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Matsukawa R, Matsuura H, Tokutome M, Okahara A, Hara A, Okabe K, Kawai S, Mukai Y. Use of a Cutting Balloon Reduces the Incidence of Distal Embolism in Acute Coronary Syndrome Requiring Predilatation Before Stenting. Circ Rep 2022; 4:345-352. [PMID: 36032387 PMCID: PMC9360986 DOI: 10.1253/circrep.cr-22-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/15/2022] [Accepted: 06/18/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Acute coronary syndrome (ACS) patients with solid lesions often require predilatation before stenting. Predilatation with high pressure may increase the risk of distal embolism, whereas direct stenting increases the risk of stent underexpansion. We recently reported that, in severely calcified lesions, using a cutting balloon (CB) can provide greater acute gain compared with other scoring balloons. Therefore, we hypothesized that predilatation with CB may reduce the incidence of distal embolism in ACS patients with solid lesions. Methods and Results: This study retrospectively analyzed data for 175 ACS patients who required predilatation, either with a conventional balloon (n=136) or CB (n=39). The occurrence of distal embolism was significantly lower in the CB than conventional balloon group (10.3% vs 32.4%, respectively; P=0.007). Multivariate analysis showed that the occurrence of distal embolism was positively associated with Thrombolysis in Myocardial Infarction (TIMI) grade and the presence of attenuated plaque, but negatively associated with the use of a CB. To support this clinical observation, we compared thrombus dispersal using a CB and non-compliant balloon in an ex vivo experimental model using a pseudo-thrombus. In this model, pseudo-thrombus dispersal was significantly smaller when a CB rather than non-compliant balloon was used (1.8±1.0% vs 2.6±1.2%, respectively; n=20, for each; P=0.002). Conclusions: In ACS patients with solid lesions that require predilatation, predilatation with a CB may reduce the incidence of distal embolism.
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Affiliation(s)
| | | | - Masaki Tokutome
- Division of Cardiology, Fukuoka Red Cross Hospital Fukuoka Japan
| | - Arihide Okahara
- Division of Cardiology, Fukuoka Red Cross Hospital Fukuoka Japan
| | - Ayano Hara
- Division of Cardiology, Fukuoka Red Cross Hospital Fukuoka Japan
| | - Kousuke Okabe
- Division of Cardiology, Fukuoka Red Cross Hospital Fukuoka Japan
| | - Shunsuke Kawai
- Division of Cardiology, Fukuoka Red Cross Hospital Fukuoka Japan
| | - Yasushi Mukai
- Division of Cardiology, Fukuoka Red Cross Hospital Fukuoka Japan
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Huang X, Zhang L, Xu M, Yuan S, Ye Y, Huang T, Yin H, Lyu J. Anti-embolism devices therapy to improve the ICU mortality rate of patients with acute myocardial infarction and type II diabetes mellitus. Front Cardiovasc Med 2022; 9:948924. [PMID: 35928930 PMCID: PMC9343674 DOI: 10.3389/fcvm.2022.948924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Anti-Embolism (AE) devices therapy is an additional antithrombotic treatment that is effective in many venous diseases, but the correlations between this medical compression therapy and cardiovascular arterial disease or comorbid diabetes mellitus (DM) are still controversial. In this study we investigated the association between compression therapy and intensive care unit (ICU) mortality in patients with a first acute myocardial infarction (AMI) diagnosis complicated with type II DM. Methods This retrospective cohort study analyzed all patients with AMI and type II DM in the Medical Information Mart for Intensive Care-IV database. We extracted the demographics, vital signs, laboratory test results, comorbidities, and scoring system results of patients from the first 24 h after ICU admission. The outcomes of this study were 28-day mortality and ICU mortality. Analyses included Kaplan-Meier survival analysis, Cox proportional-hazards regression, and subgroup analysis. Results The study included 985 eligible patients with AMI and type II DM, of who 293 and 692 were enrolled into the no-AE device therapy and AE device therapy groups, respectively. In the multivariate analysis, compared with no-AE device therapy, AE device therapy was a significant predictor of 28-day mortality (OR = 0.48, 95% CI = 0.24-0.96, P = 0.039) and ICU mortality (OR = 0.50, 95% CI = 0.27-0.90, P = 0.021). In addition to age, gender and coronary artery bypass grafting surgery, there were no significant interactions of AE device therapy and other related risk factors with ICU mortality and 28-day mortality in the subgroup analysis. Conclusions Simple-AE-device therapy was associated with reduced risks of ICU mortality and 28-day mortality, as well as an improvement in the benefit on in-hospital survival in patients with AMI complicated with type II DM.
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Affiliation(s)
- Xiaxuan Huang
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Luming Zhang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Mengyuan Xu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shiqi Yuan
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yan Ye
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Tao Huang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Haiyan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
- *Correspondence: Haiyan Yin
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
- Jun Lyu
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Reperfusing the myocardium - a damocles Sword. Indian Heart J 2018; 70:433-438. [PMID: 29961464 PMCID: PMC6034085 DOI: 10.1016/j.ihj.2017.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 10/03/2017] [Accepted: 11/07/2017] [Indexed: 12/11/2022] Open
Abstract
Return of blood flow after periodic ischemia is often accompanied by myocardial injury, commonly known as lethal reperfusion injury (RI). Experimental studies have shown that 50% of muscle die of ischemia and another 50% die because of reperfusion. It is characterized by myocardial, vascular, or electrophysiological dysfunction that is induced by the restoration of blood flow to previously ischemic tissue. This phenomenon reduces the efficiency of the present modalities used to combat the ischemic myocardium. Moreover, despite an improved understanding of the pathophysiology of this process and encouraging preclinical trials of multiple agents, most of the clinical trials to prevent RI have been disappointing and leaves us at ground zero to explore newer approaches.
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Negishi Y, Ishii H, Suzuki S, Aoki T, Iwakawa N, Kojima H, Harada K, Hirayama K, Mitsuda T, Sumi T, Tanaka A, Ogawa Y, Kawaguchi K, Murohara T. The combination assessment of lipid pool and thrombus by optical coherence tomography can predict the filter no-reflow in primary PCI for ST elevated myocardial infarction. Medicine (Baltimore) 2017; 96:e9297. [PMID: 29390391 PMCID: PMC5815803 DOI: 10.1097/md.0000000000009297] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The usefulness of distal protection devices is still controversial. Moreover, there is no report on thrombus evaluation by using optical coherence tomography (OCT) for determining whether to use a distal protection device. The aim of the present study was to investigate the predictor of filter no-reflow (FNR) by using OCT in primary percutaneous coronary intervention (PCI) for ST-elevated acute myocardial infarction (STEMI).We performed preinterventional OCT in 25 patients with STEMI who were undergoing primary PCI with Filtrap. FNR was defined as coronary flow decreasing to TIMI flow grade 0 after mechanical dilatation.FNR was observed in 13 cases (52%). In the comparisons between cases with or without the FNR, the stent length, lipid pool length, lipid pool + thrombus length, and lipid pool + thrombus index showed significant differences. In multivariate analysis, lipid pool + thrombus length was the only independent predictor of FNR (OR 1.438, 95% CI 1.001 - 2.064, P < .05). The optimal cut-off value of lipid pool + thrombus length for predicting FNR was 13.1 mm (AUC = 0.840, sensitivity 76.9%, specificity 75.0%). Moreover, when adding the evaluation of thrombus length to that of lipid pool length, the prediction accuracy of FNR further increased (IDI 0.14: 0.019-0.25, P = .023).The longitudinal length of the lipid pool plus thrombus was an independent predictor of FNR and the prediction accuracy improved by adding the thrombus to the lipid pool. These results might be useful for making intraoperative judgment about whether filter devices should be applied in primary PCI for STEMI.
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Affiliation(s)
- Yosuke Negishi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Susumu Suzuki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshijiro Aoki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Iwakawa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kojima
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiro Harada
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenshi Hirayama
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takayuki Mitsuda
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Sumi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Ogawa
- Department of Cardiology, Komaki City Hospital, Aichi, Japan
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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6
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Kelly DJ, White C, Richardson G. Noninfarct related artery embolic protection during primary PCI. Catheter Cardiovasc Interv 2014; 84:E18-20. [PMID: 24375849 DOI: 10.1002/ccd.22809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 08/29/2010] [Accepted: 08/31/2010] [Indexed: 11/11/2022]
Abstract
A 66-year old man presented with antero-lateral STEMI. An ulcerated plaque and thrombus were seen in the proximal LAD. We were unable to pass a thrombectomy catheter down the LAD. To avoid embolisation of debris a Spider FX distal protection device was placed into the circumflex artery. Following stent implantation the patient developed chest pain with inferolateral ST depression. Thrombus was extracted from the circumflex artery within the distal protection device. Noninfract related artery distal protection during primary PCI may be an appropriate safeguard where thrombectomy is not possible in an infarct-related left coronary branch.
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Affiliation(s)
- D J Kelly
- Glenfield hospital, Cardiology, Groby Road, Leicester, United Kingdom, LE3 9QP
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7
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Vecchio S, Varani E, Chechi T, Balducelli M, Vecchi G, Aquilina M, Ricci Lucchi G, Dal Monte A, Margheri M. Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management. World J Cardiol 2014; 6:381-392. [PMID: 24976910 PMCID: PMC4072828 DOI: 10.4330/wjc.v6.i6.381] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 03/26/2014] [Accepted: 04/11/2014] [Indexed: 02/06/2023] Open
Abstract
Acute ST-elevation myocardial infarction (STEMI) usually results from coronary atherosclerotic plaque disruption with superimposed thrombus formation. Detection of coronary thrombi is a poor prognostic indicator, which is mostly proportional to their size and composition. Particularly, intracoronary thrombi impair both epicardial blood flow and myocardial perfusion, by occluding major coronary arteries and causing distal embolization, respectively. Thus, although primary percutaneous coronary intervention is the preferred treatement strategy in STEMI setting, the associated use of adjunctive antithrombotic drugs and/or percutaneous thrombectomy is crucial to optimize therapy of STEMI patients, by improving either angiographical and clinical outcomes. This review article will focus on the prognostic significance of intracoronary thrombi and on current antithrombotic pharmacological and interventional strategies used in the setting of STEMI to manage thrombotic lesions.
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8
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Patel S, Hermiller J. Embolic protection: the FilterWire EZ™ Embolic Protection System. Expert Rev Med Devices 2014; 5:19-24. [DOI: 10.1586/17434440.5.1.19] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Patel VG, Brayton KM, Mintz GS, Maehara A, Banerjee S, Brilakis ES. Intracoronary and Noninvasive Imaging for Prediction of Distal Embolization and Periprocedural Myocardial Infarction During Native Coronary Artery Percutaneous Intervention. Circ Cardiovasc Imaging 2013; 6:1102-14. [DOI: 10.1161/circimaging.113.000448] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Vishal G. Patel
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Kimberly M. Brayton
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Gary S. Mintz
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Akiko Maehara
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Subhash Banerjee
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Emmanouil S. Brilakis
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
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10
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Waldo SW, Armstrong EJ, Yeo KK, Patel M, Reeves R, MacGregor JS, Low RI, Mahmud E, Rogers JH, Shunk K. Procedural success and long-term outcomes of aspiration thrombectomy for the treatment of stent thrombosis. Catheter Cardiovasc Interv 2013; 82:1048-53. [DOI: 10.1002/ccd.25007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Revised: 01/29/2013] [Accepted: 05/10/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Stephen W. Waldo
- Department of Medicine, Division of Cardiology; University of California; San Francisco California
| | - Ehrin J. Armstrong
- Department of Medicine, Division of Cardiovascular Medicine; University of California; Davis California
| | - Khung-Keong Yeo
- Department of Medicine, Division of Cardiovascular Medicine; University of California; Davis California
| | - Mitul Patel
- Department of Medicine, Division of Cardiovascular Medicine; University of California; San Diego California
| | - Ryan Reeves
- Department of Medicine, Division of Cardiovascular Medicine; University of California; San Diego California
| | - John S. MacGregor
- Department of Medicine, Division of Cardiology; University of California; San Francisco California
| | - Reginald I. Low
- Department of Medicine, Division of Cardiovascular Medicine; University of California; Davis California
| | - Ehtisham Mahmud
- Department of Medicine, Division of Cardiovascular Medicine; University of California; San Diego California
| | - Jason H. Rogers
- Department of Medicine, Division of Cardiovascular Medicine; University of California; Davis California
| | - Kendrick Shunk
- Department of Medicine, Division of Cardiology; University of California; San Francisco California
- Department of Medicine; Veterans Affairs Medical Center; San Francisco California
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Parodi G, Valenti R, Migliorini A, Maehara A, Vergara R, Carrabba N, Mintz GS, Antoniucci D. Comparison of Manual Thrombus Aspiration With Rheolytic Thrombectomy in Acute Myocardial Infarction. Circ Cardiovasc Interv 2013; 6:224-30. [DOI: 10.1161/circinterventions.112.000172] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Manual thrombus aspiration (MTA) is completely ineffective in 30% of cases, and the high profiles of the catheters prevent their use in tortuous and calcified vessels. The rheolytic thrombectomy (RT) device has the potential for improved thrombus removal in acute myocardial infarction as compared with MTA. No data exist on the comparison between the 2 techniques.
Methods and Results—
Randomized study, including 80 acute myocardial infarction patients allocated to RT or MTA before infarct artery stenting. Primary end point of this study is residual thrombus burden by optical coherence tomography. Secondary end points are (1) residual thrombolysis in myocardial infarction thrombus grade; (2) postintervention thrombolysis in myocardial infarction flow and myocardial blush; (3) early ST-segment resolution; (4) percentage of malapposed stent struts at 6 months; (5) 6-month restenosis; and (6) 6-month major adverse cardiovascular events. All but 1 patient had residual thrombus after manual aspiration thrombectomy or RT. The number of optical coherence tomography quadrants containing thrombus in MTA arm was higher than in the RT arm, but this difference did not reach significance (median value 65 and 53, respectively;
P
=0.083). Large residual thrombus was more frequently revealed in the manual aspiration thrombectomy arm (patients with number of quadrants above the median value 60% in the manual aspiration thrombectomy arm and 37% in the RT arm,
P
=0.039). All markers of reperfusion were better in the RT arm. At 6 months, the percentage of malapposed stent struts in the MTA arm was higher than in the RT arm (2.7±4.5% and 0.8±1.6%, respectively;
P
=0.019).
Conclusions—
MTA or RT allows only incomplete removal of thrombus in patients with acute myocardial infarction. The primary end point of the study was not met. However, RT as compared with MTA seems to be more effective in thrombus removal and myocardial reperfusion.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01281033.
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Affiliation(s)
- Guido Parodi
- From the Division of Cardiology, Careggi Hospital, Florence, Italy (G.P., R.V., A.M., R.V., N.C., D.A.); and Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (A.M., G.S.M.)
| | - Renato Valenti
- From the Division of Cardiology, Careggi Hospital, Florence, Italy (G.P., R.V., A.M., R.V., N.C., D.A.); and Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (A.M., G.S.M.)
| | - Angela Migliorini
- From the Division of Cardiology, Careggi Hospital, Florence, Italy (G.P., R.V., A.M., R.V., N.C., D.A.); and Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (A.M., G.S.M.)
| | - Akiko Maehara
- From the Division of Cardiology, Careggi Hospital, Florence, Italy (G.P., R.V., A.M., R.V., N.C., D.A.); and Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (A.M., G.S.M.)
| | - Ruben Vergara
- From the Division of Cardiology, Careggi Hospital, Florence, Italy (G.P., R.V., A.M., R.V., N.C., D.A.); and Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (A.M., G.S.M.)
| | - Nazario Carrabba
- From the Division of Cardiology, Careggi Hospital, Florence, Italy (G.P., R.V., A.M., R.V., N.C., D.A.); and Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (A.M., G.S.M.)
| | - Gary S. Mintz
- From the Division of Cardiology, Careggi Hospital, Florence, Italy (G.P., R.V., A.M., R.V., N.C., D.A.); and Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (A.M., G.S.M.)
| | - David Antoniucci
- From the Division of Cardiology, Careggi Hospital, Florence, Italy (G.P., R.V., A.M., R.V., N.C., D.A.); and Cardiovascular Research Foundation, Columbia University Medical Center, New York, NY (A.M., G.S.M.)
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Guo AQ, Sheng L, Lei X, Shu W. Pharmacological and physical prevention and treatment of no-reflow after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. J Int Med Res 2013; 41:537-47. [PMID: 23628920 DOI: 10.1177/0300060513479859] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
After successful primary percutaneous coronary intervention in ST-segment elevation myocardial infarction, adequate myocardial reperfusion is not achieved in up to 50% of patients. This phenomenon of no-reflow is associated with a poor in-hospital and long-term prognosis. Four main factors are thought to contribute to the occurrence of no-reflow: ischaemic injury; reperfusion injury; distal embolization; susceptibility of the microcirculation to injury. This review evaluates the literature, and in particular the clinical trials, concerned with pharmacological and physical methods for prevention and treatment of no-reflow. A number of drugs may improve no-reflow experimentally and clinically, but some have not yet been associated with conclusive improvements in clinical outcome. The complex interacting factors in no-reflow make it unlikely that any single agent will be effective for all patients. Confirmed methods known to be beneficial in the prevention of no-reflow (such as aspirin therapy, chronic statin therapy, blood glucose control, thrombus aspiration in patients with a high thrombus burden and ischaemic preconditioning) should be offered to patients as often as possible, to prevent and treat no-reflow.
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Affiliation(s)
- Ao Qiang Guo
- Department of Geriatric Nephrology, Institute of Gerontology, Chinese PLA General Hospital, Beijing 100853, China
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13
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Dragstedt CA, Bavry AA. Utility of Thrombectomy in Primary Percutaneous Coronary Intervention. Interv Cardiol Clin 2013; 2:361-374. [PMID: 28582142 DOI: 10.1016/j.iccl.2012.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Thrombectomy in the setting of primary percutaneous coronary intervention allows for improved macrovascular and microvascular perfusion, possible limitation of infarct size, and the preservation of left ventricular function and myocardial viability. The beneficial tissue level effects of thrombectomy have translated into an improvement in cardiovascular mortality. A variety of thrombectomy devices are currently available, including aspiration thrombectomy catheters and rheolytic catheters. A review of the various types of thrombectomy devices available, clinical evidence for their use, clinical pearls for use, and device troubleshooting are presented.
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Affiliation(s)
- Carl A Dragstedt
- Division of Cardiovascular Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610-0277, USA
| | - Anthony A Bavry
- Division of Cardiovascular Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32610-0277, USA.
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Kretzschmar D, Jung C, Otto S, Utschig S, Hartmann M, Lehmann T, Yilmaz A, Pörner TC, Figulla HR, Ferrari M. Detection of coronary microembolization by Doppler ultrasound in patients with stable angina pectoris during percutaneous coronary interventions under an adjunctive antithrombotic therapy with abciximab: design and rationale of the High Intensity Transient Signals ReoPro (HITS-RP) study. Cardiovasc Ultrasound 2012; 10:21. [PMID: 22613136 PMCID: PMC3407765 DOI: 10.1186/1476-7120-10-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/21/2012] [Indexed: 12/23/2022] Open
Abstract
Background Embolization of atherosclerotic debris from the rupture of a vulnerable atherosclerotic plaque occurs iatrogenically during percutaneous coronary interventions (PCI) and can induce myocardial necrosis. These microembolizations are detected as high intensity transient signals (HITS) using intracoronary Doppler technology. Presentation of the hypothesis In the presented study we will test if abciximab (ReoPro®) infusion reduces high intensity transient signals in patients with stable angina pectoris undergoing PCI in comparison to standard therapy alone. Testing the hypothesis The High Intensity Transient Signals ReoPro® (HITS-RP) study will enroll 60 patients. It is a prospective, single center, randomized, double-blinded, controlled trial. The study is designed to compare the efficacy of intravenous abciximab administration for reduction of microembolization during elective PCI. Patients will be randomized in a 1:1 fashion to abciximab or placebo infusion. The primary end point of the HITS-RP-Study is the number of HITS during PCI measured by intracoronary Doppler wire. Secondary endpoints are bleeding complications, elevation of cardiac biomarkers or ECG changes after percutaneous coronary interventions, changes in coronary flow velocity reserve, hs-CRP elevation, any major adverse cardio-vascular event during one month follow-up. Implications of the hypothesis The HITS-RP-Study addresses important questions regarding the efficacy of intravenous abciximab administration in reducing microembolization and periprocedural complications in stable angina pectoris patients undergoing PCI. Trial registration The trial is registered under http://www.drks-neu.uniklinik-freiburg.de/drks_web/:DRKS00000603.
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Affiliation(s)
- Daniel Kretzschmar
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Erlanger Allee 101, D-07740, Jena, Germany.
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2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44-122. [PMID: 22070834 DOI: 10.1016/j.jacc.2011.08.007] [Citation(s) in RCA: 1736] [Impact Index Per Article: 124.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Ting HH. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:e574-651. [PMID: 22064601 DOI: 10.1161/cir.0b013e31823ba622] [Citation(s) in RCA: 912] [Impact Index Per Article: 65.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. Catheter Cardiovasc Interv 2011; 82:E266-355. [DOI: 10.1002/ccd.23390] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kleinbongard P, Konorza T, Böse D, Baars T, Haude M, Erbel R, Heusch G. Lessons from human coronary aspirate. J Mol Cell Cardiol 2011; 52:890-6. [PMID: 21762698 DOI: 10.1016/j.yjmcc.2011.06.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 06/24/2011] [Accepted: 06/28/2011] [Indexed: 10/18/2022]
Abstract
The interventional implantation of a stent into an atherosclerotic coronary artery is a unique and paradigmatic scenario of plaque rupture in humans. The use of protection devices not only prevents the released plaque particles and the superimposed thrombotic material from being washed and embolized into the coronary microcirculation of the individual patient, but permits also the retrieval and ex vivo analysis of particulate plaque debris and soluble substances. The particulate debris comprises typical cholesterol crystals, foam cells, hyalin material and calcium deposits from the atheroma as well as platelets and coagulation material; soluble substances include vasoconstrictors, such as serotonin and thromboxane, as well as inflammatory mediators, such as TNFα which amplifies vasoconstriction by inducing endothelial dysfunction. The vasoconstriction observed in a bioassay ex vivo correlates to clinical symptoms, angiographic stenosis and plaque burden, as assessed by intravascular ultrasound. The release of TNFα into the aspirate correlates to restenosis. Detailed analysis of the human coronary aspirate may promote a better understanding of the pathophysiology of the vulnerable atherosclerotic plaque and help to better antagonize the microvascular consequences of coronary microembolization, including the no reflow phenomenon. This article is part of a Special Issue entitled "Coronary Blood Flow."
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Butler MJ, Chan W, Taylor AJ, Dart AM, Duffy SJ. Management of the no-reflow phenomenon. Pharmacol Ther 2011; 132:72-85. [PMID: 21664376 DOI: 10.1016/j.pharmthera.2011.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 05/12/2011] [Indexed: 01/03/2023]
Abstract
The lack of reperfusion of myocardium after prolonged ischaemia that may occur despite opening of the infarct-related artery is termed "no reflow". No reflow or slow flow occurs in 3-4% of all percutaneous coronary interventions, and is most common after emergency revascularization for acute myocardial infarction. In this setting no reflow is reported to occur in 30% to 40% of interventions when defined by myocardial perfusion techniques such as myocardial contrast echocardiography. No reflow is clinically important as it is independently associated with increased occurrence of malignant arrhythmias, cardiac failure, as well as in-hospital and long-term mortality. Previously the no-reflow phenomenon has been difficult to treat effectively, but recent advances in the understanding of the pathophysiology of no reflow have led to several novel treatment strategies. These include prophylactic use of vasodilator therapies, mechanical devices, ischaemic postconditioning and potent platelet inhibitors. As no reflow is a multifactorial process, a combination of these treatments is more likely to be effective than any of these alone. In this review we discuss the pathophysiology of no reflow and present the numerous recent advances in therapy for this important clinical problem.
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Affiliation(s)
- Michelle J Butler
- Department of Cardiovascular Medicine, the Alfred Hospital, Melbourne, Australia
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Migliorini A, Stabile A, Rodriguez AE, Gandolfo C, Rodriguez Granillo AM, Valenti R, Parodi G, Neumann FJ, Colombo A, Antoniucci D. Comparison of AngioJet rheolytic thrombectomy before direct infarct artery stenting with direct stenting alone in patients with acute myocardial infarction. The JETSTENT trial. J Am Coll Cardiol 2010; 56:1298-306. [PMID: 20691553 DOI: 10.1016/j.jacc.2010.06.011] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Revised: 06/01/2010] [Accepted: 06/06/2010] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether rheolytic thrombectomy (RT) before direct infarct artery stenting as compared with direct stenting (DS) alone results in improved myocardial reperfusion and clinical outcome in patients with acute myocardial infarction. BACKGROUND The routine removal of thrombus before infarct artery stenting is still a matter of debate. METHODS This is a multicenter, international, randomized, 2-arm, prospective study. Eligible patients were patients with acute myocardial infarction, angiographic evidence of thrombus grade 3 to 5, and a reference vessel diameter ≥2.5 mm. Coprimary end points were early ST-segment resolution and (99m)Tc-sestamibi infarct size. An α value = 0.05 achieved by both coprimary surrogate end points or an α value = 0.025 for a single primary surrogate end point would be considered evidence of statistical significance. Other surrogate end points were Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, corrected TIMI frame count, and TIMI grade 3 blush. Clinical end points were a composite of major adverse cardiovascular events at 1, 6, and 12 months. RESULTS From December 2005 to September 2009, 501 patients were randomly allocated to RT before DS or to DS alone. The ST-segment resolution was more frequent in the RT arm as compared with the DS alone arm: 85.8% and 78.8%, respectively (p = 0.043), while no difference between groups were revealed in the other surrogate end points. The 6-month major adverse cardiovascular events rate was 11.2% in the thrombectomy arm and 19.4% in the DS alone arm (p = 0.011). The 1-year event-free survival rates were 85.2 ± 2.3% for the RT arm, and 75.0 ± 3.1% for the DS alone arm (p = 0.009). CONCLUSIONS Although the primary efficacy end points were not met, the results of this study support the use of RT before infarct artery stenting in patients with acute myocardial infarction and evidence of coronary thrombus. (AngioJet Rheolytic Thrombectomy Before Direct Infarct Artery Stenting in Patients Undergoing Primary PCI for Acute Myocardial Infarction [JETSTENT]; NCT00275990).
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Percutaneous coronary intervention in native vessels with angiographically visible thrombus temporal trends and impact of drug-eluting stents. JACC Cardiovasc Interv 2010; 3:937-46. [PMID: 20850093 DOI: 10.1016/j.jcin.2010.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Revised: 06/11/2010] [Accepted: 06/15/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The aim of our study was to evaluate the temporal trends in outcomes following percutaneous coronary intervention in lesions with angiographically visible thrombus and to assess the impact of drug-eluting stents (DES) on long-term outcomes. BACKGROUND Percutaneous coronary intervention in the presence of angiographically visible thrombus is associated with worse clinical outcomes. Whether recent advances in devices and adjunctive pharmacotherapy have made any significant impact on clinical outcomes is unknown. Moreover, concerns have been raised about the safety of DES in thrombotic lesions. METHODS We conducted a retrospective analysis of 6,227 consecutive patients who had angiographically visible thrombus. Patients were grouped into 3 eras depending on the dominant interventional strategy of that time: early stent era (1990 to 1996), bare-metal stent era (1997 to 2003), and DES era (2003 to 2006). RESULTS Procedural success rates, although much improved, have remained unchanged in the last 2 cohorts (43%, 85%, 86%; p < 0.001). Adjusted in-hospital mortality (4.7%, 3.0%, 3.6%; p < 0.001), and major adverse cardiovascular events (7.8%, 5.0%, 5.3%; p < 0.001) decreased modestly. During long-term follow-up, mortality and the combined end point of death or myocardial infarction were similar in the 3 cohorts; but the combined end point of death, myocardial infarction, or target lesion revascularization (p < 0.001) was lower in the 2 most recent eras. CONCLUSIONS There has been a marked improvement in procedural success accompanied by a reduction in in-hospital mortality and major adverse cardiac event rates. Importantly, the introduction of DES has not been associated with a greater risk of death or myocardial infarction among patients with angiographically visible thrombus.
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Maia F, Ribamar Costa J, Abizaid A, Feres F, Costa R, Staico R, Siqueira D, Esteves V, Sousa A, Eduardo Sousa J. Preliminary results of the INSPIRE trial with the novel MGuard™ stent system containing a protection net to prevent distal embolization. Catheter Cardiovasc Interv 2010; 76:86-92. [DOI: 10.1002/ccd.22473] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Distal coronary macroemboli and thrombus aspiration in a patient with acute myocardial infarction. Am J Emerg Med 2010; 28:644.e1-4. [DOI: 10.1016/j.ajem.2009.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 09/11/2009] [Indexed: 11/22/2022] Open
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Rigattieri S, Di Russo C, Musto C, Schirripa V, Silvestri P, Biondi-Zoccai G, Ferraiuolo G, Loschiavo P. Thrombus aspiration during primary angioplasty for cardiogenic shock. Int J Cardiol 2010; 140:111-3. [PMID: 19033082 DOI: 10.1016/j.ijcard.2008.10.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2008] [Accepted: 10/31/2008] [Indexed: 02/08/2023]
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Tamhane UU, Chetcuti S, Hameed I, Grossman PM, Moscucci M, Gurm HS. Safety and efficacy of thrombectomy in patients undergoing primary percutaneous coronary intervention for acute ST elevation MI: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2010; 10:10. [PMID: 20187958 PMCID: PMC2838805 DOI: 10.1186/1471-2261-10-10] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Accepted: 02/26/2010] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Clinical trials comparing thrombectomy devices with conventional percutaneous coronary interventions (PCI) in patients with acute ST elevation myocardial infarction (STEMI) have produced conflicting results. The objective of our study was to systematically evaluate currently available data comparing thrombectomy followed by PCI with conventional PCI alone in patients with acute STEMI. METHODS Seventeen randomized trials (n = 3,909 patients) of thrombectomy versus PCI were included in this meta-analysis. We calculated the summary odds ratios for mortality, stroke, post procedural myocardial blush grade (MBG), thrombolysis in myocardial infarction (TIMI) grade flow, and post procedural ST segment resolution (STR) using random-effects and fixed-effects models. RESULTS There was no difference in risk of 30-day mortality (44/1914 vs. 50/1907, OR 0.84, 95% CI 0.54-1.29, P = 0.42) among patients randomized to thrombectomy, compared with conventional PCI. Thrombectomy was associated with a significantly greater likelihood of TIMI 3 flow (1616/1826 vs. 1533/1806, OR 1.41, P = 0.007), MBG 3 (730/1526 vs. 486/1513, OR 2.42, P < 0.001), STR (923/1500 vs. 715/1494, OR 2.30, P < 0.001), and with a higher risk of stroke (14/1403 vs. 3/1413, OR 2.88, 95% CI 1.06-7.85, P = 0.04). Outcomes differed significantly between different device classes with a trend towards lower mortality with manual aspiration thrombectomy (MAT) (21/949 vs.36/953, OR 0.59, 95% CI 0.35-1.01, P = 0.05), whereas mechanical devices showed a trend towards higher mortality (20/416 vs.10/418, OR 2.07, 95% CI 0.95-4.48, P = 0.07). CONCLUSIONS Thrombectomy devices appear to improve markers of myocardial perfusion in patients undergoing primary PCI, with no difference in overall 30-day mortality but an increased likelihood of stroke. The clinical benefits of thrombectomy appear to be influenced by the device type with a trend towards survival benefit with MAT and worsening outcome with mechanical devices.
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Affiliation(s)
- Umesh U Tamhane
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Stanley Chetcuti
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Irfan Hameed
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - P Michael Grossman
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Mauro Moscucci
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Health Care System, Ann Arbor, MI, USA
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Mongeon FP, Bélisle P, Joseph L, Eisenberg MJ, Rinfret S. Adjunctive thrombectomy for acute myocardial infarction: A bayesian meta-analysis. Circ Cardiovasc Interv 2010; 3:6-16. [PMID: 20118149 DOI: 10.1161/circinterventions.109.904037] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In available trials and meta-analyses, adjunctive thrombectomy in acute myocardial infarction (MI) improves markers of myocardial reperfusion but has limited effects on clinical outcomes. Thrombectomy devices simply aspirate thrombus or mechanically fragment it before aspiration. Simple aspiration thrombectomy may offer a distinct advantage. METHODS AND RESULTS We identified 21 eligible trials (16 that used a simple aspiration thrombectomy device) involving 4299 patients with ST-segment elevation MI randomized to reperfusion therapy by primary percutaneous coronary intervention with or without thrombectomy. By using Bayesian meta-analysis methods, we found that thrombectomy yielded substantially less no-reflow (odds ratio [OR], 0.39; 95% credible interval [CrI], 0.18 to 0.69), more ST-segment resolution > or =50% (OR, 2.22; 95% CrI, 1.60 to 3.23), and more thrombolysis in myocardial infarction/myocardial perfusion grade 3 (OR, 2.50; 95% CrI, 1.48 to 4.41). There was no evidence for a decrease in death (OR, 0.94; 95% CrI, 0.47 to 1.80), death, recurrent MI, or stroke (OR, 1.07; 95% CrI, 0.63 to 1.92) with thrombectomy. Restriction of the analysis to trials that used simple aspiration thrombectomy devices did not yield substantially different results, except for a positive effect on postprocedure thrombolysis in myocardial infarction grade 3 flow (OR, 1.49; 95% CrI, 1.14 to 1.99). CONCLUSIONS In this Bayesian meta-analysis, adjunctive thrombectomy improves early markers of reperfusion but does not substantially effect 30-day post-MI mortality, reinfarction, and stroke. The use of aspiration thrombectomy devices is not associated with a reduction in post-MI clinical outcomes. Thrombectomy is one of the rare effective preventive measures against no-reflow.
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Affiliation(s)
- François-Pierre Mongeon
- Department of Medicine, Echocardiography, and Noninvasive Cardiology Service, Montreal Heart Institute, Canada
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Heusch G, Kleinbongard P, Böse D, Levkau B, Haude M, Schulz R, Erbel R. Coronary microembolization: from bedside to bench and back to bedside. Circulation 2009; 120:1822-36. [PMID: 19884481 DOI: 10.1161/circulationaha.109.888784] [Citation(s) in RCA: 329] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coronary microembolization from the erosion or rupture of a vulnerable atherosclerotic plaque occurs spontaneously in acute coronary syndromes and iatrogenically during percutaneous coronary interventions. Typical consequences of coronary microembolization are microinfarcts with an inflammatory response, contractile dysfunction, and reduced coronary reserve. Apart from transient elevations of creatine kinase and troponin, microemboli can be visualized by intracoronary Doppler and the resulting microinfarcts by late-enhancement nuclear magnetic resonance. Statins, antiplatelet agents, and coronary vasodilators protect against microembolization and microinfarction when started before percutaneous coronary interventions. Distal protection devices can retrieve atherothrombotic debris and prevent its embolization into the microcirculation, but their effect on clinical outcome has been disappointing so far, except for saphenous vein bypass grafts. Devices for aspiration of thrombi and thrombus-derived vasoconstrictor, thrombogenic, and inflammatory substances, however, reduce thrombus burden, improve perfusion, and provide protection in patients with acute myocardial infarction.
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Affiliation(s)
- Gerd Heusch
- Institut für Pathophysiologie, Universitätsklinikum Essen, Essen, Germany.
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Extrakce trombů zlepšuje prognózu u pacientů s akutním infarktem myokardu. COR ET VASA 2009. [DOI: 10.33678/cor.2009.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Park SR, Kang YR, Seo MK, Kang MK, Cho JH, An YJ, Kwak CH, Hwang SJ, Jung YH, Hwang JY. Clinical Predictors of Incomplete ST-Segment Resolution in the Patients With Acute ST Segment Elevation Myocardial Infarction. Korean Circ J 2009; 39:310-6. [PMID: 19949636 PMCID: PMC2771846 DOI: 10.4070/kcj.2009.39.8.310] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 01/20/2009] [Indexed: 11/26/2022] Open
Abstract
Background and Objectives The failure of ST-segment resolution (STR) after primary percutaneous coronary intervention (pPCI) is associated with adverse clinical outcomes. However, the clinical predictors on admission for incomplete STR are poorly known. Subjects and Methods Patients undergoing pPCI (n=101, 79 males and 22 females, mean age 60.0 years) were divided into complete STR group (≥70%, n=58) and incomplete STR group (<70%, n=43). The groups were compared according to clinical factors including history, electrocardiographic (ECG) patterns, angiographic features and laboratory data. Results The incomplete STR group contained more frequent hypertensive patients (p=0.04) and patients displaying longer tendency in total chest pain duration (p=0.08). This group was associated with worse clinical factors such as low ejection fraction (p=0.06), higher Killip class (p=0.08) and more death (p=0.042). Grade 3 ischemia pattern of ECG and precordial ST elevation (i,e anterior myocardial infarction) at admission were more frequent in the incomplete STR group (p=0.001 and 0.002, respectively). Initial troponin I, creatinin kinase -MB and brain natriuretic peptide levels were higher in the incomplete STR group (p=0.001, 0.002, and 0.043, respectively). Coronary angiography showed that culprit lesions were more frequent in left anterior descending artery than other arteries in the incomplete STR group of patients (p=0.002). Thrombolysis In Myocardial Infarction (TIMI) flow grades 2 or less before PCI was more frequent in the incomplete STR group (p=0.029). However, TIMI flow grade after PCI was not appreciably different between the two groups. Logistic regression analysis demonstrated that TIMI flow grade 2 or less was most powerful predictor for incomplete STR {odds ratio (OR)=12.12, 95% confidence interval (CI) 1.23-119.35, p=0.032}. Other independent predictors were anterior infarction (OR=3.39, CI 1.46-10.57, p=0.007), ischemia grade 3 ECG at admission (OR=3.87, CI 1.31-11.41, p=0.014), and hypertensive patients (OR=3.03, CI 1.13-8.15, p=0.027). Conclusion Incomplete STR after pPCI is associated with poor prognostic clinical factors. TIMI flow grade 2 or less before pPCI, ST elevation on precordial leads, ischemia grade 3 pattern of initial ECG, and hypertensive patients are independent predictors for incomplete STR in the early stage.
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Affiliation(s)
- So Ra Park
- Department of Internal Medicine, Gyeongsang Institute of Health, School of Medicine, Gyeongsang National University, Jinju, Korea
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Lipiecki J, Monzy S, Durel N, Cachin F, Chabrot P, Muliez A, Morand D, Maublant J, Ponsonnaille J. Effect of thrombus aspiration on infarct size and left ventricular function in high-risk patients with acute myocardial infarction treated by percutaneous coronary intervention. Results of a prospective controlled pilot study. Am Heart J 2009; 157:583.e1-7. [PMID: 19249433 DOI: 10.1016/j.ahj.2008.11.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 11/26/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Thrombus aspiration devices have been shown to improve reperfusion criteria and to reduce distal embolization in patients treated by percutaneous coronary interventions (PCI) in the acute phase of ST-elevation myocardial infarction (STEMI). There are, however, little data about their efficacy in the reduction of infarct size. METHODS We sought to assess in a prospective randomized trial the impact of thrombus aspiration on infarct size and severity and on left ventricular function in high-risk patients with a first STEMI. The primary end point was scintigraphic infarct size, and secondary end points were infarct severity and regional and global left ventricular function. Forty-four patients with completely occluded (Thrombolysis in Myocardial Infarction flow 0-1) proximal segments of infarct-related artery were randomly assigned to thrombus aspiration group with the Export catheter (n = 20) (Medtronic, Inc, Minneapolis, MN) or PCI-only group. A rest Tc-99-mibi gated single-photon emission computed tomographic and contrast-enhanced magnetic resonance imaging were performed 6 +/- 2 days later. RESULTS Infarct size was comparable in patients in the thrombus aspiration group and PCI-only group (30.6% +/- 15.8% vs 28.5% +/- 17.9% of the left ventricle, P = .7) as was infarct severity in infarct-related artery territory (55% +/- 12% vs 55% +/- 14%, P = .9). Transmurality score as assessed by magnetic resonance imaging was similar in both groups (2.03 +/- 1.05 vs 2.16 +/- 1.21, P = .7). There was no impact of thrombus aspiration on other secondary end points. CONCLUSION In our study, thrombus aspiration with the Export catheter performed as adjunctive therapy in high-risk patients with total occlusion of the proximal part of major coronary arteries does not decrease infarct size or severity and has no effect on left ventricular regional and global function.
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AMIN AMITP, MAMTANI MANJUR, KULKARNI HEMANT. Factors Influencing the Benefit of Adjunctive Devices during Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: Meta-Analysis and Meta-Regression. J Interv Cardiol 2009; 22:49-60. [DOI: 10.1111/j.1540-8183.2008.00420.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Steg PG, Ducrocq G. Devices to protect against embolization during primary angioplasty for ST-segment elevation myocardial infarction: the good, the bad and the ugly. Eur Heart J 2008; 29:2953-4. [DOI: 10.1093/eurheartj/ehn488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: a comprehensive meta-analysis of randomized trials. Eur Heart J 2008; 29:2989-3001. [PMID: 18812323 DOI: 10.1093/eurheartj/ehn421] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
AIMS Adjunctive thrombectomy and embolic protection devices in acute myocardial infarction have been extensively studied, although outcomes have mainly focused on surrogate markers of reperfusion. Therefore, the effect of adjunctive devices on clinical outcomes is unknown. This study sought to determine whether the use of a thrombectomy or embolic protection device during revascularization for acute myocardial infarction reduces mortality compared with percutaneous coronary intervention (PCI) alone. METHODS AND RESULTS The Cochrane and Medline databases were searched for clinical trials that randomized patients with ST-elevation acute myocardial infarction to an adjuvant device prior to PCI compared with PCI alone. Devices were grouped into catheter thrombus aspiration, mechanical thrombectomy, and embolic protection. There were a total of 30 studies with 6415 patients who met our selection criteria. Over a weighted mean follow-up of 5.0 months, the incidence of mortality among all studies was 3.2% for the adjunctive device group vs. 3.7% for PCI alone (relative risk, 0.87; 95% confidence interval, 0.67-1.13). Among thrombus aspiration studies, mortality was 2.7% for the adjunctive device group vs. 4.4% for PCI alone (P = 0.018), for mechanical thrombectomy, mortality was 5.3% for the adjunctive device group vs. 2.8% for PCI alone (P = 0.050), and for embolic protection, mortality was 3.1% for the adjunctive device group vs. 3.4% for PCI alone (P = 0.69). CONCLUSION Catheter thrombus aspiration during acute myocardial infarction is beneficial in reducing mortality compared with PCI alone. Mechanical thrombectomy appears to increase mortality, whereas embolic protection appears to have a neutral effect.
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Affiliation(s)
- Anthony A Bavry
- Department of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
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Reperfusion injury in acute myocardial infarction: From bench to cath lab. Part II: Clinical issues and therapeutic options. Arch Cardiovasc Dis 2008; 101:565-75. [DOI: 10.1016/j.acvd.2008.06.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Revised: 05/26/2008] [Accepted: 06/06/2008] [Indexed: 11/16/2022]
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Thrombus aspiration during primary percutaneous coronary intervention in acute ST-elevation myocardial infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2008; 9:140-3. [DOI: 10.1016/j.carrev.2007.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Revised: 11/20/2007] [Accepted: 11/21/2007] [Indexed: 11/21/2022]
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Mongeon FP, Eisenberg MJ, Rinfret S. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med 2008; 358:2639-40; author reply 2640-1. [PMID: 18550880 DOI: 10.1056/nejmc080514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Bates ER. Aspirating and Filtering Atherothrombotic Debris During Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2008; 1:265-7. [DOI: 10.1016/j.jcin.2008.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 04/23/2008] [Indexed: 10/21/2022]
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Kaluski E, Tsai S, Klapholz M. Coronary stenting with MGuard: from conception to human trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2008; 9:88-94. [DOI: 10.1016/j.carrev.2007.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Revised: 12/03/2007] [Accepted: 12/04/2007] [Indexed: 10/22/2022]
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