Role of Aspiration and Mechanical Thrombectomy in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty

Thrombus burden and myocardial damage during primary percutaneous coronary intervention

Large thrombus burden (LTB) lesions in the context of primary percutaneous coronary intervention (p-PCI) have been related to unsuccessful angiographic reperfusion and unfavorable clinical outcomes. However, the hazard of LTB treatment on myocardial damage has not been evaluated. We investigated the impact of LTB on myocardial damage using contrast-enhanced cardiac magnetic resonance (CE-CMR) in the setting of p-PCI. In 327 patients, who underwent p-PCI without thrombus aspiration within 12 hours from symptom onset, we prospectively assessed the impact of LTB on infarct size and microvascular damage using CE-CMR. LTB was defined by the presence of Thrombolysis In Myocardial Infarction thrombus score ≥3 in patent infarct-related artery (IRA); or by "cut-off" occlusion pattern and/or large reference vessel diameter (≥3.5 mm) in occluded IRA. One hundred ninety-seven patients (60.2%) showed LTB and 130 (39.8%) did not. Distal embolization occurred in 18.8% patients with versus 6.9% without LTB (p = 0.003). At CE-CMR, patients with LTB had larger infarct size index (27.5 ± 11.1 vs 22.1 ± 17.5, p = 0.009) and more often transmural necrosis (70.5% vs 55.4%, p = 0.008) compared with patients without LTB. Excluding patients with distal embolization, patients with LTB still had larger necrosis. At multivariate analysis, occluded (IRA) at baseline, anterior infarction, and presence of LTB predicted transmural necrosis. In conclusion, LTB in the setting of p-PCI is related to larger myocardial damage as detected by CE-CMR, regardless of angiographic detectable distal embolization.

Use of Thrombectomy Devices in Primary Percutaneous Interventions for ST-elevation Myocardial Infarction - An Update

Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion modality in patients with ST-elevation myocardial infarction (STEMI). While PPCI is highly effective in achieving epicardial coronary reperfusion, a significant proportion of patients fail to achieve adequate myocardial reperfusion. This is in part due to the distal microembolisation of thrombus and plaque debris during PCI. Recognition of this has led to the development of a number of devices with different mechanisms of action that aim to reduce such distal embolisation and therefore improve end myocardial perfusion. Study results of thrombectomy devices however have been largely inconsistent, especially about clinical outcome data, and several meta-analyses have been carried out as a result. This review aims to critically analyse the literature data on thrombectomy during PPCI, taking into account the most recent studies and the latest meta-analyses looking to see whether thrombectomy use is associated with improved outcomes.

Highlights from the 2013 ACCF/AHA guidelines for the management of ST-elevation myocardial infarction and beyond

ST-segment elevation myocardial infarction (STEMI) is considered a cardiology emergency requiring immediate recognition and treatment aimed at successful and early reperfusion to ensure optimal outcomes. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have issued guidelines for the diagnosis and management of patients with acute myocardial infarction since 1990. These guidelines are based on clinical research exploring reperfusion modalities and adjunctive therapies. They are further supported by expert opinion where randomized trial evidence is lacking. In January 2013, the ACCF/AHA released the most recent guidelines for the management of patients with STEMI. This review focuses on the newest and most important recommendations taken from the 2013 ACCF/AHA Guidelines for the Management of STEMI and highlight important new studies that have emerged over the past year.

Acute coronary syndromes in 2013: Optimizing revascularization strategies in patients with ACS

Catheter-based revascularization has emerged as the gold-standard therapy for most patients with acute coronary syndromes (ACS). Optimizing outcomes in these patients requires appropriate adjunctive pharmacological therapy and percutaneous coronary intervention. Five studies published in 2013 are expected to have a major effect on treatment and prognosis of patients with ACS.

What is the optimum adjunctive reperfusion strategy for primary percutaneous coronary intervention?

Acute ST-segment elevation myocardial infarction (STEMI) is a dynamic, thrombus-driven event. As understanding of its pathophysiology has improved, the central role of platelets in initiation and orchestration of this process has become clear. Key components of STEMI include formation of occlusive thrombus, mediation and ultimately amplification of the local vascular inflammatory response resulting in increased vasoreactivity, oedema formation, and microvascular obstruction. Activation, degranulation, and aggregation of platelets are the platforms from which these components develop. Therefore, prompt, potent, and predictable antithrombotic therapy is needed to optimise clinical outcomes after primary percutaneous coronary intervention. We review present pharmacological and mechanical adjunctive therapies for reperfusion and ask what is the optimum combination when primary percutaneous coronary intervention is used as the mode of revascularisation in patients with STEMI.