The effect of thrombectomy on myocardial blush in primary angioplasty: The randomized evaluation of thrombus aspiration by two thrombectomy devices in acute myocardial infarction (RETAMI) trial

Background: In patients with ST‐segment elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) may cause thrombus dislodgment leading to microvascular function impairment, which is a negative independent predictor of myocardial function recovery. Compared with conventional stenting, pretreatment with aspiration thrombectomy during primary PCI significantly improves coronary epicardial flow and myocardial tissue perfusion parameters. We sought to evaluate the angiographic findings of two different manual aspiration thrombectomy devices (Diver‐Invatec® (DI) and Export‐Medtronic®® (EM)) in STEMI patients undergoing primary angioplasty. Methods: We randomized 103 STEMI patients referred to our hospital to undergo primary PCI (<12 hr from symptoms onset) to DI (n = 52) and EM (n = 51) devices. The primary angiographic composite end‐points were the rates of post‐thrombectomy thrombus score (TS) ≤≤2, TIMI flow grade ≥≥2, and post‐stenting myocardial blush grade (MBG) ≥≥2 in the two groups. Results: Baseline, clinical, and angiographic preprocedural findings did not differ between the two groups. After aspiration thrombectomy, a TS ≤≤ 2 was more frequently present in EM group (92.3 vs. 69.3%, P = 0.0052). Also the rate of post‐thrombectomy TIMI ≥≥ 2 (69.3 vs. 92.2%, P = 0.0052) and post‐stenting MBG ≥≥2 (88.2 vs. 69.3%, P = 0.029) were significantly higher in EM group. No significative differences were observed in terms of clinical events at 1 and 12 months. Conclusions: In this single‐center, prospective, randomized study, a EM use before stenting in STEMI patients seems to remove more thrombotic burden compared with DI, providing a greater post‐thrombectomy epicardial flow and a better post‐stenting microvascular perfusion. © 2008 Wiley‐Liss, Inc.     

Multicentre experience with MGuard™ net protective stent in ST‐elevation myocardial infarction: Safety,feasibility, and impact on myocardial reperfusion

Objective : To report, for the first time, angiographic and ECG results as well as in‐hospital and 1‐month clinical follow‐up, after MGuard net protective stent (Inspire‐MD, Tel‐Aviv, Israel—MGS) implantation in consecutive, not randomized, STEMI patients undergoing primary or rescue PCI. Background : Distal embolization may decrease coronary and myocardial reperfusion after percutaneous coronary intervention (PCI), in ST‐elevation myocardial infarction (STEMI) setting. Methods : One‐hundred consecutive patients underwent PCI, with MGS deployment for STEMI, in five different high‐volume PCI centres. Sixteen patients presented cardiogenic shock at admission. Results : All patients underwent successful procedures: mean TIMI flow grade and mean corrected TIMI frame count—cTFC(n)—improved from baseline values to 2.85 ± 0.40 and to 17.20 ± 10.51, respectively, with a mean difference in cTFC(n) between baseline and postprocedure of 46.88 ± 31.86. High‐myocardial blush grade (90% MBG 3; 10% MBG 2) was also achieved in all patients. Sixty minutes post‐PCI, a high rate (90%) of complete (≥70%) ST‐segment resolution was achieved. At in‐hospital follow‐up, seven deaths occurred: noteworthy, 5 of 16 patients with cardiogenic shock at admission died. After hospital discharge, no Major Adverse Cardiac Events have been reported up to 30‐day follow‐up. Conclusions : MGS might represent a safe and feasible option for PCI in STEMI patients, providing high perfusional and ECG improvement. Further randomized trials comparing this strategy with the conventional one are needed in the near future to assess the impact on clinical practice of this strategy. © 2009 Wiley‐Liss, Inc.     

急性ST段抬高型心肌梗死应用血栓抽吸和静脉溶栓开通冠脉的疗效比较

目的 比较急性ST段抬高型心肌梗死（STEMI）患者经导管血栓抽吸和静脉溶栓两种方法对择期PCI即刻及近期疗效的差异.方法 回顾分析2009年1月至2012年1月收治的60例急性STEMI且符合梗死相关动脉（IRA）高血栓负荷患者的临床资料.其中14例通过反复抽吸血栓使IRA血流恢复TIMI 3级,设为抽吸组;22例成功静脉溶栓患者,设为溶栓组.依其IRA的残余狭窄病变（RSL）及非IRA以外的罪犯相关病变（CRL）的冠脉造影,狭窄程度≥70％为冠脉支架置入标准,比较两组IRA的RSL病变与非IRA的CRL病变处理的差异、冠脉TIMI血流分级及心肌灌注呈色（BMG）显像分级的差异、即刻效果、1个月时心功能的差异及MACE差异.结果 IRA及CRL的病变分布及形态、支架置入无复流、支架特征（个数、直径、长度）、支架直接置入率、高压球囊使用率、最后扩张压力等指标,两组比较差异无统计学意义（P＞0.05）,但MBG达到3级者抽吸组明显优于溶栓组（93.0％比63.6％,P＜0.05）.1个月时左室直径、EF值、血浆BNP和hs-CRP,抽吸组均明显优于溶栓组（均P＜0.05）,两组均无MACE事件发生.结论 对高血栓负荷的STEMI患者进行单纯急诊血栓抽吸,择期PCI较静脉溶栓开通后择期PCI效果好,也是安全的.     

Intracoronary thrombolytic therapy: A Treatment Option for Failed Mechanical Thrombectomy

The benefit of the routine application of aspiration thrombectomy in primary percutaneous coronary intervention (PPCI) is now well established. The optimal management of patients who have “failed” thrombectomy characterized by a large residual thrombus burden after repeated mechanical thrombectomy, however, is not known. We report a case of failed aspiration thrombectomy in a 66‐year‐old woman who was admitted to our institution with chest pain associated with inferior ST segment elevation. Coronary angiography showed a thrombotic occlusion of the right coronary artery. Aspiration thrombectomy did little to reduce thrombus load and so the patient was treated with intracoronary tenecteplase. Repeat coronary angiography 18 hr later revealed marked thrombus resolution with thrombolysis in myocardial infarction (TIMI) grade 3 anterograde flow and patency of the infarct‐related artery was maintained at 2‐month follow up. This case demonstrates the potential for intracoronary thrombolytic therapy as a treatment option for the management of patients following failed thrombectomy in PPCI. © 2011 Wiley Periodicals, Inc.     

Comparison of benefit and safety between different loading dose of clopidogrel on elderly patients undergoing primary percutaneous cronary intervention for ST-segment elevation myocardial infarction

Background Despite the proven benefit of 600-mg loading dose of clopidogrel in patients with acute ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous cronary intervention (PCI), there is still concern about its benefit and safety on elderly population. Methods Data of 172 consecutive elderly patients (≥75 years) with STEMI who underwent primary PCI at Guangdong Provincial Cardiovascular Institute from January 2008 to December 2011 were retrospectively collected. Patients were divided into 600-mg loading clopidogrel group and 300-mg clopidogrel group accoring to the loading dose of clopidogrel before primary percunaeous coronary intervention(PCI). Enzymatic myocardial infarction size estimated by peak creatine kinase-myocardial band (CK-MB) and patency of the infarct-related artery (IRA) were compared. Thirty-day major adverse cardiac events (MACEs), which consist of death, nonfatal myocardial infarction (MI), nonfatal stroke, target vessel revascularization (TVR) or stent thrombosis (ST) were compared to assess the efficacy of different loading dose. Bleeding information was compared as well to assess the safety of different pretreatment stragety before primary PCI. Results 96 patients were adminstered with 600-mg loading clopidogrel before primary PCI while 76 were administered with 300-mg. Patency of the IRA was significantly higher in patients administered with 600-mg loading clopidogrel therapy as compared with those who received 300-mg loading clopidogrel (94.8% vs. 85.5%, P = 0.038). 600-mg loading dose of clopidogrel was associated with lower incidence of 30-day MACEs compared with 300-mg loading dose of clopidogrel (8.3% vs. 19.7%, P = 0.029) while did not increase the risk of TIMI major (3.1% vs. 3.9%, P = 0.770) and minor bleeding (10.4% vs. 6.6%, P = 0.376). Conclusion 600-mg loading clopidogrel improves final patency of the IRA and clinical outcome as compared with 300-mg loading clopidogrel without increasing bleeding hazard.