Thrombus aspiration during ST-Segment Elevation Myocardial Infarction (TASTE trial)
Selected in The NEW ENGLAND JOURNAL of MEDICINE by G. Harris
Ole Fröbert, M.D., Ph.D., Bo Lagerqvist, M.D., Ph.D., Göran K. Olivecrona, M.D., Ph.D., Elmir Omerovic, M.D., Ph.D., Thorarinn Gudnason, M.D., Ph.D., Michael Maeng, M.D., Ph.D., Mikael Aasa, M.D., Ph.D., Oskar Angerås, M.D., Fredrik Calais, M.D., Mikael Danielewicz, M.D., David Erlinge, M.D., Ph.D., Lars Hellsten, M.D., Ulf Jensen, M.D., Ph.D., Agneta C. Johansson, M.D., Amra Kåregren, M.D., Johan Nilsson, M.D., Ph.D., Lotta Robertson, M.D., Lennart Sandhall, M.D., Iwar Sjögren, M.D., Ollie Östlund, Ph.D., Jan Harnek, M.D., Ph.D., and Stefan K. James, M.D., Ph.D.
September 1, 2013DOI: 10.1056/NEJMoa1308789
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Several trials have evaluated the use of both manual and mechanical thrombectomy devices in patients with STEMI. The TAPAS trial (NEJM 2008) showed both angiographic benefit (improved myocardial blush score) as well as clinical benefit (improved cardiac mortality or reduced nonfatal myocardial infarction) at one year when using the manual thrombectomy device.
The JETSTENT trial (mechanical thrombectomy device) could show no benefit. The INFUSE-AMI trial (which was a 2x2 multifactorial trial could also show no benefit when using a thrombectomy device (manual aspiration).
A meta-analysis in 2012 (International Journal of Cardiology) demonstrated a statistically higher rate of stroke in patients receiving thrombus aspiration therapy.
An analysis performed by Barry & Bhatt (European Heart Journal 2008), demonstrated that mechanical thrombectomy led to both improved myocardial blush and ST segment resolution, distal protection device to improved myocardial blush but no improvement in ST segment resolution and that mechanical thrombectomy improved neither myocardial blush nor ST segment resolution.
The EXPIRA trial (AHA Scientific sessions 2009) demonstrated improved myocardial blush and complete ST segment resolution when using an Export catheter in patients with STEMI. Further, micro vascular integrity was shown by MRI to be superior in the thrombectomy group, as well as improved limitation of infarct size at 3 months.
- There was no significant difference in the 1E endpoint (all-cause mortality) at 30 days between the two groups (2.8% (thrombus aspiration plus PCI) vs. 3.0% (PCI only); P=0.63).
- Rates of hospitalisation for recurrent myocardial infarction at 30 days were 0.5% and 0.9% (P=0.09) respectively.
- Rates for stent thrombosis were 0.2% and 0.5 %( P=0.09).
- No significant differences concerning neurologic related complications.
It is true; there was no significant mortality difference at 30 days. But surely this is far too short a period to base an opinion regarding a mortality difference. The TAPAS trial benefit was shown at one year. The prognostic importance of repeated myocardial infarction is known, and with a 40% lower rate in the aspiration group, the mortality benefit should manifest itself with time. Importantly, there was no rate of increased stroke in this trial.
As pointed out by the authors, the use of pharmacological agents in thrombus formation prevention may be more important than mechanical removal of the clot, as shown in the INFUSE-AMI trial.
It is also important to note that the TASTE trial made use of a population based registry, resulting in significant cost savings (in running the trial).
The TOTAL trial (manual thrombectomy) is currently underway, with a 1e end point of; 1st occurrence of death, recurrent myocardial infarction, cardiogenic shock or NYHA class 4 heart failure. These results as well as the 1 year data from the TASTE trial are eagerly awaited. I think it is too early to want to change the guidelines, based on this trial.