Thrombus Embolisation: Prevention is Better than Cure

Prediction of massive coronary thrombosis of the infarct-related artery in ST-elevation myocardial infarction

Aim    To identify clinical, laboratory and angiographic predictors for development of massive coronary thrombosis in patients with ST-segment elevation myocardial infarction (STEMI).Material and methods    This prospective, single-site study included 137 patients with STEMI (mean age, 66.5±13.2 years). Among these patients, 59 were in the group of massive coronary thrombosis and 78 patients were in the group of minor thrombosis. To identify predictors for the development of massive coronary thrombosis, medical history data, blood count and biochemistry, coagulogram, and angiography data were analyzed. A predictive model was constructed using the method of binary logistic regression followed by a search for the optimum value of the prognostic function with a ROC analysis. Results    The study showed statistically significant roles of total bilirubin, platelets, prothrombin ratio (PTR), activated partial thromboplastin time (APTT), and presence of inferior myocardial infarction in prediction of massive coronary thrombosis in STEMI. The model sensitivity was 71.2 %, specificity 75.6 %, and overall diagnostic efficacy 73.7 %.Conclusion    The predictive model for the development of massive coronary thrombosis in STEMI based on laboratory and instrumental data potentially allows assessing the thrombus load in the infarction-involved coronary artery and determining the optimum tactics of percutaneous coronary intervention in patients with STEMI. This reduces the probability of distal embolization with fragments of the disintegrated thrombus and improves the prognosis of STEMI patients both during the stay in the hospital and in the long-term. According to results of this study, the prognostic model for massive coronary thrombosis in STEMI based on such indexes as the platelet count, PTR, APTT, total bilirubin, and presence of inferior myocardial infarction provides accurate predictions in 73.7 % of cases. Independent predictors of massive coronary thrombosis were inferior myocardial infarction and total bilirubin.

Intra-Aortic Balloon Pump During Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction With High Thrombus Burden and Cardiogenic Shock

BACKGROUND

Percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) with high-grade thrombus is a high-risk intervention associated with poor clinical outcomes. Circulatory support with an intra-aortic balloon pump (IABP) during PCI may potentially improve coronary hemodynamics and clinical outcomes in such patients. As existing data on this situation are sparse, we did an observational study to determine short-term outcomes of PCI with IABP support in STEMI patients with high thrombus burden.

OBJECTIVES

To determine whether IABP has a potential role in improving outcomes in patients with STEMI with high thrombus burden who are undergoing PCI.

METHODS AND RESULTS

Thirty consecutive patients of STEMI with high thrombus burden undergoing PCI with IABP assistance were included. Ninety-three percent of patients had a cardiogenic shock. Clinical and angiographic outcomes assessed include a change in left ventricular ejection fraction (LVEF), 30-day mortality, and assessment of TIMI (thrombolysis in myocardial infarction) flow, TIMI frame count, and TIMI myocardial perfusion grade in the culprit vessel. IABP was initiated before coronary angiography in 36.6% (n=11), between angiography and PCI in 30% (n=9), and after PCI in 33.3% (n=10) of patients. During the 30-day follow-up period, 50% (n=15) of patients died. 86.6% (n=13) of survivors had pre-PCI IABP initiation compared to only 46.6% (n=7) among those who died (p=0.020). With pre-PCI IABP initiation (n=20), 30-day mortality was 35% (n=7) compared to 80% (n=8) with post-PCI IABP initiation (n=10) (p=0.020).

CONCLUSION

IABP initiation before PCI in STEMI complicated by cardiogenic shock and high angiographic thrombus burden can decrease mortality without any effect on angiographic parameters.

A New Score for Determining Thrombus Burden in STEMI Patients: The MAPH Score

Aim

to investigate whether the MAPH score, which is a new score that combines blood viscosity biomarkers such as mean platelet volume (MPV), total protein and hematocrit, can be used to predict thrombus burden in ST-segment elevation myocardial infarction (STEMI) patients.

Methods

A total of 473 consecutive patients with STEMI were included in the study. Intracoronary tirofiban/abciximab infusion was applied to patients with thrombus load ≥3 and these patients (n = 71) were defined as the patient group with high thrombus load. MPV, age, hematocrit and total protein values of the patients were recorded. High shear rate (HSR) and low shear rate (LSR) were calculated from total protein and hematocrit values. Cut-off values were determined for high thrombus load by using Youden index, and score was determined as 0 or 1 according to cut-offs. The sum of the scores was calculated as the MAPH score.

Results

The mean age of the patients included in the study was 59.6 ± 12.6 (n = 354 male, 74.8%). There was no difference between the groups in terms of gender, HT and DM (P = .127, P = .402 and P = .576, respectively). In the group with high thrombus load; total protein, MPV and hematocrit values were higher (P < .001, P = .001 and P = .03, respectively). Comparison of receiver operating characteristic (ROC) curve analysis revealed that the MAPH score had better performance in predicting higher thrombus load than both other self-containing parameters and HSR and LSR.

Conclusion

The MAPH score may be a new score that can be used to determine thrombus burden in STEMI patients.

Approach to high intracoronary thrombus burden in the era of COVID-19

Since the start of the COVID-19 pandemic, several cases have reported extensive multivessel coronary thrombosis as a cardiovascular manifestation of SARS-CoV-2 infection. This case describes a patient who developed non-ST elevation myocardial infarction during hospitalization for acute hypoxic respiratory failure due to COVID-19. We review the immediate and delayed revascularisation strategies of culprit and non-culprit lesions in the setting of high intracoronary thrombus burden induced by SARS-CoV-2. Successful percutaneous intervention and stenting of a culprit lesion and resolution of an intracoronary thrombus using a delayed strategy of lesion passivation with adjuvant pharmacotherapy are demonstrated on index and follow-up angiography.

Large intracoronary thrombus and its management during primary PCI

Large intracoronary thrombus has been reported in significant number of patients with STEMI. Primary PCI is the current standard of care in patients of STEMI. Despite the availability of dual antiplatelets, GP IIb/IIIa inhibitor and effective anticoagulation regimens, large intracoronary thrombus remains one of the biggest challenge to interventional cardiologists during primary PCI. Large intracoronary thrombus may lead to distal embolization, no/slow reflow or embolization into a non-culprit vessel and is associated with adverse cardiovascular outcome. There is no ideal management strategy. We hereby discuss the current available methods/strategies to deal with large thrombus burden encountered during primary PCI, in the current manuscript.