Role of Aspiration and Mechanical Thrombectomy in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty

Selected in Journal of the American College of Cardiology by M Bollati

References

Authors

Dharam J. Kumbhani, Anthony A. Bavry, Milind Y. Desai, Sripal Bangalore, Deepak L. Bhatt

Reference

J Am Coll Cardiol. 2013;62(16):1409-1418

Published

October 2013

Link

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My Comment

ST elevation miocardial infarction (STEMI) remains one of the most important percutaneous coronary intervention (PCI) field, considering its strong prognosis effect.

In this contest, thrombus aspiration before PCI is still debated, considering the discordant data about clinical endpoints coming from different trials and meta-analyses. Moreover, mechanical aspiration devices usefulness instead manual aspiration is not proven.

In their work, Kumbhani et al performed a meta-analysis of randomized trial comparing conventional primary PCI vs aspiration thrombectomy or conventional primary PCI vs mechanical thrombectomy

Major findings

  • 18 trials (Aspiration thombectomy vs conventional PCI, n=3936), and 7 trials (mechanical vs manual thrombectomy, n=1598)
  • Aspiration thrombectomy resulted superior to conventional primary PCI both in term of major adverse cardiac events (MACE) (risk ratio [RR]: 0.76; 95% confidence interval [CI]: 0.63 to 0.92; p <0.006) and all-cause mortality (RR: 0.71; 95% CI: 0.51 to 0.99; p <0.049)
  • Thrombolysis In Myocardial Infarction blush grade (TBG) 3 post-procedure (RR: 1.37; 95% CI: 1.19 to 1.59; p <0.0001) occurrence was higher in the aspiration group
  • 60 min ST resolution was more easily achieved in the aspiration group (RR: 1.31; 95% CI: 1.16 to 1.48; p <0.0001)
  • No significant difference in term of infarct size and 30 days ejection fraction
  • Mechanical thrombectomy was superior to manual thrombectomy only in STR at 60 min (RR: 1.25; 95% CI: 1.06 to 1.47; p <0.007). Surprisingly, TBG 3 (RR: 1.09; 95% CI: 0.86 to 1.38; p <0.48) occurrence was similar in the two groups.

My comments

“Ubi pus, ibi evacua”. And if find thrombus, let’s aspirate: it appears so simple, even self evident.

But data are different and discordant: a clear clinical efficacy evidence is still lacking. For this reason, the comparision we have to do is not between mechanical and manual aspiration, but our work has to be addressed to understanding the exact mechanism of embolisation and preventing it. It matters, and in this manner we could have devices with clear and significant improuvement in hard clinical endpoint, like death rate.

TBG and infarct size by magnetic resonance are important. But we need more. More life.

1 comment

  • mahesh honnalli 17 Jun 2014

    I had IWMI patient who received thrombolysis within 1 hr. He developed CHB with cardiogenic shock. He was taken up for rescue PTCA , CAG showed proximal RCA 100% occlusion. Thrombus aspiration was done to reveal 3 cm proximal RCA aneurysm. I think such cases with heavy clot burden will definitely benefit from thrombus aspiration. Dr. Mahesh Honnalli