 after MT (OR: 4.11) and final TIMI 3 (OR: 2.44). There was a linear and continuous relationship between DDTA score and all endpoints. DDTA score ≥ 4 was independently associated to lower no-reflow, in-hospital MACE or mortality. The lowest incidence of in-hospital mortality or MACE was in patients who had DDTA score ≥ 4 and Zwolle risk score 0-3.

CONCLUSIONS

MT is associated to higher rate of final TIMI3 in patients with the DDTA score ≥ 4. Patients with DDTA score ≥ 4 had lower no-reflow and in-hospital complications.

Association of Thrombus Aspiration With Time and Mortality Among Patients With ST-Segment Elevation Myocardial Infarction: A Post Hoc Analysis of the Randomized TOTAL Trial

IMPORTANCE

Patients with shorter ischemic times have a greater viable myocardium and may derive greater benefit from thrombus aspiration.

OBJECTIVE

To study the association of thrombus aspiration with outcomes among patients presenting with ST-segment elevation myocardial infarction (STEMI) based on time.

DESIGN, SETTING, AND PARTICIPANTS

The TOTAL (Thrombectomy With PCI vs PCI Alone in Patients with STEMI) trial was an international randomized clinical trial of 10 732 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) within 12 hours of symptom onset. Patients were recruited between August 5, 2010, and July 25, 2014, and were followed up for 1 year. Data analysis was performed from February 22, 2019, to January 5, 2021.

INTERVENTIONS

Thrombus aspiration vs PCI alone.

MAIN OUTCOMES AND MEASURES

Post hoc subgroup analyses were performed for total ischemic time and first medical contact (FMC)-to-device time for the primary outcomes (cardiovascular [CV] mortality, myocardial Infarction [MI], cardiogenic shock, and New York Heart Association class IV heart failure) and angiographically determined distal embolization. In addition, a multivariable analysis was performed to assess the association of total ischemic time and FMC-to-device time with CV mortality at 1 year.

RESULTS

The study randomized 10 732 patients, and 9986 underwent primary PCI and had time data available (7737 men [77.5%]; mean [SD] age, 61.0 [12.0] years). For the randomized comparison of thrombus aspiration, there was a reduction in angiographic distal embolization with thrombus aspiration that was more pronounced in patients with short ischemic times (<2 hours: odds ratio [OR], 0.23 [95% CI, 0.09-0.62]; 2-6 hours: OR, 0.54 [95% CI, 0.39-0.73]; >6 hours: OR, 0.70 [95% CI, 0.33-1.50]; P = .12 for interaction). However, for the primary composite outcome, there was no benefit based on (1) total ischemic time (<2 hours: hazard ratio [HR], 0.77 [95% CI, 0.46-1.28]; 2-6 hours: HR, 1.03 [95% CI, 0.85-1.25]; >6 hours: HR, 0.87 [95% CI, 0.60-1.27]; P = .46 for interaction) or (2) FMC-to-device time (<60 minutes: HR, 1.14 [95% CI, 0.66-1.95]; 60-90 minutes: HR, 0.94 [95% CI, 0.67-1.32]; >90-120 minutes: HR, 1.19 [95% CI, 0.85-1.67]; >120 minutes: HR, 0.89 [95% CI, 0.70-1.14]; P = .54 for interaction). In a multivariable analysis, both total ischemic time (>2 hours: HR, 1.26 [95% CI, 1.00-1.58) and FMC-to-device time (>120 minutes: HR, 1.45 [95% CI, 1.18-1.79]) were independently associated with CV mortality.

CONCLUSIONS AND RELEVANCE

This analysis suggests that thrombus aspiration does not appear to be associated with an improvement in clinical outcomes regardless of ischemic time. In the current STEMI era, both total ischemic time and FMC-to-device times continue to be important factors associated with mortality.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01149044.

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

Background

Routine 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.

Results

The 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.

Conclusion

In 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.

Aspiration thrombectomy in ST-Elevation myocardial infarction: Further insights from a network meta-analysis of randomized trials

Background

The initial enthusiasm for thrombectomy during percutaneous coronary intervention (PCI) of ST-elevation myocardial infarction (STEMI) patients has given way to restraint. There has been some limited interest whether it is beneficial in a few selected subgroups. Hence, we performed a network meta-analysis to compare conventional PCI (cPCI), Aspiration or manual thrombectomy (AT) and Mechanical thrombectomy (McT) for clarification.

Methods

Electronic databases were searched for randomized studies that compared AT, McT, or cPCI. A network meta-analysis was performed and odd’s ratio (OR) with 95% confidence intervals was generated for major adverse cardiac events (MACE), mortality, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST), stroke, left ventricular ejection fraction (LVEF), myocardial blush grade (MBG) and ST segment resolution (STR).

Results

A total of 43 randomized trials (n = 26,682) were included. The risk of MACE (OR 0.86 95% CI 0.73–1.00), Mortality (OR 0.85 95% CI 0.73–0.99), MI (OR 0.65, 95% CI: 0.44–0.95) and TVR (OR 0.86, 95% CI: 0.74–1.00) were lower with AT compared to cPCI. The risk of ST and stroke was no different with the use of adjunctive AT. MBG, STR, and LVEF improved with the use of AT while the infarct size was no different in the two groups.

Conclusions

Our comprehensive network meta-analysis suggests conflicting outcomes with AT. While Mortality, MACE, MI seem better, there is a suggestion that, Stroke and ST might be worse. Whether AT can still be pursued in any select cases should be further scrutinized.

Prediction of no-reflow phenomenon in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

No-reflow is an important complication among patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).A retrospective study of 1658 STEMI patients undergoing direct PCI was performed. Patients were randomly assigned at a 7:3 ratio into development cohort and validation cohort and into no-reflow and normal blood flow groups. Clinical data and laboratory examinations were compared to identify independent risk factors and establish a no-reflow risk scoring system.In the development cohort (n = 1122), 331 (29.5%) had no-reflow. Multivariate analysis showed age ≥ 65 years (OR = 1.766, 95% confidence interval (CI): 1.313-2.376, P < .001), not using angiotonase inhibitor/angiotensin receptor antagonists (OR = 1.454, 95%CI: 1.084-1.951, P = .013), collateral circulation <grade 2 (OR = 3.056, 95%CI: 1.566-5.961, P = .001), thrombosis burden ≥4 points (OR = 2.033, 95%CI: 1.370-3.018, P < .001), diameter of target lesion ≥3.5 mm (OR = 1.511, 95%CI: 1.087-2.100, P = .014), thrombosis aspiration (OR = 1.422, 95%CI: 1.042-1.941, P = .026), and blood glucose >8 mmol/L (OR = 1.386, 95%CI: 1.007-1.908, P = .045) were related to no-reflow. Receiver operating characteristic (ROC) area under the curve was 0.648 (95%CI: 0.609-0.86). At 0.349 cutoff sensitivity was 42.0%, specificity was 79.3%, positive predictive value (PPV) was 44.7%, negative predictive value (NPV) was 77.4%, P < .001. The resulting risk scoring system was tested in the validation cohort (n = 536), with 30.1% incidence of no-reflow. The area under the ROC curve was 0.637 (95%CI: 0.582-0.692). At a cutoff of 0.349 sensitivity was 53.2% and specificity was 66.7%, PPV was 41.2%, NPV was 76.4%, P < .001.The no-reflow risk scoring system was effective in identifying high-risk patients.

A simple score to select patients for manual thrombectomy in emergent percutaneous coronary interventions: the DDTA score

BACKGROUND

The objective of manual thrombectomy is the removal of occlusive thrombus to improve the results of primary angioplasty. The better understanding of the factors associated with successful manual thrombectomy may provide relevant information regarding thrombus formation and resolution.

METHODS

Observational study of all consecutive patients remitted for emergent percutaneous coronary intervention (PCI) in a single centre. Successful manual thrombectomy was considered when TIMI 3 was achieved after using the device and a score to predict successful manual thrombectomy was designed.

RESULTS

We included 618 patients, 65.1% treated with manual thrombectomy. No relevant differences in clinical features or time delays were observed between patients treated with vs. without manual thrombectomy, but manual thrombectomy treated patients received more often dual antiplatelet treatment (DAPT) before PCI. Final TIMI flow 3 was achieved in most patients and more frequently in manual thrombectomy treated patients (94.8 vs. 86.6%; P < 0.01). The successful manual thrombectomy rate was 81.3% and it was higher in patients pretreated with DAPT (89.0 vs. 73.3%; P < 0.01). The time delay to first medical contact was not related to the final TIMI 3, but it was significantly and negatively related to successful manual thrombectomy. According to the multivariate analysis, we designed the DDTA score: DAPT pretreatment (2), delay less than 2 h (3) or 2-4 h (2), TIMI flow improvement after wiring the lesion (2) and age less than 55 years (3). Patients with DDTA score at least 4 had lower no-reflow, mortality and major cardiovascular complications incidence.

CONCLUSION

The DDTA score (DAPT pretreatment, time delays, TIMI flow improvement after wiring the lesion and age) identifies patients who benefit mostly from manual thrombectomy.

Long-term Impact of Thrombus Aspiration in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) is reported to improve myocardial reperfusion. However, the long-term prognostic implication of TA remains unclear. We aimed to investigate the influence of adjunctive TA on long-term outcomes in ST-segment elevation myocardial infarction (STEMI) patients undergoing PPCI. All STEMI patients from China that included in the TOTAL trial who were ≥18 years old and referred for PPCI within the 12 hours after symptom onset between January 2011 and November 2012 were retrospectively analyzed. Patients were divided into 2 groups based on the use of TA or not. The primary efficacy outcomes were 5-year major adverse cardiac events, a composite of cardiovascular death, recurrent MI, cardiogenic shock, or heart failure hospitalization. The primary safety outcome was a 5-year stroke. A total of 563 patients were included. The incidence rate of major adverse cardiac events at 5 years in the TA group was similar to that in the PCI group (hazard ratio [HR] 0.70; 95% confidence interval [CI] 0.42 to 1.17). In addition, TA was significantly associated with a nearly sevenfold increased risk of stroke at 5 years compared with PCI alone (HR 7.32, 95% CI 1.33 to 40.31). Our propensity scoring match analyses suggested that patients with an occluded lesion might benefit from the TA (HR 0.24, 95% CI 0.08 to 0.70). In conclusion, TA is not associated with improved outcomes in patients with STEMI but may have an adverse impact on stroke. Patients with an occluded infarct-related artery could benefit from the TA.

Effect of thrombus aspiration on microcirculatory resistance and ventricular function in patients with high thrombus burden

Background

Studies have not demonstrated consistent outcomes following thrombus aspiration in Primary Percutaneous Coronary Intervention (PPCI). We investigated the relationship between thrombus aspiration and microvascular obstruction as measured using Index of Microcirculatory Resistance (IMR) immediately following PPCI and Left Ventricle Function Improvement measured using Global Longitudinal Strain (GLS) six months following PPCI. Our aim is to determine microvascular obstruction and left ventricle function improvement six months following thrombus aspiration during PPCI.

Methods

This was a single-center, observational, prospective non-randomized study involving 45 patients with thrombus score 4–5 (defined as high thrombus burden) and Thrombolysis in Myocardial Infarction (TIMI) flow of 0–2 who subsequently underwent PPCI. Thrombus aspiration was conducted based on physician discretion. The IMR was measured immediately following the procedure. All patients underwent echocardiography to measure GLS at 24 h, 3 months and 6 months following PPCI.

Results

Thirty-three (73%) patients underwent thrombus aspiration during PPCI and twelve (27%) patients underwent the conventional PPCI. No significant difference in IMR was found between the group that underwent thrombus aspiration and the group that underwent conventional PCI (51.9 ± 41.5 vs 47.1 ± 35.6 p = 0.723). TIMI flow after PPCI was worse in thrombus aspiration group (OR 5.2 [1.2–23.2], p = 0.041). There was no difference in GLS between two groups at 6-month follow-up (− 13.0 ± 3.4 vs − 12.8 ± 4.6, p = 0.912).

Conclusion

This study indicates no benefit of thrombus aspiration during PPCI in reducing either microvascular obstruction or left ventricular function at 6-month follow-up for patients with high thrombus burden. Nevertheless, further studies are required before definite conclusions can be made.

Aspiration Thrombectomy for Acute ST-Elevation Myocardial Infarction: Literature Review

Over the years, aspiration thrombectomy for management of acute coronary syndrome was the center of discussion however due to multiple randomized control trials which did not provide sufficient evidence supporting use of this approach, this method is not routinely used. The benefit of this approach remains unknown, however, it is important to acknowledge the evolution of aspiration catheters and their potential in minimizing complications which were previously the set back of this approach. We provide a comprehensive review of the previous trials and how those catheters have since evolved significantly.

Association of Physician Variation in Use of Manual Aspiration Thrombectomy With Outcomes Following Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction: The National Cardiovascular Data Registry CathPCI Registry

Importance

Following negative randomized clinical trials, US guidelines downgraded support for routine manual aspiration thrombectomy (AT) during primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI). However, some PCI operators continue to endorse a clinical benefit with AT use despite the lack of supportive data.

Objective

To examine temporal trends and comparative outcomes of AT use during pPCI for STEMI.

Design, Setting, and Participants

Retrospective cohort study of the National Cardiovascular Data Registry (NCDR) CathPCI Registry from July 1, 2009, to June 30, 2016, to assess temporal trends and in-hospital outcomes associated with AT use. To evaluate outcomes through 180 days, a subanalysis was conducted among Centers for Medicare and Medicaid Services-linked patients from July 1, 2009, through December 31, 2014. The comparative effectiveness analysis was performed using instrumental variable analyses to account for treatment selection bias. The instrumental variable was operator's preference to use AT during pPCI. Data were analyzed between February 1, 2017, and April 1, 2018.

Exposures

Aspiration thrombectomy use during pPCI for STEMI.

Main Outcomes and Measures

Primary outcomes included in-hospital stroke and death. Secondary outcomes included heart failure, stroke, all-cause rehospitalization, and death through 180 days of follow-up.

Results

Among all pPCIs performed (683 584), the mean (SD) age of patients was 61.7 (12.8) years, 489 257 were male (71.6%), and 596 384 were white (87.2%). Among patients undergoing pPCI, AT use increased from 2009 through 2011, with peak use of 13.8%. This was followed by a decline of more than 9%, reaching 4.7% by mid-2016. Overall, AT was used in 10.8% of pPCIs (lowest operator group median, 0%; highest operator group median, 33.8%). After instrumental variable analysis, AT use was associated with no difference in in-hospital death (adjusted absolute risk difference, -0.18%; 95% CI, -0.53% to 0.16%; P = .29) and a small increase in in-hospital stroke (adjusted RD, 0.14%; 95% CI, 0.01%-0.30%; P = .03). Among Centers for Medicare and Medicaid Services-linked patients, AT use was not associated with differences in death, heart failure, stroke, or rehospitalization at 180 days.

Conclusions and Relevance

In this large, nationwide analysis, AT use during STEMI pPCI declined by more than 50% since 2011, with use as of mid-2016 at less than 5%. Selective AT use was associated with a small excess risk of in-hospital stroke and no difference in other outcomes through 180 days of follow-up.

Impact of Thrombus Aspiration on Clinical Outcomes in Korean Patients with ST Elevation Myocardial Infarction

We evaluated whether thrombus aspiration (TA) during primary percutaneous coronary intervention (PCI) reduces adverse clinical outcomes within 30-days and 1-year periods. There is no well-designed, Korean data about the clinical impact of intracoronary TA during primary PCI in patients with ST-segment elevation myocardial infarction (STEMI). From the Korea Acute Myocardial Infarction Registry-National Institute of Health, 3749 patients with STEMI undergoing primary PCI within 12 hours (60.8±12.9 years, 18.7% women) with pre-procedural Thrombolysis in Myocardial Infarction (TIMI) flow 0, 1 in coronary angiography were enrolled between November 2011 and December 2015. The patients were divided into two groups: PCI with TA (n=1630) and PCI alone (n=2119). The primary end-point was major adverse cardiac event (MACE), defined as the composite of cardiovascular death (CVD), recurrent MI and stroke for 30-days and 1-year. TA did not diminish the risk of MACE, all-cause mortality and CVD in all patients during 30-days or 1-year. After performing the propensity score matching, TA also did not reduce the risk of MACE (Hazard ratio (HR) with 95% Confidence Interval (CI):1.187 [0.863-1.633], p value=0.291), all-cause mortality (HR with 95% CI: 1.130 [0.776-1.647], p value=0.523) and CVD (HR with 95% CI: 1.222 [0.778-1.920], p value=0.384) during the 1-year period. In subgroup analysis, there was no benefit of clinical outcomes favoring PCI with TA. In conclusion, primary PCI with TA did not reduce MACE, all-cause mortality or CVD among the Korean patients with STEMI and pre-procedural TIMI flow 0, 1 during the 30-day and 1-year follow ups.

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

Microvascular Obstruction in ST-Segment Elevation Myocardial Infarction: Looking Back to Move Forward. Focus on CMR

After a myocardial infarction (MI), despite the resolution of the coronary occlusion, the deterioration of myocardial perfusion persists in a considerable number of patients. This phenomenon is known as microvascular obstruction (MVO). Initially, the focus was placed on re-establishing blood flow in the epicardial artery. Then, the observation that MVO has profound negative structural and prognostic repercussions revived interest in microcirculation. In the near future, the availability of co-adjuvant therapies (beyond timely coronary reperfusion) aimed at preventing, minimizing, and repairing MVOs and finding convincing answers to questions regarding what, when, how, and where to administer these therapies will be of utmost importance. The objective of this work is to review the state-of-the-art concepts on pathophysiology, diagnostic methods, and structural and clinical implications of MVOs in patients with ST-segment elevation MIs. Based on this knowledge we discuss previously-tested and future opportunities for the prevention and repair of MVO.

Intracoronary arterial retrograde thrombolysis with percutaneous coronary intervention: a novel use of thrombolytic to treat acute ST-segment elevation myocardial infarction

Background

Clearance of coronary arterial thrombosis is necessary in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing urgent percutaneous coronary intervention (PCI). There is currently no highly-recommended method of thrombus removal during interventional procedures. We describe a new method for opening culprit vessels to treat STEMI: intracoronary arterial retrograde thrombolysis (ICART) with PCI.

Methods & Results

Eight patients underwent ICART. The guidewire was advanced to the distal coronary artery through the occlusion lesion. Then, we inserted a microcatheter into the distal end of the occluded coronary artery over the guidewire. Urokinase (5-10 wu) mixed with contrast agents was slowly injected into the occluded section of the coronary artery through the microcatheter. The intracoronary thrombus gradually dissolved in 3-17 min, and the effect of thrombolysis was visible in real time. Stents were then implanted according to the characteristics of the recanalized culprit lesion to achieve full revascularization. One patient experienced premature ventricular contraction during vascular revascularization, and no malignant arrhythmias were seen in any patient. No reflow or slow flow was not observed post PCI. Thrombolysis in myocardial infarction flow grade and myocardial blush grade post-primary PCI was 3 in all eight patients. No patients experienced bleeding or stroke.

Conclusions

ICART was accurate and effective for treating intracoronary thrombi in patients with STEMI in this preliminary study. ICART was an effective, feasible, and simple approach to the management of STEMI, and no intraprocedural complications occurred in any of the patients. ICART may be a breakthrough in the treatment of acute STEMI.

An analysis of randomized controlled trials underpinning ST-elevation myocardial infarction management guidelines

BACKGROUND

The fragility index (FI) is calculated by iteratively changing one outcome "event" to a "non-event" within a trial until the associated p-value exceeds 0.05.

PURPOSE

To investigate the FI and fragility quotient (FQ) of trial endpoints referenced in the ACCF/AHA/SCAI guidelines in the management of ST-elevation myocardial infarctions. Secondarily, we assess the post-hoc power and risk of bias for these specific outcomes and whether differences exist between adequately and inadequately powered studies on fragility measures.

BASIC PROCEDURES

All citations referenced in the guideline were screened for inclusion criteria. The FI and FQ for all included trials were then calculated. The Cochrane 'risk of bias' Tool 2.0 was used to evaluate the likelihood and sources of bias in the included trials.

MAIN FINDINGS

Forty-two randomized controlled trials were included for assessment. The median FI was 10 with a FQ of 0.0055. Seven trials were at a high risk of bias, all due to bias in the randomization process. Fifteen trials were found to be underpowered. Adequately powered studies had higher FIs and FQs compared to underpowered studies.

PRINCIPAL CONCLUSIONS

Our findings support the use of FI and FQ analyses with power analyses in future methodology of randomized control trials. With understanding and reporting of FI and FQ, evidence of studies can be readily available and quickly eliminate some readers' concern for possible study limitations.

Polycythemia Vera Presenting as Cardiac Arrest: Novel Management Strategies

Acute coronary syndromes (ACS) usually occur in patients with multiple cardiac risk factors. In young adults, drug use and hypercoagulable states are common causes for ACS presentations. We report a case of a man in his early 30s who was diagnosed with polycythemia vera (PV) and had a cardiac arrest due to an anterolateral ST elevation myocardial infarction. We discuss his unique management and review the evidence on the management of arterial thromboembolism in PV patients.

Comparison of clinical outcomes between sufficient versus insufficient diagonal branch flow in anterior acute myocardial infarction

In primary percutaneous coronary intervention (PCI), revascularization to the main branch is considered to be more important than that to the side branch. The purpose of the present study was to compare in-hospital clinical outcomes between sufficient and insufficient diagonal flow in patients with anterior ST-elevation acute myocardial infarction. A total of 229 left anterior descending artery (LAD)-AMI with final Thrombolysis in Myocardial Infarction (TIMI)-3 LAD flow were included, and divided into the sufficient diagonal flow group (TIMI-3 diagonal flow: n = 170) and the insufficient diagonal flow group (TIMI ≤ 2 diagonal flow: n = 59). The primary endpoint was the incidence of mechanical complication. The secondary endpoints were incidences of in-hospital death, heart failure at discharge, and left ventricular thrombus. There were no significant differences in the primary endpoint (the sufficient diagonal flow group: 1.2%, the insufficient diagonal flow group: 0%, P = 0.403). In-hospital death was more frequently observed in the insufficient diagonal flow group (8.5%) than the sufficient diagonal flow group (2.9%) without reaching statistical significance (P = 0.073). The incidence of heart failure at discharge, and thrombus in left ventricular were not different between the two groups. In conclusion, in-hospital outcomes were not significantly different between the sufficient and insufficient diagonal flow groups. We may not stick to the diagonal flow in LAD-STEMI, as long as the LAD flow is maintained by PCI.