Comparison of myocardial perfusion by distal protection before and after primary stenting for acute myocardial infarction: angiographic and clinical results of a randomized controlled trial.

OBJECTIVES: To assess the myocardium-reperfusing effect of a distal protection device, GuardWire Plus (GuardWire Plus), in patients with acute myocardial infarction (AMI). BACKGROUND: Distal embolization may result in reduced myocardial perfusion, increasing the risk of non-Q-wave myocardial infarction and death. Distal protection devices may protect the microcirculation from embolic debris, improving short- and long-term clinical outcomes. METHODS: From February 2002 to July 2003, a total of 341 AMI patients at 22 institutions in Japan were enrolled in the present, multicenter, prospective, randomized trial. Patients experiencing AMI within 12 hr of symptom onset, who were considered treatable by stenting and who met the inclusion criteria, were eligible for randomization. Stenting with and without GuardWire Plus was conducted to examine whether the device provides faster and more complete ST-segment resolution, smaller infarct size, and improved myocardial blush score. RESULTS: The rates of slow flow and no-reflow immediately after PCI were 5.3 and 11.4% in the GuardWire Plus and control groups, respectively (P = 0.05). Blush score 3 acquisition rates immediately after PCI were 25.2 and 20.3% in the GuardWire Plus and control groups, respectively (P = 0.26), and the rates at 30 days after PCI were 42.9 and 30.4%, respectively (P = 0.035). CONCLUSIONS: A significant difference was found between the GuardWire Plus and control groups with respect to the total incidence of distal embolization, indicating that GuardWire Plus angiographically improved myocardial perfusion without demonstrating the preventive effect of myocardial damage.     

The role of distal myocardial protection devices during percutaneous coronary interventions

Opinion statement The success of intervention and clinical outcome is markedly reduced in patients who sustain distal embolization during percutaneous coronary intervention (PCI). Such embolization occurs in up to 15% of patients with acute myocardial infarction (AMI) undergoing PCI, and angiographic indicators of embolization are highly predictive of clinical and functional outcome. Saphenous vein graft (SVG) interventions carry a 20% risk of major adverse cardiac events (MACE), predominantly AMI, and significant risk of no-reflow. There are four types of embolic protection: distal occlusion/aspiration systems, filters, proximal occlusion/aspiration devices, and thrombectomy catheters. There seem to be no data to suggest that routine use of any embolic protection system is beneficial in patients with ST-elevation myocardial infarction (STEMI) undergoing PCI. The message from both the EMERALD and PROMISE trials is that embolic protection does not improve perfusion in the setting of AMI. Although pretreatment with thrombus aspiration before PCI improves angiographic reperfusion rates compared with standard PCI, enzymatic release and early clinical outcomes are not improved. Although the clinical implications of routine thrombus aspiration have yet to be established, selective use may be justified in patients with the highest thrombus burden. In addition, it should be considered in those with acute stent thrombosis and elective use of filter-based protection considered in very high risk vessel PCI (eg, last remaining conduit). There is no easy way to anticipate which SVG intervention will result in embolization. In SVG intervention, both balloon occlusion/aspiration and filter-based distal protection devices have significantly reduced the incidence of 30-day MACE, driven by AMI and should, I believe, be used routinely. Risk of complications is low with all the established devices. The profile and deliverability are continuing to improve with newer devices. Cost-effectiveness of selective use in high-risk graft cases has only recently been demonstrated.     

Intracoronary thrombectomy improves myocardial reperfusion in patients undergoing direct angioplasty for acute myocardial infarction

OBJECTIVES: We sought to evaluate the effects of mechanical thrombectomy on myocardial reperfusion during direct angioplasty for acute myocardial infarction (AMI). BACKGROUND: Embolization of thrombus and plaque debris may occur during direct angioplasty for AMI. This may lead to distal vessel or side branch occlusion and to obstructions in the microvascular system, resulting in impaired myocardial reperfusion. Mechanical thrombectomy is used to reduce distal embolization. METHODS: Ninety-two patients with AMI and angiographic evidence of intraluminal thrombus were randomized to either intracoronary thrombectomy followed by stenting or to a conventional strategy of stenting. Thrombectomy was performed using the X-Sizer catheter (EndiCOR Inc., San Clemente, California). Myocardial reperfusion was assessed by myocardial blush and ST resolution. RESULTS: Postprocedure Thrombolysis in Myocardial Infarction-3 flow was not different between groups (93.5% vs. 95.7%, p = 0.39). Myocardial blush-3 was observed in 71.7% of patients undergoing thrombectomy and in 36.9% of patients undergoing conventional strategy (p = 0.006). ST-segment resolution >or=50% occurred more often in patients undergoing thrombectomy (82.6% vs. 52.2%, p = 0.001). By multivariate analysis, adjunctive thrombectomy was an independent predictor of blush-3 (odds ratio, 3.27; 95% confidence interval, 1.06 to 10.05; p = 0.039). CONCLUSIONS: Intracoronary thrombectomy as adjunct to stenting during direct angioplasty for AMI improves myocardial reperfusion as assessed by myocardial blush and ST resolution.     

血栓抽吸导管在急性心肌梗死患者治疗中的临床应用

目的评估ZEEK血栓抽吸导管在急性心肌梗死患者治疗中的临床应用。方法将316例行急诊介入治疗的急性心肌梗死患者分为两组,其中使用ZEEK血栓抽吸导管127例患者作为ZEEK组,未使用ZEEK血栓抽吸导管189例患者作为对照组。观察无复流发生率、术后ST段下降率、住院病死率及左心室射血分数等。结果ZEEK组4例发生无复流,发生率为3.1%,住院期间无死亡。对照组189例中有18例发生无复流,发生率9.5%,死亡6例(3.2%)。两组患者的无复流发生率、ST段下降率、住院病死率及心功能均具有显著差异(P<0.05)。结论急性心肌梗死在急诊介入治疗中,应用ZEEK血栓抽吸导管可以降低无复流发生率和住院病死率。     

Effect of delayed vs immediate stent implantation on myocardial perfusion and cardiac function in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous intervention with thrombus aspiration

Background

Optimizing microcirculation in STEMI patients with thrombus-containing lesion undergoing percutaneous coronary intervention (PCI) remains challenging. Our objective was to compare the effects on myocardial perfusion and cardiac function of delayed vs immediate stent implantation after thrombus aspiration in STEMI patients undergoing PCI.

Methods

Eighty-seven STEMI patients with thrombus-containing lesion undergoing PCI were enrolled. After thrombus aspiration was performed, subjects were divided into 2 groups according to residual thrombus score (TS): immediate stent implantation (ISI) group (n = 47, residual TS < 2; stenting was performed immediately), and delayed stent implantation (DSI) group (n = 40, residual TS ≥ 2; stenting was performed 7 days later). Corrected thrombolysis in myocardial infarction frame count and myocardial blush grade were analyzed immediately after PCI. The wall motion score index was assessed on admission and at 6-month follow-up.

Results

At the end of the PCI procedure, the corrected thrombolysis in myocardial infarction frame count was significantly shorter and the myocardial blush grade 3 was more frequent in the DSI group than in the ISI group. Compared with the ISI group, the DSI group had a lower incidence of thrombus-related angiographic events, including distal embolization and no reflow. A significantly greater improvement in wall motion score index from baseline to 6-month follow-up was observed in the DSI group compared with the ISI group.

Conclusions

In STEMI patients presenting with thrombus containing lesion undergoing PCI, delayed stent implantation after thrombus aspiration leads to better myocardial perfusion and cardiac functional recovery in comparison with immediate stent implantation.     

Effects of a distal protection device during primary stenting in patients with acute anterior myocardial infarction.

BACKGROUND: The angiographic no-reflow phenomenon is an adverse prognostic factor in patients with acute myocardial infarction (AMI). The aim of the present study was to evaluate the effects of an occlusive balloon type distal protection device (PercuSurge GuardWire: GW) during primary stenting in patients with anterior AMI. METHODS AND RESULTS: The GW group included 42 patients treated by primary stenting with GW protection and the control group included 30 patients treated by primary stenting after thrombectomy without distal protection. Left ventricular (LV) function was measured and compared by left ventriculography obtained soon after percutaneous coronary intervention (PCI) and 3 weeks after onset. The corrected TIMI frame count values were lower in the GW group than in the control group (27.5+/-2.3 vs 35.1 +/-2.5, p=0.030). The number of patients with myocardial blush grade 3 after PCI was higher in the GW group than in the control group (45.7 vs 20.0%, p=0.029). Peak concentration of creatine kinase myocardial fraction was lower in the GW group than in the control group (326.6+/-41.5 vs 454.9+/-46.2 mg/dl, p=0.043). GW patients showed greater improvement at 3 weeks after PCI in terms of LV ejection fraction (+4.6+/-1.2 vs -1.1+/-1.5, p=0.004), LV end-systolic volume index (+0.5+/-2.4 vs +9.0+/-2.7, p=0.023), and regional wall motion abnormalities (-2.03+/-0.14 vs -2.51+/-0.14, p=0.018). CONCLUSION: Primary stenting with GW protection can restore epicardial coronary flow and myocardial perfusion, and also preserve LV function in anterior AMI.     

血栓抽吸联合替罗非班对急性ST段抬高心肌梗死患者心肌再灌注的影响

目的 探讨急性ST段抬高心肌梗死急诊经皮冠状动脉介入治疗（PCI）中联合应用ZEEK血栓抽吸导管和替罗非班对心肌组织灌注及临床预后的影响.方法 84例经冠脉造影证实为血栓负荷病变的急性ST段抬高心肌梗死患者随机分为血栓抽吸＋替罗非班42例（A组）和标准PCI 42例（B组）,比较两组患者手术后即刻梗死相关动脉（IRA）的心肌梗死溶栓（TIMI）血流、心肌灌注分级（MBG）、心电图ST段回落百分比、左心室射血分数（LVEF）及住院期间主要心脏不良事件（MACE）和出血性并发症发生率.结果 A组术后即刻TIMI血流、MBG、ST段抬高回落百分比及LVEF均明显优于B组（P〈0.05）,两组住院期间的MACE发生率及出血并发症比较差异无统计学意义（P〉0.05）.结论 在急性心肌梗死急诊PCI中联合使用ZEEK导管血栓抽吸和替罗非班安全可行,可有效清除冠状动脉内血栓,改善心肌组织灌注和术后心脏功能,并且不增加主要心脏不良事件的发生率.     

急性心肌梗死直接介入治疗中Diver CE血栓抽吸术的应用

目的探讨和评价急性心肌梗死（AMI）急诊冠状动脉介入治疗（PCI）中联合应用Div-erCE血栓抽吸术的疗效及安全性。方法选择符合急诊PCI的AMI并经冠状动脉造影明确梗死相关冠状动脉（IRA）内高负荷血栓性病变的56例患者,随机分为两组,Diver CE组（n=28）用DiverCE血栓抽吸导管抽吸血栓后再行PCI治疗,对照组（n=28）直接行PCI治疗。结果Diver CE血栓抽吸术后的PCI术后ST段回落（STR）（〉70%）明显优于对照组（71.4%比39.3%,P〈0.05） 术后冠状动脉TIMI血流（2.8±0.4比2.0±0.6,P〈0.05）、血栓积分（TS）（0.1±0.2比1.5±1.0,P〈0.05）、左室舒张末期容积（left ventricular end-diastolic volume,LVEDV）（50±12mL比60±14mL,P〈0.05）、左室射血分数（LVEF）（0.58±0.18比0.46±0.14,P〈0.05）较对照组明显改善,慢血流/无复流发生率低（3.6%比14.3%,P〈0.05） 30d时主要不良心脏事件（MACE）包括死亡、心肌梗死和靶血管再成形术和缺血性卒中的发生率两组未见明显差异（0比3.6%,P〉0.05）。未见与Diver CE血栓抽吸相关的血管并发症。结论Diver CE血栓抽吸术能促进AMI急诊PCI术后STR,改善TIMI血流、TS和左心室功能 该方法操作简单,安全性高 对AMI患者,若其冠状动脉内以血栓性病变为主,应考虑应用Diver CE血栓抽吸术。     

Thrombectomy with Rescue Aspiration Catheter and Distal Protection with EPI FilterWire in Primary Angioplasty for Acute Myocardial Infarction

AMI (Acute Myocardial Infarction) is usually caused by abrupt plague rupture followed by thrombus formation inside the coronary artery. Primary angioplasty for heavy thrombus loaded vessels may be complicated by distal embolization, leading to no reflow and myocardial damage. We present a case of acute thrombotic occlusion of the left anterior descending artery (LAD), in which we performed simultaneous thrombus removal by the rescue aspiration thrombectomy catheter together with an EPI FilterWire for distal protection against embolization. The lesion was successfully stented with excellent perfusion to the distal capillaries. A huge load of debris (red and white) was retrieved by both devices. The patient remained asymptomatic at 9 months. This case illustrates the possible DUAL protective roles of Aspiration Thrombectomy and Filtering devices in high risk angioplasty for AMI patients.     

X-sizer for thrombectomy in acute myocardial infarction improves ST-segment resolution: results of the X-sizer in AMI for negligible embolization and optimal ST resolution (X AMINE ST) trial

OBJECTIVES: We sought to compare, in a prospective randomized multicenter study, the effect of adjunctive thrombectomy using X-Sizer (eV3, White Bear Lake, Minnesota) before percutaneous coronary intervention (PCI) versus conventional PCI in patients with acute myocardial infarction (AMI) for <12 h and Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 to 1. The primary end point was the magnitude of ST-segment resolution after PCI. BACKGROUND: Despite a high rate of TIMI flow grade 3 achieved by PCI in patients with AMI, myocardial reperfusion remains relatively low. Distal embolization of thrombotic materials may play a major role in this setting. METHODS: We conducted a prospective, randomized, multicenter study in patients with AMI <12 h and initial TIMI flow grade 0 to 1 who were treated with primary PCI. The magnitude of ST-segment resolution 1 h after PCI was the primary end point. RESULTS: A total of 201 patients were included. Treatment groups were comparable by age (61 +/- 13 years), diabetes (22%), previous MI (8%), anterior MI (52%), onset-to-angiogram (258 +/- 173 min), and glycoprotein IIb/IIIa inhibitor use (59%). The magnitude of ST-segment resolution was greater in the X-Sizer group compared with the conventional group (7.5 vs. 4.9 mm, respectively; p = 0.033) as ST-segment resolution >50% (68% vs. 53%; p = 0.037). The occurrence of distal embolization was reduced (2% vs. 10%; p = 0.033) and TIMI flow grade 3 was obtained in 96% vs. 89%, respectively (p = 0.105). Myocardial blush grade 3 was similar (30% vs. 31%; p = NS). Six-month clinical outcome was comparable (death, 6% vs. 4% and major adverse cardiac and cerebral events, 13% vs. 13%, respectively). By multivariate analysis, independent predictors of ST-segment resolution >50% were: younger age, non-anterior MI, use of the X-Sizer, and a short time interval from symptom onset. CONCLUSIONS: Reducing thrombus burden with X-Sizer before stenting leads to better myocardial reperfusion, as illustrated by a reduced risk of distal embolization and better ST-segment resolution.     

Safety and efficacy of the FilterWire EZ in acute ST-segment elevation myocardial infarction

Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) achieves a high epicardial reperfusion rate; however, it is often suboptimal in achieving myocardial reperfusion due to distal embolization of atherothrombotic particles. The present study assessed whether the capture of embolic particles during PCI would improve myocardial reperfusion outcome. In a multicenter, prospective, randomized, controlled study, 100 patients with STEMI and coronary angiographic evidence of thrombotic occlusion were randomly assigned to PCI using the FilterWire EZ (n=51) or a control group (n=49) using regular guidewires. The FilterWire EZ was successfully delivered across the lesion in 84% of patients in the FilterWire EZ group. Primary efficacy end points, including markers of epicardial (Thrombolysis In Myocardial Infarction grade flow) and myocardial reperfusion (myocardial blush score and percent early resolution of ST-segment elevation), did not differ between the 2 study groups. Further, 60- and 90-minute percent ST-segment resolutions were identical in the 2 groups. In a subgroup analysis, a blush score of 3 was achieved in 94% of patients in whom the filter's landing zone was in a vessel diameter>2.5 mm compared with only 55% in those with smaller vessel diameter (p=0.04). This corresponds to a better debris capture in filters located in large versus small vessels (p=0.08). In conclusion, in patients with STEMI, use of the FilterWire EZ as an adjunct to primary PCI did not improve angiographic or electrocardiographic measurements of reperfusion compared with conventional PCI only.     

急性心肌梗死介入治疗中应用抽吸导管对心肌再灌注的影响

目的:分析在急性ST段抬高型心肌梗死(STEMI)急诊行经皮冠状动脉介入治疗(PCI)中应用抽吸导管对心肌再灌注影响.方法:首次STEMI行PCI患者80例,随机分为试验组(41例,应用抽吸导管后再行PCI),对照组(39例,直接行PCI).比较2组术后即刻计算校正TIMI计帧数和心肌Blush分级、术中慢复流现象、心电图90 min ST段下降率.在术后24 h、1周时应用心肌声学造影计算灌注对比积分指数(CSI)、室壁运动积分指数(WMSI).结果:PCI后试验组的校正TIMI计帧数明显低于对照组,Blush分级≥2级获得率高于对照组,慢复流现象减少;再通后90 min心电图相关导联ST段下降率试验组明显大于对照组(P<0.05).同时在研究的每一个时点,试验组CSI、WMSI较对照组明显降低(P<0.05).结论:在STEMI急诊行PCI中应用抽吸导管可改善梗死相关血管前向血流情况,改善心肌再灌注,减少无复流现象.     

血栓抽吸导管在急性心肌梗死患者经皮冠状动脉介入治疗中的应用

目的评价急性心肌梗死(AMI)患者经皮冠状动脉介入治疗(PCI)中应用Diver CE血栓抽吸导管的可靠性、实用性与安全性。方法选择我院2006年7月至2007年7月接受直接PCI的AMI患者64例,分成血栓抽吸后经皮冠状动脉介入治疗组(PT+PCI)与单纯PCI组,比较两组间TIMI血流、心肌灌注分级(TMP)(2.65±0.54)级、2 h ST段回落率56.07%±9.20%、左室射血分数(LVEF)及血管重建率。结果PT+PCI组的TIMI血流(2.54±0.18)级、TMP(2.65±0.54)级、2 h ST段回落率89.73%±9.43%、LVEF值56.07%±9.20%及血管重建率0%,明显优于单纯PCI组的TIMI血流(2.01±0.28)级、TMP(1.52±0.47)级、2 hST段回落率56.41%±12.59%、LVEF值51.11%±8.97%及血管重建率3.33%(P<0.05)。结论PCI中应用Diver CE血栓抽吸装置能明显减少冠状动脉血栓及远端栓塞,有效地改善心肌灌注,减少无复流发生,使用安全,效果明显。     

血栓抽吸装置在经皮冠状动脉介入治疗中对心肌再灌注的影响

目的:评估血栓抽吸装置在急性心肌梗塞(AMI)急诊冠状动脉介入治疗(PCI)患者治疗中的临床应用。方法:86例行急诊PCI治疗的AMI患者被随机分为血栓抽吸组(41例,应用抽吸导管后再行PCI),直接PCI组(45例,直接行PCI),观察无复流发生率、术后ST段下降率及左心室射血分数等。结果:PCI后血栓抽吸组患者的无复流发生率明显低于直接PCI组(4.9%∶11.1%,P0.05),ST段回落率(66.67%、75.61%)、LVEF[(54.02±8.93)%∶(49.23±9.12)%]均优于直接PCI组(P均0.05)。结论:急诊冠脉介入治疗急性心肌梗塞患者时,应用血栓抽吸导管可以降低无复流发生率,改善心功能,且安全有效。     

急性ST段抬高心肌梗死冠状动脉内血栓抽吸后延迟支架植入术的疗效观察

目的对急性ST段抬高性心肌梗死患者行急诊冠状动脉介入（percutaneous coronary intervention,PCI）治疗,经冠状动脉内血栓抽吸后使心肌梗死溶栓试验（TIMI）血流达3级后,比较延期支架植入与即刻支架植入两种治疗方式对预后的影响。方法选择2010年1月至2012年1月符合急诊PCI治疗条件的急性心肌梗患者共149例．经冠状动脉内血栓抽吸后使心肌梗死溶栓试验血流达2～3级后,93例当时植入支架患者为即刻支架植入组．56例术后经强化抗凝及抗血小板治疗5～7d后再次手术植入支架者为延迟支架植入组,观察两组ST段术后回落超过50％的患者例数、慢血流或无复流发生率、心肌染色分级及支架使用情况,同时随访术后3个月时心功能状态及主要心血管事件（包括心肌梗死、血运重建、卒中、各种原因的死亡）。结果延期支架组心电图ST段回落比例明显高于即刻支架植入组,差异有统计学意义（62％vs.46％,P〈0．01）。无复流及慢血流在延迟支架组明显少于即刻支架组,差异有统计学意义（8％vs．17％,P〈0．01）。延迟支架组支架使用量明显少于即刻支架组,差异有统计学了意义[（2．3±0．7）枚 vs.（3．5±1．1）枚,P〈0．01]。3个月后两组主要心血管事件及左心室功能状态比较,差异无统计学意义（P〉0．05）。结论冠状动脉内血栓抽吸后延迟支架植入,可减少支架使用量,有利于减少无复流及慢血流现象的发生,对近期预后无不利影响。     

Predicting angiographic distal embolization following percutaneous coronary intervention in patients with acute myocardial infarction

The aim of this study was to investigate the relation between lesion morphology identified by intravascular ultrasound (IVUS) before intervention and angiographic distal embolization after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). PCI for AMI has already been established as beneficial therapy, although some complications remain unresolved. Distal embolization is 1 of the important complications of PCI. Recently, some new devices have been developed for the prevention of distal embolization. However, few studies exist that look into the relation between lesion morphology and distal embolization. IVUS was performed safely in 140 consecutive patients with AMI before coronary intervention. No patient received thrombolytic therapy. From the incidence of angiographic distal embolization, patients were divided into 2 groups--an embolization group and a nonembolization group--and clinical background, IVUS, and angiographic information were evaluated. Distal embolization was observed in 12 patients (9%). Peak creatine kinase levels (3,877 +/- 2,285 vs 2,293 +/- 1,792 IU/L, p <0.05) and the incidence of angiographic thrombus (25% vs 5%, p <0.05) and intracoronary mobile mass detected by IVUS (75% vs 16%, p <0.001) were higher for patients in the embolization group. From the multivariate logistic regression analysis, only an intracoronary mobile mass detected by IVUS emerged as a predictor of distal embolization (odds ratio 53, 95% confidence interval 2.7 to 1,040, p <0.01). Patients with an intracoronary mobile mass detected by IVUS are prone to distal embolization after PCI and larger infarction. IVUS imaging before PCI may be useful for determining which patients need a distal protection device.     

血栓抽吸导管对急性心肌梗死患者心肌灌注水平影响的临床研究

目的分析在血栓负荷较大的急性心肌梗死(AMI)患者行急诊PCI中,应用抽吸导管对心肌再灌注的影响及安全性。方法选择经急诊冠状动脉造影显示血栓负荷较大的AMI患者36例作为血栓抽吸组,另选同期采用常规PCI的AMI患者36例作为对照组,比较2组的血栓负荷、TIMI分级、TIMI心肌灌注(TMP)分级、心肌酶峰值、ST段回落幅度、LVEF、住院期间心血管不良事件。结果血栓抽吸组患者经抽吸后血栓负荷明显降低;血栓抽吸组患者TIMI分级和TMP分级明显优于对照组,差异有统计学意义(P0.01);血栓抽吸组患者较对照组肌酸激酶、肌酸激酶同工酶峰值明显降低,术后1 h ST段回落百分比明显增高,LVEF明显升高,左心室舒张末内径明显下降,差异有统计学意义(P0.01)。结论在血栓负荷较重的AMI患者行急诊PCI时,应用血栓抽吸导管安全可行,可显著改善梗死相关血管前向血流情况,改善心肌再灌注,减少无复流现象和心肌酶的释放。     

Usefulness of thrombus aspiration for the treatment of coronary stent thrombosis

Current treatment for coronary stent thrombosis (ST) often lacks satisfactory results and clinical outcome is poor. We investigated the impact of manual thrombus aspiration during percutaneous coronary intervention (PCI) on myocardial reperfusion and clinical outcome in patients with angiographically proved ST. We interrogated our PCI registry for patients with a first stent placement from January 2002 through May 2010 who had undergone an emergency repeated PCI procedure and systematically reviewed coronary angiograms and hospital records for evidence of ST. We identified 113 patients with ST. Thrombus aspiration was used in 51 patients and 62 patients received conventional PCI. Histopathologic analysis of thrombus aspirates was performed in 6 patients. Use of thrombus aspiration predicted postprocedure Thrombolysis In Myocardial Infarction grade 3 flow (odds ratio 3.16, 95% confidence interval 1.22 to 8.17, p = 0.018) and myocardial blush grade 2/3 (odds ratio 3.20, 95% confidence interval 1.20 to 8.55, p = 0.020) after multivariable adjustment with bootstrap model selection. Distal embolization was lower in the thrombus aspiration group compared to the conventional PCI group (14% vs 37%, p = 0.017). In most patients, aspirated thrombus was large and contained platelet and erythrocyte components at histopathologic analysis. Mortality in the thrombus aspiration group and conventional PCI group was 9.8% versus 16% at 30 days (p = 0.351) and 12% versus 21% at 1 year (p = 0.220), respectively. In conclusion, use of manual thrombus aspiration in patients with ST was associated with greater epicardial and microvascular myocardial reperfusion. In addition, mortality was lower in patients treated with thrombus aspiration, although not statistically significant.     

Frequency, correlates, and clinical implications of myocardial perfusion after primary angioplasty and stenting, with and without glycoprotein IIb/IIIa inhibition, in acute myocardial infarction

OBJECTIVES: We sought to determine the prognostic importance of myocardial reperfusion after various contemporary interventional strategies in patients with acute myocardial infarction (AMI). BACKGROUND: The frequency, correlates, and clinical implications of myocardial perfusion after primary angioplasty in AMI have not been examined in a large-scale prospective study. Similarly, whether glycoprotein (GP) IIb/IIIa inhibitors and/or stents improve myocardial perfusion beyond balloon angioplasty has not been investigated. METHODS: Tissue-level perfusion assessed by the myocardial blush grade was evaluated in 1,301 patients with AMI randomized to balloon angioplasty versus stenting, each with or without abciximab. RESULTS: Despite Thrombolysis In Myocardial Infarction flow grade 3 restoration in 96.1% of patients, myocardial perfusion was normal in only 17.4% of patients, reduced in 33.9%, and absent in 48.7%. Myocardial perfusion status post-coronary intervention stratified patients into three distinct risk categories, with 1-year mortality rates of 1.4% (normal blush), 4.1% (reduced blush), and 6.2% (absent blush) (p = 0.01). Among patients randomized to angioplasty, angioplasty + abciximab, stenting, and stenting + abciximab, normal myocardial perfusion was restored in 17.7%, 17.0%, 17.5%, and 17.6%, respectively (p = 0.95), which was associated with similar 1-year rates of mortality in patients randomized to stenting versus angioplasty (4.5% vs. 4.8%, p = 0.91) and abciximab versus no abciximab (4.3% vs. 5.0%, p = 0.63). CONCLUSIONS: Restoration of normal tissue-level perfusion is a powerful determinate of survival after primary PCI in AMI and is achieved in a minority of patients. Neither stents nor GP IIb/IIIa inhibitors significantly enhance myocardial perfusion compared to balloon angioplasty alone, underlying the similar long-term mortality with these different mechanical reperfusion strategies.     

Impact of thrombus aspiration use and direct stenting on final myocardial blush score in patients presenting with ST-elevation myocardial infarction

BackgroundMany studies have reported that low final thrombolysis in myocardial infarction (TIMI) flow and/or myocardial blush grade (MBG) are independent predictors of mortality in patients with ST-elevation myocardial infarction (STEMI). In addition, distal coronary embolization is a major pitfall of conventional percutaneous coronary intervention (PCI) in such a context.AimThis study aimed to assess the impact of thrombus aspiration (TA) use before primary PCI on final myocardial reperfusion in patients presenting with STEMI.MethodsFrom January to December 2006, 100 patients presenting with STEMI in our catheterization laboratory were considered for the present study. During this time period, 50 patients underwent TA before primary PCI for treatment of STEMI and were then matched 1:1 to 50 controls who underwent conventional primary PCI for treatment of STEMI without TA. Patients of the control group were chosen after matching on age±3 years, sex, history of diabetes, and distribution of the infarct related coronary artery during the same period.ResultsBaseline clinical characteristics, initial TIMI flow and initial MBG of both groups were similar. There was a trend for a better final TIMI flow in the group with TA and the final MBG was significantly improved in the group with TA compared to the group without TA: final MBG of two or three in 70% versus 30% of the cases (P=.001). In addition, direct stenting was significantly more often used in the TA group (92% versus 64%, P=.001). There were four patients with evident distal embolizations in the group without TA and none in the group with TA.ConclusionTA use before primary PCI for STEMI treatment resulted in improved final myocardial reperfusion. Of importance, TA use may have led to a better choice of the stent size and more frequent direct stenting. This benefit may directly improve patient outcomes.