Archives of Cardiovascular Disease (2014) 107, 672—680
Available online at
ScienceDirect www.sciencedirect.com
CLINICAL RESEARCH
Impact of manual thrombectomy on myocardial reperfusion as assessed by ST-segment resolution in STEMI patients treated by primary PCI Impact de la thromboaspiration manuelle sur la reperfusion myocardique évaluée par la résolution du segment ST chez les patients traités par angioplastie primaire pour un syndrome coronaire aigu avec sus-décalage du segment ST Nathan Messas a, Sébastien Hess a, Adraa El Adraa a, Jessica Ristorto a, Franck Goïorani a, Julien Brocchi a, Bogdan Radulsecu a, Laurence Jesel a, Michel Zupan a, Patrick Ohlmann a, Olivier Morel a,∗,b a
Pôle d’activité médico-chirurgicale cardiovasculaire, université de Strasbourg, Nouvel hôpital civil, BP 426, 67091 Strasbourg, France b EA 7293 stress vasculaire et tissulaire en transplantation, université de Strasbourg, Strasbourg, France Received 6 February 2014; received in revised form 30 May 2014; accepted 3 July 2014 Available online 11 September 2014
KEYWORDS Acute coronary syndrome; Myocardial infarction; Lethal reperfusion injuries; Thrombosis
∗
Summary Background. — In STEMI patients treated by primary PCI, damage of the microvascular circulation caused by distal embolization of thrombotic material affects the quality of myocardial reperfusion. Important controversies remain concerning the usefulness of the manual thrombectomy to improve myocardial perfusion. The aim of this study is to evaluate the impact of manual thrombectomy on ST resolution as a surrogate of reperfusion extent. Methods. — Two hundred and thirty-nine consecutive STEMI patients with an 70%) resolution of ST segment elevation. Results. — A complete resolution of ST segment elevation occurred in 51.4% of patients in the thrombectomy group and in 35,6% of those in the conventional-PCI group (P = 0.018). Thrombectomy strategy was associated with a lower use of stents. Multivariate analysis identified manual thrombectomy (HR = 2.08 IC 95% (1.01—4.26); P = 0.046), inferior location and short ischemic delay ( 70 %) post procédural. Résultats. — Une résolution complète du segment ST a été observée chez 51,4 % des patients du groupe Thromboaspiration et 35,6 % des patients du groupe angioplastie conventionelle (p = 0,018). La stratégie de thromboaspiration était associée à une moindre utilisation de stents. En analyse multivariée, la thromboaspiration manuelle, la localisation inférieure de l’infarctus et un délai court de reperfusion (< 180 min) sont apparus être des facteur prédictifs de résolution complète du segment ST. L’analyse de Kaplan Meier portant sur les évènements cardio-vasculaires adverses ne montrait pas de différences significatives entre les deux groupes pour un suivi de 1,3 ans. Conclusion. — Chez les patients se présentant pour un syndrome coronaire aigu avec susdécalage du segment ST, la thromboaspiration manuelle entraîne une amélioration de la reperfusion myocardique attestée par une fréquence accrue de résolution complète du segment ST et une moindre utilisation de stents. Cependant, dans cette cohorte de taille limitée, cette stratégie ne s’est pas accompagnée d’une amélioration du pronostic cardiovasculaire à 1 an. © 2014 Elsevier Masson SAS. Tous droits réservés.
Introduction Developments in ischemic myocardial reperfusion strategies have considerably improved the prognosis of patients presenting with acute ST-elevation myocardial infarction (STEMI). The main objective of reperfusion strategies in STEMI is to limit infarct size and improve outcomes. Primary percutaneous coronary intervention (primary PCI) is the reperfusion reference strategy for patients presenting with STEMI within 12 hours of symptom onset [1]. Nevertheless, despite restoration of epicardial infarct related artery flow, damage of the microvascular circulation (microvascular
obstruction) occurs in a sizeable portion of cases [2]. Angioplasty can be complicated by spontaneous or procedural induced distal thrombotic material embolization that may alleviate the extent of myocardial reperfusion. Recent optical coherence tomography data have nicely demonstrated the huge amount of the atherothrombotic burden that follows stent implantation, with a residual thrombus being detected in 100% of cases. None surprisingly, important residual thrombotic burden was associated with angiographic no-flow, embolization distal occlusion and was evidenced as a strong predictor of ST resolution failure [3]. The extent of these microvascular injuries is associated with
674 worse clinical outcome [4]. Preventing embolization theoretically should result in improved reperfusion success as measured electrocardiographically (increased ST-segment resolution [STR]), and clinically (enhanced survival free from MACE and heart failure events). In this occurrence, adjunctive devices have been developed to reduce the thrombus burden and to minimize the risk of fragmentation and embolization. In this view, manual thrombus aspiration systems appear to be an appealing issue. However, evidences supporting a systematic use of manual thrombectomy before primary PCI are still debated and were very recently challenged by the TASTE trial [5]. Moreover, thrombus aspiration may not be a risk-free procedure. Systemic embolization can occur, and in a recent meta-analysis, thrombus aspiration was associated with a trend toward an increased rate of stroke [6,7]. The aim of this study was to assess the impact of manual thrombus aspiration on myocardial reperfusion through ST-segment resolution assessment and new Q waves generation, in a cohort of STEMI patients undergoing primary PCI.
Methods Study population The data analyzed in this study were obtained from a single-centre cohort. In the institutional PCI database, we identified consecutive STEMI patients who underwent primary PCI, in the cardiology centre at University hospital of Strasbourg, France, between January 2009 and September 2011. Patients were eligible for inclusion if they presented ischemic chest pain within 12 hours of symptom onset, and a 2 mm ST elevation in the V1 to V3 leads or 1 mm ST elevation in the remaining leads. When thrombus aspiration was performed, only STEMI patients treated with 6F aspiration catheter (Export, Medtronic, Dancers, MA, USA) were included in the final study cohort. Exclusion criteria from the analysis were ischemic symptoms for >12 h, prehospital cardiac arrest, an ECG showing left bundle branch block or ventricular pacing, and patients already included in another STEMI research protocol. The primary PCI procedure and pharmacological treatment was performed according to the standard of care at the time of hospital admission. The choice to perform manual thrombus aspiration was at the discretion of the operator. Data including demographic, clinical, biological, angiographic and procedural characteristics were extracted from the PCI and the ICU databases. The study protocol complied with the tenets of the Declaration of Helsinki. Study was approved by our Institutional Review Board and all participants gave informed consent.
N. Messas et al. measured in the lead with the most prominent ST-segment deviation. A complete ST segment elevation resolution (complete STR) was defined when the regression of the sum of ST-segment elevation before and after PCI reached more then 70%.
Clinical outcomes Follow up of the study cohort allowed to collect the following cardiac events. Major adverse cardiac events (MACE), hospitalisation for acute heart failure. MACE was defined as a composite of all-cause death, recurrent myocardial infarction, and target vessel revascularization (TVR). Evidence of myocardial reinfarction was defined as chest pain or ECG changes accompanied by a reelevation in level (>3 times the upper limit of normal). Target vessel revascularization was defined as the need for new PCI or coronary artery bypass graft of the culprit vessel because of either symptom recurrence or a positive ischemic functional test at follow-up.
End points The primary study end point was the extent of myocardial reperfusion assessed by the presence or not of complete STsegment elevation resolution (STR > 70%), 60 minutes after PPCI, taking into account the sum of ST elevation in all 12 leads (cumulative ST elevation). Secondary endpoints included the incidence of new Q waves generation, and the incidence of MACE (death, myocardial infarction, target vessel revascularisation), of hospitalisation for acute heart failure, and of a composite end point of MACE and hospitalisation for acute heart failure.
Statistical analysis The normal distribution of the studied variables was tested using the D’agostino and Pearson omnibus normality test. Categorical variables were expressed as count and percentages. Continuous variables were reported as mean and SD for continuous, or as medians and interquartile ranges according to their distribution. Categorical variables were compared with Chi2 test or Fisher’s exact test. Continuous variables were compared with the use of Mann-Whitney test. To determine the effect of thrombus aspiration on the primary outcome, logistic regression analysis was performed. Association between thrombus aspiration and occurrence of clinical outcomes was assessed by Kaplan Meier analysis and log rank test. All tests were 2-sided. A P value < 0.05 was considered significant. Calculations were performed using SPSS 13.0 for Windows (SPSS Inc., Chicago, IL, USA).
Electrocardiography Analysis of ST-segment deviation was performed (in a blinded fashion according to use or not of manual thrombectomy) by comparing ECG obtained at time of first medical contact and ECG obtained 60 minutes after primary PCI. The following parameters were assessed (measured in millimeters): sum of ST-segment elevation in all 12 leads (cumulative ST elevation), and maximal ST elevation
Results Study population and baseline characteristics The final study cohort comprised 239 patients who were treated with primary PCI and who did meet the inclusion and exclusion criteria between January 1, 2009 and
Impact of manual thrombectomy on myocardial reperfusion Table 1
675
Demographic and clinical characteristics.
Demographic Male sex, n (%) Age, year Cardiovascular risk factor, n (%) Current smoking Diabetes mellitus Hypertension Family history of CAD Hypercholesterolemia BMI > 30 kg/m2 Medical history, n (%) STEMI NSTEMI PCI CABG Stroke Chronic kidney disease Clinical Anterior STEMI Systolic blood pressure, mmHg Diastolic blood pressure, mmHg Heart Rate, bpm Killip class 1 2 3 4
Conventional PCI (n = 132)
Thrombectomy (n = 107)
P
98 (74.2)
78 (72.9)
0.88
59.8 ± 13.5
62.8 ± 15.3
0.11
76 (57.6) 24 (18.2) 63(47.7) 25 (18.9) 58 (43.9) 36 (27.3)
70 17 43 20 42 17
0.23 0.73 0.29 1 0.51 0.042
8 (6.1) 5 (3.8) 10 (7.6) 4 (3) 5 (3.8) 6 (4.5)
5 3 7 2 0 5
59 (44.7) 134.4 ± 23.9 78.3 ± 13.4 76.8 ± 15.7
39 (36.4) 132 ± 23.3 77.2 ± 14.3 75.2 ± 16
0.3 0.47 0.55 0.46
120 (90.9) 10 (7.6) 0 (0) 2 (1.5)
90 (84.1) 11 (10.3) 3 (2.8) 3 (2.8)
0.17
September 30, 2011. Of these patients, 137 patients were treated with primary PCI (conventional PCI group) and 102 patients underwent adjunctive manual thrombus aspiration using a 6F export aspiration catheter before primary PCI (thrombectomy group). Baseline demographic and clinical characteristics are given in Table 1. The percentage of obese patients (BMI > 30 kg/m2 ) was higher in the conventional PCI group (27.3% vs. 15.9%, P = 0.042). Other demographic and clinical characteristics were similar in the two groups of patients.
Angiographic and procedural data Angiographic and procedural characteristics data are shown respectively in Tables 2 and 3. Ischemic time (time delay between onset of symptoms and balloon inflation) did not significantly differ between the two groups. Initial TIMI flow were of grade 0 to 1 more frequently in the thrombus aspiration group (95.3% vs. 84.1%, P = 0.006). The percentage of direct stenting and the use of GPIIbIIIa antagonists was equivalent between groups. The rate of stent implantation was lower in the thromboaspiration group (89.7 vs. 100%; P < 0.001). In addition, the diameter of the stent was higher in the thromboaspiration group (3.5 vs. 2.7 mm, P = 0.005). Post procedural TIMI 2 to 3 flow grade was not significantly different between the two groups (conventional PCI group, 97.7%; thrombus aspiration group, 95.7%; P = 0.11).
(65.4) (15.9) (40.2) (18.7) (39.3) (15.9)
(4.7) (2.8) (6.5) (1.9) (0) (4.7)
0.77 0.73 0.8 0.69 0.06 1
Biological data Biological data are given in Table 4. Leukocytes (15,423/mm3 vs.12,410/mm3 ; P = 0.04) and platelets counts (267.103 /mm3 vs. 235.103 /mm3 ; P = 0.006) were higher in the thrombectomy group as was peak troponin I (103.7 vs. 154.3 g/l; P < 0.001).
ECG analysis and myocardial reperfusion The results of ECG analysis are provided in Table 5. Post procedural ST-segment resolution (expressed as a percentage) could be assessed in all patients. In the full cohort, complete ST-segment resolution (cumulative STR > 70%) occurred in 42% of cases after primary PCI. Thrombectomy before stenting resulted in improved myocardial reperfusion documented by a complete STR in 55 of the 107 patients (51.4%) in the thrombus aspiration group as compared with 47 of the 132 pts (35.6%) in the conventional PCI group (P = 0.018). In addition, Q waves less frequently observed in the thrombectomy group (46.7% vs. 61,4%; P < 0.02).
Patients characteristics according to ST-segment resolution Comparison of patients with and without complete STR is shown in Table 6. Complete STR was associated with higher
676 Table 2
N. Messas et al. Angiographic characteristics.
Infarct related artery, n (%) Left anterior descending artery Left circumflex artery Right coronary artery Left main coronary artery No of diseased vessel, n (%) 1 2 3 Initial TIMI flow 0—1 2—3 Final TIMI flow 0—1 2—3
Table 3
Conventional PCI (n = 132)
Thrombectomy (n = 107)
P
59 30 39 4
39 28 39 2
0.35 0.54 0.79 0.69
(44.8) (22.7) (29.5) (3)
(36.4) (26.2) (35.5) (1.9)
63 (47.7) 37 (28) 32 (24.2)
65 (60.7) 21 (19.7) 20 (18.7)
0.051 0.17 0.34
111 (84.1) 21 (15.9)
102 (95.3) 5 (4.7)
0.006
3 (2.3) 129 (97.7)
7 (6.7) 98 (93.3)
0.11
Procedural characteristics.
Total ischemic time, h Stent implantation, n (%) Balloon PCI alone, n (%) Direct stenting, n (%) Stent diameter (mm) Stent length (mm) No of stent per patient (median (IQR) BMS, n (%) DES, n (%) GPIIbIIIa antagonists, n (%)
Conventional PCI (n = 132)
Thrombectomy (n = 107)
P
4.4 ± 2.8 132 (100) 0 (0) 68 (51.5) 3 (2.7—3) 20 (16—28) 1 (1—2) 107 (81.1) 25 (18.9) 94 (71.2)
5.1 ± 3.2 96 (89.7) 7 (6.5) 57 (53.3) 3 (3—3.5) 22 (16.5—30.7) 1 (1—2) 81 (84.4) 15 (15.6) 84 (78.5)
0.12 70%) Univariate and multivariate analysis Characteristics
Univariate OR (95% CI)
P
Multivariate OR (95% CI)
P
Thrombectomy Ischemic time < 3 h (symptoms to balloon) Initial TIMI flow 0-1 Non-anterior infarct location Current smoking BMI > 30 kg/m2 Troponin I peak Maximal ST elevation Diabetes mellitus Killip class > 2
1.91 2.03 0.28 1.54 1.51 1.14 0.79 1.02 1.06 0.80
0.01 0.01 0.01 0.01 0.10 0.16 0.16 0.56 0.86 0.76
1.82 (1.02—3.27) 2.73 (1.52—4.90) 0.66 (0.43—1.01) 1.70 (0.74—3.90) 1.21 (0.67—2.16) 1.21(0.61—2.38) 0.99 (0.99—1.00)
0.043 0.001 0.056 0.20 0.51 0.57 0.29
(1.13—3.21) (1.13—3.67) (0.10—0.78) (1.07—2.21) (0.88—2.57) (0.62—2.11) (0.0.78—1.01) (0.95—1.09) (0.53—2.09) (0.18—3.42)
Impact of manual thrombectomy on myocardial reperfusion Table 8
679
Incidence of Major cardiac events (MACE) and Acute heart failure. Conventional PCI (n = 132)
Death, n (%) Cardiac death, n (%) Myocardial reinfarction, n (%) TVR, n (%) MACE, n (%) Admission for acute Heart Failure, n (%) MACE + AHF
in the EXPIRA trial, thrombectomy improved the myocardial reperfusion as assessed by a higher rate of ST segment resolution [9]. In the latter trial, the improvement of myocardial perfusion was associated with a reduction of infarct size as assessed by MRI analysis. Accordingly, two recent metaanalyses have suggested that manual thrombus aspiration strategy might improve the quality of myocardial perfusion [10,11]. This promising paradigm ‘‘reduction of thrombus burden as a tool to avoid micro-embolization’’ was however challenged by data obtained in larger cohort of multi-centre trials. For instance, in the INFUSE-AMI study that have explored four strategies (abciximab, thrombus aspiration, thrombus aspiration + abciximab, and no abciximab + no thromboaspiration), the infarct size endpoint assessed at 30 days by cardiac magnetic resonance imaging (MRI) was nearly identical in the aspiration and control arms as were TIMI flow, MBG, and STR [12]. Although the extent of ST resolution was not investigate in the TASTE trial, cardiac enzyme release as a surrogate marker of infarct size was not significantly reduced in the thrombus aspiration group [5].
Other predictors of ST resolution Besides the reduction of the thrombus load using manual thrombectomy, short reperfusion delay represent other predictors of ST resolution. In univariate analysis, a short delay is associated with better reperfusion evidenced by a higher frequency of post-procedure complete ST resolution (STR > 70%, OR = 0.86, 95% CI 0.78—0.95; P = 0.001) and becomes an independent predicting factor of complete STR even after adjustment for confounding factors. Taking into account the temporal evolution of myonecrosis [13], these data underlined the fact that early reperfusion is probably an ideal condition to demonstrate myocardial salvage which is also consistent with histopathology findings on thromboaspiration products. Whilst the thrombus is mainly of platelet origin within the two first hours, older thrombus are characterized by a complex network of fibrin and erythrocytes more likely resistant to the fibrin-degrading proteolytic enzyme and probably less accessible to adequate thromboaspiration [14]. In the literature, the impact of initial TIMI flow on ST resolution remains controversial. According to Erden et al., the ST resolution was lower in patients with spontaneous coronary reperfusion prior PCI [15]. Conversely, other work has suggested that TIMI flow grade 2 or less before pPCI could be an independent predictor of impaired ST resolution [16].
5 4 3 11 19 7 26
(4.1) (3.3) (2.5) (9.1) (15.7) (5.8) (19.6)
Thrombectomy (n = 107) 2 2 1 8 12 2 14
(2) (2) (1) (8.2) (12.2) (2) (13)
Manual thrombectomy and clinical outcomes In spite of improved ST resolution, no differences in MACE and heart failure could be evidenced at 1.3 years follow up. The notion that manual thrombectomy has a real impact on cardiovascular outcome was recently challenged by the TASTE trial. Previous observations from the TAPAS trial have suggested that thrombus aspiration resulted in a trend toward improved 30-day survival, which became significant by one year [17]. Surprisingly, this improvement on survival was observed in spite of any sizeable reduction of infarct size measured by cardiac enzyme release. Therefore, the pathophysiological basis associating thrombus aspiration and reduction of cardiac mortality remained unclear. Recent meta-analysis have reported conflicting findings, showing either a reduction of 30-days mortality rate, mainly draw by the TAPAS trial [10,18] or a lack of efficiency [11]. In the multicenter INFUSE MI trial, no significant reduction of mortality could be established in patients treated by thrombus aspiration. Likewise, the 30 days outcome of patients enrolled in the large TASTE trial has been recently published. In this nation wide large multicenter trial enrolling 7244 patients, thrombus aspiration did not improve the 30 days rate of death, rehospitalisation for heart failure or stroke. Stent thrombosis or rehospitalisation for myocardial infarction tended to be lower in the thrombus aspiration group [5]. In our study, in spite of the improvement of STsegment resolution observed in the thrombectomy group, ST resolution failure was detected in 48%. The question whether unsuccessful microcirculatory perfusion is due to micro-embolization or results from lethal reperfusion injury deserves further investigation.
Limitations The present work is monocentric and has the inherent limitations of any small non-randomized series. Blush score and TIMI frame count, other markers of myocardial perfusion were not assessed. Infarct size and no reflow phenomenon were not analyzed by MRI. The thrombotic material was not quantified. However, in STEMI patients the evaluation of the thrombotic burden by the measurement of the thrombotic material retrieved by thrombectomy remains difficult to assess: • large thrombus could not be aspirate by the current available device;
680 • even in case of thrombectomy, residual thrombotic materials could be detected within the implanted stent by OCT in almost 100% of the cases [3]. Other limitations are represented by the absence of ECG independent reviewing and the absence of accurate collaterally evaluation. Finally, given the limited size of our population, and the low number of adverse events recorded during follow up, the present study was not powered to draw definite conclusion on the impact of thrombus aspiration strategy on clinically relevant hard points.
Conclusion In STEMI patients treated by primary PCI, manual thrombectomy results in improved myocardial reperfusion as assessed by ST segment resolution and a lower use of stents. However, in this cohort of limited size, this strategy did not translate into an improved cardiovascular outcome at 1-year follow-up.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Steg PG, James SK, Atar D, Badano LP, Lundqvist CB, Borger MA, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012. [2] Stone GW, Peterson MA, Lansky AJ, Dangas G, Mehran R, Leon MB. Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction. J Am Coll Cardiol 2002;39:591—7 [Research Support, Non-U.S. Gov’t Validation Studies]. [3] Magro M, Regar E, Gutierrez-Chico JL, Garcia-Garcia H, Simsek C, Schultz C, et al. Residual atherothrombotic material after stenting in acute myocardial infarction — an optical coherence tomographic evaluation. Int J Cardiol 2013;167:656—63. [4] Wu KC, Zerhouni EA, Judd RM, Lugo-Olivieri CH, Barouch LA, Schulman SP, et al. Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation 1998;97(8):765—72 [Research Support, Non-U.S. Gov’t Research Support, U.S. Gov’t, P.H.S.]. [5] Frobert O, Lagerqvist B, Olivecrona GK, Omerovic E, Gudnason T, Maeng M, et al. Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med 2013;369(17):1587—97 [Comparative Study Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. [6] Lin MS, Wu LS, Cheng NJ, Lin PC, Chang CJ. Thrombus aspiration complicated by systemic embolization in patients with acute myocardial infarction. Circ J 2009;73(7):1356—8.
N. Messas et al. [7] De Luca G, Navarese EP, Suryapranata H. A meta-analytic overview of thrombectomy during primary angioplasty. Int J Cardiol 2013;166(3):606—12. [8] Svilaas T, Vlaar PJ, van der Horst IC, Diercks GF, de Smet BJ, van den Heuvel AF, et al. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med 2008;358(6):557—67 [Comparative Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. [9] Sardella G, Mancone M, Bucciarelli-Ducci C, Agati L, Scardala R, Carbone I, et al. 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. J Am Coll Cardiol 2009;53(4):309—15 [Randomized Controlled Trial]. [10] De Luca G, Dudek D, Sardella G, Marino P, Chevalier B, Zijlstra F. Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized trials. Eur Heart J 2008;29(24):3002—10 [meta-analysis review validation studies]. [11] Mongeon FP, Belisle P, Joseph L, Eisenberg MJ, Rinfret S. Adjunctive thrombectomy for acute myocardial infarction: a bayesian meta-analysis. Circ Cardiovasc Interv 2010;3(1):6—16 [meta-analysis]. [12] Stone GW, Maehara A, Witzenbichler B, Godlewski J, Parise H, Dambrink JH, et al. Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: the INFUSE-AMI randomized trial. JAMA 2012;307(17):1817—26 [Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. [13] Reimer KA, Lowe JE, Rasmussen MM, Jennings RB. The wavefront phenomenon of ischemic cell death. 1. Myocardial infarct size vs duration of coronary occlusion in dogs. Circulation 1977;56(5):786—94 [Research Support, U.S. Gov’t, P.H.S.]. [14] Beygui F, Collet JP, Nagaswami C, Weisel JW, Montalescot G. Images in cardiovascular medicine. Architecture of intracoronary thrombi in ST-elevation acute myocardial infarction: time makes the difference. Circulation 2006;113(2):e21—3 [case reports]. [15] Erden EC, Erden I, Turker Y, Aslantas Y, Yalcin S, Karabacak A. Amount of ST wave resolution in patients with and without spontaneous coronary reperfusion in the infarct -related artery after primary PCI: an observational study. Anadolu Kardiyol Derg 2012;12(1):30—4. [16] Park SR, Kang YR, Seo MK, Kang MK, Cho JH, An YJ, et al. Clinical predictors of incomplete ST-segment resolution in the patients with acute ST segment elevation myocardial infarction. Korean Circ J 2009;39(8):310—6. [17] Vlaar PJ, Svilaas T, van der Horst IC, Diercks GF, Fokkema ML, de Smet BJ, et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet 2008;371(9628):1915—20 [Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. [18] Noman A, Egred M, Bagnall A, Spyridopoulos I, Jamieson S, Ahmed J. Impact of thrombus aspiration during primary percutaneous coronary intervention on mortality in ST-segment elevation myocardial infarction. Eur Heart J 2012;33(24):3054—61.
Available online at
ScienceDirect www.sciencedirect.com
CLINICAL RESEARCH
Impact of manual thrombectomy on myocardial reperfusion as assessed by ST-segment resolution in STEMI patients treated by primary PCI Impact de la thromboaspiration manuelle sur la reperfusion myocardique évaluée par la résolution du segment ST chez les patients traités par angioplastie primaire pour un syndrome coronaire aigu avec sus-décalage du segment ST Nathan Messas a, Sébastien Hess a, Adraa El Adraa a, Jessica Ristorto a, Franck Goïorani a, Julien Brocchi a, Bogdan Radulsecu a, Laurence Jesel a, Michel Zupan a, Patrick Ohlmann a, Olivier Morel a,∗,b a
Pôle d’activité médico-chirurgicale cardiovasculaire, université de Strasbourg, Nouvel hôpital civil, BP 426, 67091 Strasbourg, France b EA 7293 stress vasculaire et tissulaire en transplantation, université de Strasbourg, Strasbourg, France Received 6 February 2014; received in revised form 30 May 2014; accepted 3 July 2014 Available online 11 September 2014
KEYWORDS Acute coronary syndrome; Myocardial infarction; Lethal reperfusion injuries; Thrombosis
∗
Summary Background. — In STEMI patients treated by primary PCI, damage of the microvascular circulation caused by distal embolization of thrombotic material affects the quality of myocardial reperfusion. Important controversies remain concerning the usefulness of the manual thrombectomy to improve myocardial perfusion. The aim of this study is to evaluate the impact of manual thrombectomy on ST resolution as a surrogate of reperfusion extent. Methods. — Two hundred and thirty-nine consecutive STEMI patients with an 70%) resolution of ST segment elevation. Results. — A complete resolution of ST segment elevation occurred in 51.4% of patients in the thrombectomy group and in 35,6% of those in the conventional-PCI group (P = 0.018). Thrombectomy strategy was associated with a lower use of stents. Multivariate analysis identified manual thrombectomy (HR = 2.08 IC 95% (1.01—4.26); P = 0.046), inferior location and short ischemic delay ( 70 %) post procédural. Résultats. — Une résolution complète du segment ST a été observée chez 51,4 % des patients du groupe Thromboaspiration et 35,6 % des patients du groupe angioplastie conventionelle (p = 0,018). La stratégie de thromboaspiration était associée à une moindre utilisation de stents. En analyse multivariée, la thromboaspiration manuelle, la localisation inférieure de l’infarctus et un délai court de reperfusion (< 180 min) sont apparus être des facteur prédictifs de résolution complète du segment ST. L’analyse de Kaplan Meier portant sur les évènements cardio-vasculaires adverses ne montrait pas de différences significatives entre les deux groupes pour un suivi de 1,3 ans. Conclusion. — Chez les patients se présentant pour un syndrome coronaire aigu avec susdécalage du segment ST, la thromboaspiration manuelle entraîne une amélioration de la reperfusion myocardique attestée par une fréquence accrue de résolution complète du segment ST et une moindre utilisation de stents. Cependant, dans cette cohorte de taille limitée, cette stratégie ne s’est pas accompagnée d’une amélioration du pronostic cardiovasculaire à 1 an. © 2014 Elsevier Masson SAS. Tous droits réservés.
Introduction Developments in ischemic myocardial reperfusion strategies have considerably improved the prognosis of patients presenting with acute ST-elevation myocardial infarction (STEMI). The main objective of reperfusion strategies in STEMI is to limit infarct size and improve outcomes. Primary percutaneous coronary intervention (primary PCI) is the reperfusion reference strategy for patients presenting with STEMI within 12 hours of symptom onset [1]. Nevertheless, despite restoration of epicardial infarct related artery flow, damage of the microvascular circulation (microvascular
obstruction) occurs in a sizeable portion of cases [2]. Angioplasty can be complicated by spontaneous or procedural induced distal thrombotic material embolization that may alleviate the extent of myocardial reperfusion. Recent optical coherence tomography data have nicely demonstrated the huge amount of the atherothrombotic burden that follows stent implantation, with a residual thrombus being detected in 100% of cases. None surprisingly, important residual thrombotic burden was associated with angiographic no-flow, embolization distal occlusion and was evidenced as a strong predictor of ST resolution failure [3]. The extent of these microvascular injuries is associated with
674 worse clinical outcome [4]. Preventing embolization theoretically should result in improved reperfusion success as measured electrocardiographically (increased ST-segment resolution [STR]), and clinically (enhanced survival free from MACE and heart failure events). In this occurrence, adjunctive devices have been developed to reduce the thrombus burden and to minimize the risk of fragmentation and embolization. In this view, manual thrombus aspiration systems appear to be an appealing issue. However, evidences supporting a systematic use of manual thrombectomy before primary PCI are still debated and were very recently challenged by the TASTE trial [5]. Moreover, thrombus aspiration may not be a risk-free procedure. Systemic embolization can occur, and in a recent meta-analysis, thrombus aspiration was associated with a trend toward an increased rate of stroke [6,7]. The aim of this study was to assess the impact of manual thrombus aspiration on myocardial reperfusion through ST-segment resolution assessment and new Q waves generation, in a cohort of STEMI patients undergoing primary PCI.
Methods Study population The data analyzed in this study were obtained from a single-centre cohort. In the institutional PCI database, we identified consecutive STEMI patients who underwent primary PCI, in the cardiology centre at University hospital of Strasbourg, France, between January 2009 and September 2011. Patients were eligible for inclusion if they presented ischemic chest pain within 12 hours of symptom onset, and a 2 mm ST elevation in the V1 to V3 leads or 1 mm ST elevation in the remaining leads. When thrombus aspiration was performed, only STEMI patients treated with 6F aspiration catheter (Export, Medtronic, Dancers, MA, USA) were included in the final study cohort. Exclusion criteria from the analysis were ischemic symptoms for >12 h, prehospital cardiac arrest, an ECG showing left bundle branch block or ventricular pacing, and patients already included in another STEMI research protocol. The primary PCI procedure and pharmacological treatment was performed according to the standard of care at the time of hospital admission. The choice to perform manual thrombus aspiration was at the discretion of the operator. Data including demographic, clinical, biological, angiographic and procedural characteristics were extracted from the PCI and the ICU databases. The study protocol complied with the tenets of the Declaration of Helsinki. Study was approved by our Institutional Review Board and all participants gave informed consent.
N. Messas et al. measured in the lead with the most prominent ST-segment deviation. A complete ST segment elevation resolution (complete STR) was defined when the regression of the sum of ST-segment elevation before and after PCI reached more then 70%.
Clinical outcomes Follow up of the study cohort allowed to collect the following cardiac events. Major adverse cardiac events (MACE), hospitalisation for acute heart failure. MACE was defined as a composite of all-cause death, recurrent myocardial infarction, and target vessel revascularization (TVR). Evidence of myocardial reinfarction was defined as chest pain or ECG changes accompanied by a reelevation in level (>3 times the upper limit of normal). Target vessel revascularization was defined as the need for new PCI or coronary artery bypass graft of the culprit vessel because of either symptom recurrence or a positive ischemic functional test at follow-up.
End points The primary study end point was the extent of myocardial reperfusion assessed by the presence or not of complete STsegment elevation resolution (STR > 70%), 60 minutes after PPCI, taking into account the sum of ST elevation in all 12 leads (cumulative ST elevation). Secondary endpoints included the incidence of new Q waves generation, and the incidence of MACE (death, myocardial infarction, target vessel revascularisation), of hospitalisation for acute heart failure, and of a composite end point of MACE and hospitalisation for acute heart failure.
Statistical analysis The normal distribution of the studied variables was tested using the D’agostino and Pearson omnibus normality test. Categorical variables were expressed as count and percentages. Continuous variables were reported as mean and SD for continuous, or as medians and interquartile ranges according to their distribution. Categorical variables were compared with Chi2 test or Fisher’s exact test. Continuous variables were compared with the use of Mann-Whitney test. To determine the effect of thrombus aspiration on the primary outcome, logistic regression analysis was performed. Association between thrombus aspiration and occurrence of clinical outcomes was assessed by Kaplan Meier analysis and log rank test. All tests were 2-sided. A P value < 0.05 was considered significant. Calculations were performed using SPSS 13.0 for Windows (SPSS Inc., Chicago, IL, USA).
Electrocardiography Analysis of ST-segment deviation was performed (in a blinded fashion according to use or not of manual thrombectomy) by comparing ECG obtained at time of first medical contact and ECG obtained 60 minutes after primary PCI. The following parameters were assessed (measured in millimeters): sum of ST-segment elevation in all 12 leads (cumulative ST elevation), and maximal ST elevation
Results Study population and baseline characteristics The final study cohort comprised 239 patients who were treated with primary PCI and who did meet the inclusion and exclusion criteria between January 1, 2009 and
Impact of manual thrombectomy on myocardial reperfusion Table 1
675
Demographic and clinical characteristics.
Demographic Male sex, n (%) Age, year Cardiovascular risk factor, n (%) Current smoking Diabetes mellitus Hypertension Family history of CAD Hypercholesterolemia BMI > 30 kg/m2 Medical history, n (%) STEMI NSTEMI PCI CABG Stroke Chronic kidney disease Clinical Anterior STEMI Systolic blood pressure, mmHg Diastolic blood pressure, mmHg Heart Rate, bpm Killip class 1 2 3 4
Conventional PCI (n = 132)
Thrombectomy (n = 107)
P
98 (74.2)
78 (72.9)
0.88
59.8 ± 13.5
62.8 ± 15.3
0.11
76 (57.6) 24 (18.2) 63(47.7) 25 (18.9) 58 (43.9) 36 (27.3)
70 17 43 20 42 17
0.23 0.73 0.29 1 0.51 0.042
8 (6.1) 5 (3.8) 10 (7.6) 4 (3) 5 (3.8) 6 (4.5)
5 3 7 2 0 5
59 (44.7) 134.4 ± 23.9 78.3 ± 13.4 76.8 ± 15.7
39 (36.4) 132 ± 23.3 77.2 ± 14.3 75.2 ± 16
0.3 0.47 0.55 0.46
120 (90.9) 10 (7.6) 0 (0) 2 (1.5)
90 (84.1) 11 (10.3) 3 (2.8) 3 (2.8)
0.17
September 30, 2011. Of these patients, 137 patients were treated with primary PCI (conventional PCI group) and 102 patients underwent adjunctive manual thrombus aspiration using a 6F export aspiration catheter before primary PCI (thrombectomy group). Baseline demographic and clinical characteristics are given in Table 1. The percentage of obese patients (BMI > 30 kg/m2 ) was higher in the conventional PCI group (27.3% vs. 15.9%, P = 0.042). Other demographic and clinical characteristics were similar in the two groups of patients.
Angiographic and procedural data Angiographic and procedural characteristics data are shown respectively in Tables 2 and 3. Ischemic time (time delay between onset of symptoms and balloon inflation) did not significantly differ between the two groups. Initial TIMI flow were of grade 0 to 1 more frequently in the thrombus aspiration group (95.3% vs. 84.1%, P = 0.006). The percentage of direct stenting and the use of GPIIbIIIa antagonists was equivalent between groups. The rate of stent implantation was lower in the thromboaspiration group (89.7 vs. 100%; P < 0.001). In addition, the diameter of the stent was higher in the thromboaspiration group (3.5 vs. 2.7 mm, P = 0.005). Post procedural TIMI 2 to 3 flow grade was not significantly different between the two groups (conventional PCI group, 97.7%; thrombus aspiration group, 95.7%; P = 0.11).
(65.4) (15.9) (40.2) (18.7) (39.3) (15.9)
(4.7) (2.8) (6.5) (1.9) (0) (4.7)
0.77 0.73 0.8 0.69 0.06 1
Biological data Biological data are given in Table 4. Leukocytes (15,423/mm3 vs.12,410/mm3 ; P = 0.04) and platelets counts (267.103 /mm3 vs. 235.103 /mm3 ; P = 0.006) were higher in the thrombectomy group as was peak troponin I (103.7 vs. 154.3 g/l; P < 0.001).
ECG analysis and myocardial reperfusion The results of ECG analysis are provided in Table 5. Post procedural ST-segment resolution (expressed as a percentage) could be assessed in all patients. In the full cohort, complete ST-segment resolution (cumulative STR > 70%) occurred in 42% of cases after primary PCI. Thrombectomy before stenting resulted in improved myocardial reperfusion documented by a complete STR in 55 of the 107 patients (51.4%) in the thrombus aspiration group as compared with 47 of the 132 pts (35.6%) in the conventional PCI group (P = 0.018). In addition, Q waves less frequently observed in the thrombectomy group (46.7% vs. 61,4%; P < 0.02).
Patients characteristics according to ST-segment resolution Comparison of patients with and without complete STR is shown in Table 6. Complete STR was associated with higher
676 Table 2
N. Messas et al. Angiographic characteristics.
Infarct related artery, n (%) Left anterior descending artery Left circumflex artery Right coronary artery Left main coronary artery No of diseased vessel, n (%) 1 2 3 Initial TIMI flow 0—1 2—3 Final TIMI flow 0—1 2—3
Table 3
Conventional PCI (n = 132)
Thrombectomy (n = 107)
P
59 30 39 4
39 28 39 2
0.35 0.54 0.79 0.69
(44.8) (22.7) (29.5) (3)
(36.4) (26.2) (35.5) (1.9)
63 (47.7) 37 (28) 32 (24.2)
65 (60.7) 21 (19.7) 20 (18.7)
0.051 0.17 0.34
111 (84.1) 21 (15.9)
102 (95.3) 5 (4.7)
0.006
3 (2.3) 129 (97.7)
7 (6.7) 98 (93.3)
0.11
Procedural characteristics.
Total ischemic time, h Stent implantation, n (%) Balloon PCI alone, n (%) Direct stenting, n (%) Stent diameter (mm) Stent length (mm) No of stent per patient (median (IQR) BMS, n (%) DES, n (%) GPIIbIIIa antagonists, n (%)
Conventional PCI (n = 132)
Thrombectomy (n = 107)
P
4.4 ± 2.8 132 (100) 0 (0) 68 (51.5) 3 (2.7—3) 20 (16—28) 1 (1—2) 107 (81.1) 25 (18.9) 94 (71.2)
5.1 ± 3.2 96 (89.7) 7 (6.5) 57 (53.3) 3 (3—3.5) 22 (16.5—30.7) 1 (1—2) 81 (84.4) 15 (15.6) 84 (78.5)
0.12 70%) Univariate and multivariate analysis Characteristics
Univariate OR (95% CI)
P
Multivariate OR (95% CI)
P
Thrombectomy Ischemic time < 3 h (symptoms to balloon) Initial TIMI flow 0-1 Non-anterior infarct location Current smoking BMI > 30 kg/m2 Troponin I peak Maximal ST elevation Diabetes mellitus Killip class > 2
1.91 2.03 0.28 1.54 1.51 1.14 0.79 1.02 1.06 0.80
0.01 0.01 0.01 0.01 0.10 0.16 0.16 0.56 0.86 0.76
1.82 (1.02—3.27) 2.73 (1.52—4.90) 0.66 (0.43—1.01) 1.70 (0.74—3.90) 1.21 (0.67—2.16) 1.21(0.61—2.38) 0.99 (0.99—1.00)
0.043 0.001 0.056 0.20 0.51 0.57 0.29
(1.13—3.21) (1.13—3.67) (0.10—0.78) (1.07—2.21) (0.88—2.57) (0.62—2.11) (0.0.78—1.01) (0.95—1.09) (0.53—2.09) (0.18—3.42)
Impact of manual thrombectomy on myocardial reperfusion Table 8
679
Incidence of Major cardiac events (MACE) and Acute heart failure. Conventional PCI (n = 132)
Death, n (%) Cardiac death, n (%) Myocardial reinfarction, n (%) TVR, n (%) MACE, n (%) Admission for acute Heart Failure, n (%) MACE + AHF
in the EXPIRA trial, thrombectomy improved the myocardial reperfusion as assessed by a higher rate of ST segment resolution [9]. In the latter trial, the improvement of myocardial perfusion was associated with a reduction of infarct size as assessed by MRI analysis. Accordingly, two recent metaanalyses have suggested that manual thrombus aspiration strategy might improve the quality of myocardial perfusion [10,11]. This promising paradigm ‘‘reduction of thrombus burden as a tool to avoid micro-embolization’’ was however challenged by data obtained in larger cohort of multi-centre trials. For instance, in the INFUSE-AMI study that have explored four strategies (abciximab, thrombus aspiration, thrombus aspiration + abciximab, and no abciximab + no thromboaspiration), the infarct size endpoint assessed at 30 days by cardiac magnetic resonance imaging (MRI) was nearly identical in the aspiration and control arms as were TIMI flow, MBG, and STR [12]. Although the extent of ST resolution was not investigate in the TASTE trial, cardiac enzyme release as a surrogate marker of infarct size was not significantly reduced in the thrombus aspiration group [5].
Other predictors of ST resolution Besides the reduction of the thrombus load using manual thrombectomy, short reperfusion delay represent other predictors of ST resolution. In univariate analysis, a short delay is associated with better reperfusion evidenced by a higher frequency of post-procedure complete ST resolution (STR > 70%, OR = 0.86, 95% CI 0.78—0.95; P = 0.001) and becomes an independent predicting factor of complete STR even after adjustment for confounding factors. Taking into account the temporal evolution of myonecrosis [13], these data underlined the fact that early reperfusion is probably an ideal condition to demonstrate myocardial salvage which is also consistent with histopathology findings on thromboaspiration products. Whilst the thrombus is mainly of platelet origin within the two first hours, older thrombus are characterized by a complex network of fibrin and erythrocytes more likely resistant to the fibrin-degrading proteolytic enzyme and probably less accessible to adequate thromboaspiration [14]. In the literature, the impact of initial TIMI flow on ST resolution remains controversial. According to Erden et al., the ST resolution was lower in patients with spontaneous coronary reperfusion prior PCI [15]. Conversely, other work has suggested that TIMI flow grade 2 or less before pPCI could be an independent predictor of impaired ST resolution [16].
5 4 3 11 19 7 26
(4.1) (3.3) (2.5) (9.1) (15.7) (5.8) (19.6)
Thrombectomy (n = 107) 2 2 1 8 12 2 14
(2) (2) (1) (8.2) (12.2) (2) (13)
Manual thrombectomy and clinical outcomes In spite of improved ST resolution, no differences in MACE and heart failure could be evidenced at 1.3 years follow up. The notion that manual thrombectomy has a real impact on cardiovascular outcome was recently challenged by the TASTE trial. Previous observations from the TAPAS trial have suggested that thrombus aspiration resulted in a trend toward improved 30-day survival, which became significant by one year [17]. Surprisingly, this improvement on survival was observed in spite of any sizeable reduction of infarct size measured by cardiac enzyme release. Therefore, the pathophysiological basis associating thrombus aspiration and reduction of cardiac mortality remained unclear. Recent meta-analysis have reported conflicting findings, showing either a reduction of 30-days mortality rate, mainly draw by the TAPAS trial [10,18] or a lack of efficiency [11]. In the multicenter INFUSE MI trial, no significant reduction of mortality could be established in patients treated by thrombus aspiration. Likewise, the 30 days outcome of patients enrolled in the large TASTE trial has been recently published. In this nation wide large multicenter trial enrolling 7244 patients, thrombus aspiration did not improve the 30 days rate of death, rehospitalisation for heart failure or stroke. Stent thrombosis or rehospitalisation for myocardial infarction tended to be lower in the thrombus aspiration group [5]. In our study, in spite of the improvement of STsegment resolution observed in the thrombectomy group, ST resolution failure was detected in 48%. The question whether unsuccessful microcirculatory perfusion is due to micro-embolization or results from lethal reperfusion injury deserves further investigation.
Limitations The present work is monocentric and has the inherent limitations of any small non-randomized series. Blush score and TIMI frame count, other markers of myocardial perfusion were not assessed. Infarct size and no reflow phenomenon were not analyzed by MRI. The thrombotic material was not quantified. However, in STEMI patients the evaluation of the thrombotic burden by the measurement of the thrombotic material retrieved by thrombectomy remains difficult to assess: • large thrombus could not be aspirate by the current available device;
680 • even in case of thrombectomy, residual thrombotic materials could be detected within the implanted stent by OCT in almost 100% of the cases [3]. Other limitations are represented by the absence of ECG independent reviewing and the absence of accurate collaterally evaluation. Finally, given the limited size of our population, and the low number of adverse events recorded during follow up, the present study was not powered to draw definite conclusion on the impact of thrombus aspiration strategy on clinically relevant hard points.
Conclusion In STEMI patients treated by primary PCI, manual thrombectomy results in improved myocardial reperfusion as assessed by ST segment resolution and a lower use of stents. However, in this cohort of limited size, this strategy did not translate into an improved cardiovascular outcome at 1-year follow-up.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Steg PG, James SK, Atar D, Badano LP, Lundqvist CB, Borger MA, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J 2012. [2] Stone GW, Peterson MA, Lansky AJ, Dangas G, Mehran R, Leon MB. Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction. J Am Coll Cardiol 2002;39:591—7 [Research Support, Non-U.S. Gov’t Validation Studies]. [3] Magro M, Regar E, Gutierrez-Chico JL, Garcia-Garcia H, Simsek C, Schultz C, et al. Residual atherothrombotic material after stenting in acute myocardial infarction — an optical coherence tomographic evaluation. Int J Cardiol 2013;167:656—63. [4] Wu KC, Zerhouni EA, Judd RM, Lugo-Olivieri CH, Barouch LA, Schulman SP, et al. Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation 1998;97(8):765—72 [Research Support, Non-U.S. Gov’t Research Support, U.S. Gov’t, P.H.S.]. [5] Frobert O, Lagerqvist B, Olivecrona GK, Omerovic E, Gudnason T, Maeng M, et al. Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med 2013;369(17):1587—97 [Comparative Study Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. [6] Lin MS, Wu LS, Cheng NJ, Lin PC, Chang CJ. Thrombus aspiration complicated by systemic embolization in patients with acute myocardial infarction. Circ J 2009;73(7):1356—8.
N. Messas et al. [7] De Luca G, Navarese EP, Suryapranata H. A meta-analytic overview of thrombectomy during primary angioplasty. Int J Cardiol 2013;166(3):606—12. [8] Svilaas T, Vlaar PJ, van der Horst IC, Diercks GF, de Smet BJ, van den Heuvel AF, et al. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med 2008;358(6):557—67 [Comparative Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. [9] Sardella G, Mancone M, Bucciarelli-Ducci C, Agati L, Scardala R, Carbone I, et al. 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. J Am Coll Cardiol 2009;53(4):309—15 [Randomized Controlled Trial]. [10] De Luca G, Dudek D, Sardella G, Marino P, Chevalier B, Zijlstra F. Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized trials. Eur Heart J 2008;29(24):3002—10 [meta-analysis review validation studies]. [11] Mongeon FP, Belisle P, Joseph L, Eisenberg MJ, Rinfret S. Adjunctive thrombectomy for acute myocardial infarction: a bayesian meta-analysis. Circ Cardiovasc Interv 2010;3(1):6—16 [meta-analysis]. [12] Stone GW, Maehara A, Witzenbichler B, Godlewski J, Parise H, Dambrink JH, et al. Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: the INFUSE-AMI randomized trial. JAMA 2012;307(17):1817—26 [Multicenter Study Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. [13] Reimer KA, Lowe JE, Rasmussen MM, Jennings RB. The wavefront phenomenon of ischemic cell death. 1. Myocardial infarct size vs duration of coronary occlusion in dogs. Circulation 1977;56(5):786—94 [Research Support, U.S. Gov’t, P.H.S.]. [14] Beygui F, Collet JP, Nagaswami C, Weisel JW, Montalescot G. Images in cardiovascular medicine. Architecture of intracoronary thrombi in ST-elevation acute myocardial infarction: time makes the difference. Circulation 2006;113(2):e21—3 [case reports]. [15] Erden EC, Erden I, Turker Y, Aslantas Y, Yalcin S, Karabacak A. Amount of ST wave resolution in patients with and without spontaneous coronary reperfusion in the infarct -related artery after primary PCI: an observational study. Anadolu Kardiyol Derg 2012;12(1):30—4. [16] Park SR, Kang YR, Seo MK, Kang MK, Cho JH, An YJ, et al. Clinical predictors of incomplete ST-segment resolution in the patients with acute ST segment elevation myocardial infarction. Korean Circ J 2009;39(8):310—6. [17] Vlaar PJ, Svilaas T, van der Horst IC, Diercks GF, Fokkema ML, de Smet BJ, et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet 2008;371(9628):1915—20 [Randomized Controlled Trial Research Support, Non-U.S. Gov’t]. [18] Noman A, Egred M, Bagnall A, Spyridopoulos I, Jamieson S, Ahmed J. Impact of thrombus aspiration during primary percutaneous coronary intervention on mortality in ST-segment elevation myocardial infarction. Eur Heart J 2012;33(24):3054—61.
