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Kotronias RA, Marin F, Emfietzoglou M, Langrish JP, Lucking AJ, Channon KM, Banning AP, De Maria GL. Rationale and Design of a Randomized Controlled Pilot Trial to Assess Stent Retriever Thrombectomy for Thrombus Burden Reduction in Patients with Acute Myocardial Infarction: The RETRIEVE-AMI Study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 52:75-85. [PMID: 36894360 DOI: 10.1016/j.carrev.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/14/2023] [Accepted: 02/14/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND ST-elevation myocardial infarction (STEMI) is typically caused by thrombotic occlusion of a coronary artery with subsequent hypoperfusion and myocardial necrosis. In approximately half of patients with STEMI, despite successful restoration of epicardial coronary patency, downstream myocardium perfusion remains impeded. Coronary microvascular injury is one of the key mechanisms behind suboptimal myocardial perfusion and it is primarily, yet not exclusively, related to distal embolization of atherothrombotic material following recanalization of the culprit artery. Routine manual thrombus-aspiration has failed to show clinical efficacy in this scenario. This could be related with limitations in technology adopted as well as patients' selection. To this end, we set out to explore the efficacy and safety of stent retriever-assisted thrombectomy based on clot-removal device routinely used in stroke intervention. STUDY DESIGN AND OBJECTIVES The stent RETRIEVEr thrombectomy for thrombus burden reduction in patients with Acute Myocardial Infarction (RETRIEVE-AMI) study has been designed to establish whether stent retriever-based thrombectomy is safe and more efficacious in thrombus modification than the current standard of care: manual thrombus aspiration or stenting. The RETRIEVE-AMI trial will enrol 81 participants admitted for primary PCI for inferior STEMI. Participants will be 1:1:1 randomised to receive either standalone PCI, thrombus aspiration and PCI, or retriever-based thrombectomy and PCI. Change in thrombus burden will be assessed via optical coherence tomography imaging. A telephone follow-up at 6 months will be arranged. CONCLUSIONS It is anticipated by the investigators that stent retriever thrombectomy will more effectively reduce the thrombotic burden compared to current standard of care whilst being clinically safe.
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Affiliation(s)
- Rafail A Kotronias
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom; Department of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Federico Marin
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Maria Emfietzoglou
- Department of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Jeremy P Langrish
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Andrew J Lucking
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Keith M Channon
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom; Department of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Adrian P Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom; Department of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom.
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Kotronias RA, Fielding K, Greenhalgh C, Lee R, Alkhalil M, Marin F, Emfietzoglou M, Banning AP, Vallance C, Channon KM, De Maria GL. Machine learning assisted reflectance spectral characterisation of coronary thrombi correlates with microvascular injury in patients with ST-segment elevation acute coronary syndrome. Front Cardiovasc Med 2022; 9:930015. [PMID: 36204570 PMCID: PMC9530633 DOI: 10.3389/fcvm.2022.930015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/25/2022] [Indexed: 12/04/2022] Open
Abstract
Aims We set out to further develop reflectance spectroscopy for the characterisation and quantification of coronary thrombi. Additionally, we explore the potential of our approach for use as a risk stratification tool by exploring the relation of reflectance spectra to indices of coronary microvascular injury. Methods and results We performed hyperspectral imaging of coronary thrombi aspirated from 306 patients presenting with ST-segment elevation acute coronary syndrome (STEACS). Spatially resolved reflected light spectra were analysed using unsupervised machine learning approaches. Invasive [index of coronary microvascular resistance (IMR)] and non-invasive [microvascular obstruction (MVO) at cardiac magnetic resonance imaging] indices of coronary microvascular injury were measured in a sub-cohort of 36 patients. The derived spectral signatures of coronary thrombi were correlated with both invasive and non-invasive indices of coronary microvascular injury. Successful machine-learning-based classification of the various thrombus image components, including differentiation between blood and thrombus, was achieved when classifying the pixel spectra into 11 groups. Fitting of the spectra to basis spectra recorded for separated blood components confirmed excellent correlation with visually inspected thrombi. In the 36 patients who underwent successful thrombectomy, spectral signatures were found to correlate well with the index of microcirculatory resistance and microvascular obstruction; R2: 0.80, p < 0.0001, n = 21 and R2: 0.64, p = 0.02, n = 17, respectively. Conclusion Machine learning assisted reflectance spectral analysis can provide a measure of thrombus composition and evaluate coronary microvascular injury in patients with STEACS. Future work will further validate its deployment as a point-of-care diagnostic and risk stratification tool for STEACS care.
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Affiliation(s)
- Rafail A. Kotronias
- Oxford Heart Centre, National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
- Department of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Kirsty Fielding
- Department of Chemistry, University of Oxford, Oxford, United Kingdom
| | | | - Regent Lee
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Mohammad Alkhalil
- Department of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
- Cardiothoracic Centre, Freeman Hospital, Newcastle, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Federico Marin
- Oxford Heart Centre, National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Maria Emfietzoglou
- Department of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Adrian P. Banning
- Oxford Heart Centre, National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Claire Vallance
- Department of Chemistry, University of Oxford, Oxford, United Kingdom
| | - Keith M. Channon
- Oxford Heart Centre, National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
- Department of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Oxford University Hospitals, Oxford, United Kingdom
- Department of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
- *Correspondence: Giovanni Luigi De Maria,
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Alkhalil M. Novel Applications for Invasive and Non-invasive Tools in the Era of Contemporary Percutaneous Coronary Revascularisation. Curr Cardiol Rev 2022; 18:e190122191004. [PMID: 33530910 PMCID: PMC9241120 DOI: 10.2174/1573403x17666210202102549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 11/08/2020] [Accepted: 11/24/2020] [Indexed: 11/22/2022] Open
Abstract
Percutaneous coronary intervention (PCI) is an expanding treatment option for patients with coronary artery disease (CAD). It is considered the default strategy for the unstable presentation of CAD. PCI techniques have evolved over the last 4 decades with significant improvements in stent design, an increase in functional assessment of coronary lesions, and the use of intra-vascular imaging. Nonetheless, the morbidity and mortality related to CAD remain significant. Advances in technology have allowed a better understanding of the nature and progression of CAD. New tools are now available that reflect the pathophysiological changes at the level of the myocardium and coronary atherosclerotic plaque. Certain changes within the plaque would render it more prone to rupture leading to acute vascular events. These changes are potentially detected using novel tools invasively, such as near infra-red spectroscopy, or non-invasively using T2 mapping cardiovascular magnetic resonance imaging (CMR) and 18F-Sodium Fluoride positron emission tomography/ computed tomography. Similarly, changes at the level of the injured myocardium are feasibly assessed invasively using index microcirculatory resistance or non-invasively using T1 mapping CMR. Importantly, these changes could be detected immediately with the opportunity to tailor treatment to those considered at high risk. Concurrently, novel therapeutic options have demonstrated promising results in reducing future cardiovascular risks in patients with CAD. This Review article will discuss the role of these novel tools and their applicability in employing a mechanical and pharmacological treatment to mitigate cardiovascular risk in patients with CAD.
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Affiliation(s)
- Mohammad Alkhalil
- Department of Cardiothoracic Services, Freeman hospital, Newcastle-upon-Tyne UK.,Department of Cardiology, Toronto General Hospital, Toronto Canada
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