Cath Lab Digest - April 2008 - (Page 26)

26 STEMI INTERVENTIONS APRIL 2008 The Missing Link in STEMI Interventions – Thrombus Aspiration during Primary Percutaneous Coronary Intervention Thrombus Aspiration during Primary Percutaneous Coronary Intervention Tone Svilaas, M.D., Pieter J. Vlaar, M.Sc., Iwan C. van der Horst, M.D., Ph.D., Gilles F.H. Diercks, M.D., Ph.D., Bart J.G.L. de Smet, M.D., Ph.D., Ad F.M. van den Heuvel, M.D., Ph.D., Rutger L. Anthonio, M.D., Ph.D., Gillian A. Jessurun, M.D., Ph.D., EngShiong Tan, M.D., Albert J.H. Suurmeijer, M.D., Ph.D., and Felix Zijlstra, M.D., Ph.D. This article is available in full for free at http://content.nejm.org/cgi/content/full/358/6/557 Abstract Background. Primary percutaneous coronary intervention (PCI) is effective in opening the infarct-related artery in patients with myocardial infarction with ST-segment elevation. However, the embolization of atherothrombotic debris induces microvascular obstruction and diminishes myocardial reperfusion. Methods. We performed a randomized trial assessing whether manual aspiration was superior to conventional treatment during primary PCI. A total of 1,071 patients were randomly assigned to the thrombusaspiration group or the conventional-PCI group before undergoing coronary angiography. Aspiration was considered to be successful if there was histopathological evidence of atherothrombotic material. We assessed angiographic and electrocardiographic signs of myocardial reperfusion, as well as clinical outcome. The primary end point was a myocardial blush grade of 0 or 1 (defined as absent or minimal myocardial reperfusion, respectively). Results. A myocardial blush grade of 0 or 1 occurred in 17.1% of the patients in the thrombus-aspiration group and in 26.3% of those in the conventional-PCI group (P<0.001). Complete resolution of ST-segment elevation occurred in 56.6% and 44.2% of patients, respectively (P<0.001). The benefit did not show heterogeneity among the baseline levels of the prespecified covariates. At 30 days, the rate of death in patients with a myocardial blush grade of 0 or 1, 2, and 3 was 5.2%, 2.9%, and 1.0%, respectively (P=0.003), and the rate of adverse events was 14.1%, 8.8%, and 4.2%, respectively (P<0.001). Histopathological examination confirmed successful aspiration in 72.9% of patients. Conclusions. Thrombus aspiration is applicable in a large majority of patients with myocardial infarction with ST-segment elevation, and it results in better reperfusion and clinical outcomes than conventional PCI, irrespective of clinical and angiographic characteristics at baseline. (Current Controlled Trials number, ISRCTN16716833 [controlledtrials.com].) Source Information From the University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. Address reprint requests to Dr. Svilaas at the Thorax Center, Department of Cardiology, Triadegebouw, Gang LM1.004, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands, or at fzijlstra@thorax.umcg.nl. From Svilaas T, Vlaar PJ, van der Horst IC, et al. Thrombus Aspiration during Primary Percutaneous Coronary Intervention. N Eng J Med 2008 Feb 7;358(6):557-567. Copyright © 2008 Massachusetts Medical Society. All rights reserved. T Sameer Mehta, MD, FACC, MBA is studying ST-elevation myocardial infarction interventions in his work with short door-to-balloon time primary PCI and the Single INdividual Community Experience REgistry for Primary PCI (SINCERE) database at 5 community hospitals in Miami, Florida, now over 280 patients. A past chief of interventional cardiology and director of the cardiovascular laboratory at Cedars Medical Center in Miami, as well as former President of the American Heart Association (Miami Dade Division), Dr. Mehta is a Voluntary Associate Clinical Professor of Medicine at the University of Miami-School of Medicine. Dr. Mehta is also president of the Indo-American Society of Interventional Cardiologists (ISIC) and a course director for the Lumen-Vascular Interventions Symposium. He has recently published the Textbook of STEMI Interventions (available through HMP Communications, at http:// www.stemiinterventions.com). Dr. Mehta will be commenting on the important work going on around the world as societies and their hospitals struggle to educate patients about the importance of timely intervention in ST-elevation myocardial infarction, and work collaboratively to decrease the time from patient arrival to intervention. he dots in ST-elevation myocardial infarction (STEMI) interventions finally get connected through the robust results of the Thrombus Aspiration during Primary Percutaneous Coronary Intervention (TAPAS), published in the recent edition of the New England Journal of Medicine (NEJM 2008; 358:557-67; see sidebar). In this landmark randomized trial of primary percutaneous coronary intervention (PCI), Felix Zijlstra and colleagues report better reperfusion and clinical outcomes than conventional PCI with thrombus aspiration performed with the 6French Export Aspiration Catheter (Medtronic, Inc., Santa Clara, CA), irrespective of clinical and angiographic characteristics at baseline. In a total of 1,071 patients that were randomly assigned to the thrombusaspiration group or the conventionalPCI group, the researchers reported a myocardial blush grade of 0 or 1 in 17.1% of the patients in the thrombus-aspiration group and in 26.3% of those in the conventional-PCI group (p<0.0001). In addition, complete resolution of ST-segment elevation occurred in 56.6% and 44.2% of patients respectively (p<0.0001). Most critically, the TAPAS investigators demonstrated the critical importance of the surrogates of myocardial blush grade (MPG) and ST-segment resolution (STR) as appropriate endpoints. At 30 days, the rate of death in patients with a myocardial blush grade of 0 or 1, 2 and 3 was 5.2%, 2.9% and 1% respectively (p<0.003) and the rate of adverse events was 14.1%, 8.8% and 4.2% respectively (p<0.0001). Although numerous trials (Table 1) have demonstrated favorable trends in the use of aspiration and thrombectomy devices, TAPAS provides irrefutable benefits of thrombectomy for STEMI lesions. Benefits with thrombus aspiration were seen across the board and thrombus aspiration was better irrespective of the sex, age, http://content.nejm.org/cgi/content/full/358/6/557 http://controlledtrials.com http://controlledtrials.com http://www.stemiinterventions.com http://www.stemiinterventions.com

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Cath Lab Digest - April 2008 Kaiser San Rafael Medical Center Orbital Atherectomy: A New Treatment for Complex Peripheral Arterial Disease Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Contents Clinical Editor’s Corner CEU Education Center The Missing Link in STEMI Interventions — Thrombus Aspiration during Primary Percutaneous Coronary Intervention Predicting Stent Thrombosis Using A Clinical Risk Score Use of a New Guidewire: The Tigerwire Should I Stay or Should I Go? Weighing Options for New Opportunities Navigating Tortuous Coronary Sinus Anatomy Using a Bipolar Lead The National Society of Radiology Practitioner Assistants (NSRPA) Holds 9th Annual Educational Conference For Medical Imaging Physician Extenders and Mid-Level Healthcare Providers Cath Lab & Beyond: A Meeting Update The Ten-Minute Interview with… Dale Hansen RT, CVT Sometimes, You Just Know Twin Circumflex Arteries: A Rare Coronary Artery Anomaly What Do You Think? Meetings Calendar News from the American College of Cardiology (ACC) Scientific Session and the Society of Cardiovascular Angiography & Interventions (SCAI) Annual Scientific Sessions in Partnership with the ACC i2 Summit Clinical & Industry News Cath Laughs Classifieds Advertisers Index

Cath Lab Digest - April 2008

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