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Background
In the largest randomized trial so far, thrombus aspiration failed to reduce the primary endpoint of microvascular obstruction (MVO) in patients with ST-elevation myocardial infarction (STEMI) presenting late after symptom onset. Long-term clinical outcome data of this trial have not been reported yet.
Methods and results
A total of 144...
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Study objectives:
Timely coronary reperfusion is critical for favorable outcomes after ST-elevation myocardial infarction (STEMI). A substantial proportion of the total ischemic time is patient related, occurring before first medical contact (FMC). We aimed to expand the limited current understanding of the associations between prehospital interva...
AimsTo perform a pairwise meta-analysis of randomized controlled trials (RCTs) comparing multivessel percutaneous coronary intervention (PCI) and culprit vessel-only PCI in ST-elevation myocardial infarction (STEMI) patients without cardiogenic shock.Methods
We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase for RCTs co...
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....
Background:
Complete revascularization (CR) of ST-elevation myocardial infarction patients with multivessel coronary artery disease (MVD) has proven better regarding combined endpoints than incomplete revascularization (IR) in recent randomized control trials with no impact on survival.
Objective:
To retrospectively evaluate the impact of comple...
Background
There is a lack of large randomized controlled trials (RCTs) that comprehensively evaluate the effects of venoarterial extracorporeal membrane oxygenation (V-A ECMO)- assisted treatment of patients with ST-segment elevation myocardial infarction (STEMI) combined with Cardiogenic shock (CS). This meta-analysis aims to identify predictors...
Citations
... Это, вероятно, связано с высокой стоимостью и ограниченной доступностью данных методов. В двух исследованиях, вошедших в наш анализ, использовались методы МРТ сердца с гадолинием для оценки степени микроваскулярной обструкции и ОФЭКТ с целью оценки индекса спасения миокарда (таблица 4)[35,36]. В исследовании Freund А, et al. (2019) тромбоаспирация не продемонстрировала эффективности в уменьшении степени микроваскулярной обструкции во время госпитализации и частоты развития МАСЕ через 4 года. В исследованииRezq А, et al. (2018) тромбоаспирация ассоциировалась с лучшим индексом спасения миокарда по данным ческих характеристик, но и клинических данных, тромбоаспирация может применяться как эффективный и безопасный метод лечения пациентов с ИМпST. ...
Thrombus aspiration has not shown significant advantages over routine percutaneous coronary intervention in reducing the incidence of major adverse cardiovascular events (MACEs) in the general heterogeneous population of patients with ST-segment elevation myocardial infarction (STEMI). However, it is still practically used in cases of massive coronary artery thrombosis. This review presents the results of studies on thrombus aspiration in patients with STEMI with a focus on favorable outcomes. According to the literature data, thrombus aspiration proved to be effective in following groups of STEMI patients: 1) patients with hyperglycemia; 2) patients with high D-dimer levels; 3) elderly and frail patients. In order to assess the effectiveness of reperfusion, only angiographic characteristics are still used in routine practice, while multimodal imaging methods have not yet become widespread. Moreover, optimal and unified thrombus aspiration protocols have not yet been developed.
... In the clinical setting, patients with coronary no-reflow and/or delayed presentation after onset of symptoms -so called sub-acute MI -show signs of thrombo-inflammation and are characterized by worse clinical outcome (53)(54)(55). However, biomarkers other than Q-waves or T wave inversion in electrocardiography (56) are currently not established to predict poor outcomes of patients with MI which is not timely reperfused. ...
Despite major advances in acute interventions of myocardial infarction (MI), adverse cardiac remodeling and excess fibrosis post MI causing ischemic heart failure (IHF) remains a leading cause of death worldwide. Here we identify a pro-fibrotic coagulation signaling pathway that can be targeted for improved cardiac function following MI with persistent ischemia. Quantitative phospho-proteomics of cardiac tissue revealed an up-regulated mitogen activated protein kinase (MAPK) pathway in human IHF. Intervention in this pathway with trametinib improves myocardial function and prevents fibrotic remodeling in a murine model of non-reperfused MI. MAPK activation in MI requires myeloid cell signaling of protease activated receptor 2 linked to the cytoplasmic domain of the coagulation initiator tissue factor (TF). They act upstream of pro-oxidant NOX2 NADPH oxidase, ERK1/2 phosphorylation, and activation of pro-fibrotic transforming growth factor β1 (TGF-β1). Specific targeting with the TF inhibitor nematode anticoagulant protein c2 (NAPc2) starting one day after established experimental MI averts IHF. Increased TF cytoplasmic domain phosphorylation in circulating monocytes from patients with sub-acute MI identifies a potential thrombo-inflammatory biomarker reflective of increased risk for IHF and suitable for patient selection to receive targeted TF inhibition therapy.
... Infarct size was expressed as percentage of the left ventricular myocardial mass [29]. Microvascular obstruction was defined as "hypo-enhancement" within the area of LGE [30]. Presence and extent of microvascular obstruction were evaluated [31,32]. ...
Background
The role of left ventricular (LV) myocardial strain by cardiac magnetic resonance feature tracking (CMR-FT) for the prediction of adverse remodeling following ST-elevation myocardial infarction (STEMI), as well as its prognostic validity compared to LV ejection fraction (LVEF) and CMR infarct severity parameters, is unclear. This study aimed to evaluate the independent and incremental value of LV strain by CMR-FT for the prediction of adverse LV remodeling post-STEMI.MethodsSTEMI patients treated with primary percutaneous coronary intervention were enrolled in this prospective observational study. CMR core laboratory analysis was performed to assess LVEF, infarct pathology and LV myocardial strain. The primary endpoint was adverse remodeling, defined as ≥ 20% increase in LV end-diastolic volume from baseline to 4 months.ResultsFrom the 232 patients included, 38 (16.4%) reached the primary endpoint. Global longitudinal strain (GLS), global radial strain, and global circumferential strain were all predictive of adverse remodeling (p < 0.01 for all), but only GLS was an independent predictor of adverse remodeling (odds ratio: 1.36[1.03–1.78]; p = 0.028) after adjustment for strain parameters, LVEF and CMR markers of infarct severity. A GLS > − 14% was associated with a fourfold increase in the risk for LV remodeling (odds ratio: 4.16[1.56–11.13]; p = 0.005). Addition of GLS to a baseline model comprising LVEF, infarct size and microvascular obstruction resulted in net reclassification improvement of 0.26 ([0.13–0.38]; p < 0.001) and integrated discrimination improvement of 0.02 ([0.01–0.03]; p = 0.006).Conclusions
In STEMI survivors, determination of GLS using CMR-FT provides important prognostic information for the development of adverse remodeling that is incremental to LVEF and CMR markers of infarct severity.Clinical Trial RegistrationNCT04113356.
... Manual thrombus aspiration (e.g., export catheter) has been used as an adjunct to limit these microvascular complications of downstream clot migration with it previously considered routine prior to stent deployment during primary PCI. However, recent studies have created uncertainty and suggested possible harm such as increased stroke rates and no clear mortality benefit [5][6][7][8][9][10][11][12]. Trials such as INFUSE-AMI [13] and COCTAIL II [14] compared the benefit of utilising intracoronary abciximab and aspiration thrombectomy by measuring infarct size using Cardiac magnetic resonance (CMR) imaging and did not demonstrate an advantage in patients who undergo manual thrombus aspiration. ...
Background:
Recent studies have suggested that the routine use of aspiration thrombectomy catheters during primary percutaneous coronary intervention (PCI) do not result in improved mortality and may be associated with an increased stroke rate. This study sought to investigate this hypothesis.
Methods:
This was an observational study analysing data from a prospective database of 6366 patients undergoing primary PCI between August 2003 and May 2015 at a UK cardiac centre. Patients' details were collected from the hospital electronic database. Primary outcome was thirty-day stroke rates.
Results:
3989 (62.7%) patients underwent PCI alone and 2,377 (37.3%) patients underwent PCI with adjuctive thrombus aspiration. PCI alone group had an older demographic (63 (± 14) years vs 60.7 (± 14)), a lower proportion of male participants 75% vs 79% (P=0.001) and cardiovascular risk factors such as hypertension 22.4% vs 25.3% (P=0.007), hypercholesterolemia 18.5% vs 22.6% (P<0.0001) and a history of smoking 33.5% vs 44.3% (P<0.0001). Thrombus aspiration was associated with a higher 30-day stroke rate [16 (0.7%) vs 11 (0.3%) (HR 2.51; 95% CI 1.03-6.08, P 0.03). Multivariate analysis suggested that this increased risk of stroke was maintained following adjustment for confounders (HR: 1.86; 95% CI 1.02-4.38). There was 379 deaths of which 114 (4.8%) were in the thrombus aspiration cohort vs 265 (6.6%) in PCI only cohort over the follow-up period (60 months). This resulted in a significantly lower rate of all-cause-mortality HR 0.70 (95% CI 0.52-0.94; P 0.02). There was no statistically significant difference in observed myocardial infarction rates HR 0.76 (95% CI 0.47-1.23; P 0.27) and the rates of unscheduled revascularisations HR 0.70 (95% CI 0.43-1.13; P 0.14) between the two groups.
Conclusions:
Our data series of STEMI patients, suggest that routine thrombus aspiration during primary PCI is associated with a significantly higher stroke, rate however, thrombus aspiration reduced mortality rate. This is consistent with current guidelines which don't recommend the routine use of thrombus aspiration for primary PCI. A possible mortality reduction in patients with high thrombus grades was seen which may warrant further study.
... Questionnaires evaluating patients' behaviors and attitudes were not available in time and should be part of future research. Moreover, to further substantiate our hypothesis of delayed admission of ACS patients, additional factors, including long-term mortality should be taken into consideration [21]. However, our study compared the current data with the previous years' using similar diagnostic methods and thus allows us to profoundly quantify the effects in this population during similar and good comparable time periods. ...
AimsThe coronavirus SARS-CoV-2 outbreak led to the most recent pandemic of the twenty-first century. To contain spread of the virus, many nations introduced a public lockdown. How the pandemic itself and measures of social restriction affect hospital admissions due to acute cardiac events has rarely been evaluated yet.Methods and ResultsGerman public authorities announced measures of social restriction between March 21st and April 20th, 2020. During this period, all patients suffering from an acute cardiac event admitted to our hospital (N = 94) were assessed and incidence rate ratios (IRR) of admissions for acute cardiac events estimated, and compared with those during the same period in the previous three years (2017–2019, N = 361). Admissions due to cardiac events were reduced by 22% as compared to the previous years (n = 94 vs. an average of n = 120 per year for 2017–2019). Whereas IRR for STEMI 1.20 (95% CI 0.67–2.14) and out-of-hospital cardiac arrest IRR 0.82 (95% CI 0.33–2.02) remained similar, overall admissions with an IRR of 0.78 (95% CI 0.62–0.98) and IRR for NSTEMI with 0.46 (95% CI 0.27–0.78) were significantly lower. In STEMI patients, plasma concentrations of high-sensitivity troponin T at admission were significantly higher (644 ng/l, IQR 372–2388) compared to 2017–2019 (195 ng/l, IQR 84–1134; p = 0.02).Conclusion
The SARS-CoV-2 pandemic and concomitant social restrictions are associated with reduced cardiac events admissions to our tertiary care center. From a public health perspective, strategies have to be developed to assure patients are seeking and getting medical care and treatment in time during SARS-CoV-2 pandemic.
... However, recently long-term outcome data of a randomized trial investigating the impact of thrombus aspiration in STEMI patients presenting late (12-48 h) after symptom onset have been published [22]. During 4 years of follow-up, no significant differences in the clinical outcome could be observed [23]. Despite these negative results the continuous separation of the Kaplan-Meier curves, as seen in the present study, indicates that the favorable effects of thrombus aspiration may increase over time and thus, could not be detected earlier. ...
AimsTo investigate the long-term prognostic value of aspiration thrombectomy in conjunction with primary percutaneous coronary intervention (PCI) compared to conventional PCI in patients with non-ST-elevation myocardial infarction (NSTEMI).Methods
In the randomized TATORT-NSTEMI (Thrombus aspiration in thrombus containing culprit lesions in non-ST-elevation myocardial infarction) trial, NSTEMI patients with thrombus containing culprit lesions were randomized to either PCI with aspiration thrombectomy or conventional PCI. The endpoint was a combination of all-cause death, reinfarction and new congestive heart failure.ResultsFrom 440 patients initially randomized, outcome data were available in 432 (98.2%) patients at a median follow-up of 4.9 (interquartile range [IQR] 4.4–5.0) years. Thrombectomy was associated with a significant reduction of the combined endpoint compared to conventional PCI (19.9% vs. 30.7%, p = 0.01). This finding was primarily driven by a reduced rate of reinfarction with thrombectomy (3.4% vs. 10.3%, p = 0.01). Thrombectomy was still independently associated with the combined endpoint after multivariable adjustment (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.30–0.76, p = 0.002). Findings were consistent across all analyzed subgroups (p values for interaction all > 0.05).Conclusions
In NSTEMI, thrombus aspiration is associated with favorable clinical outcome during long-term follow-up.Clinical trial registrationNCT01612312.
... The present analysis is a substudy of a randomized trial of thrombus aspiration (TA) in STEMI patients presenting late after symptom onset. Design and results of the trial have been published previously [7,8]. In brief, a total of 152 STEMI patients, presenting between 12 and 48 h after symptom onset were randomized in a 1:1 fashion to primary percutaneous coronary intervention (PCI) with or without manual TA. ...
... Briefly summarized, the main trial did not show a significant difference in the extent of MVO, IS, myocardial salvage, LV ejection fraction or angiographic endpoints between patients assigned to TA and the control group. In addition, clinical outcomes at short-and long-term follow were similar [7,8]. ...
Background
The role of coronary collaterals in ST-elevation myocardial infarction (STEMI) remains controversial. So far, studies examining the effect of collaterals on outcome mainly focused on patients presenting early after symptom onset. We sought to investigate the prognostic influence of coronary collateralization in patients presenting with prolonged ischemia late after symptom onset.Methods and resultsThe study is a subanalysis of a randomized trial addressing thrombus aspiration in STEMI patients presenting between 12 and 48 h after symptom onset with a follow-up period of a minimum of 4 years. A total of 95 patients with a Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 or 1 prior to percutaneous coronary intervention (PCI) were included in the analysis. Of these, 62 patients (65%) had none or poor coronary collateralization according to the Rentrop classification (Rentrop grade 0 or 1) compared to 33 (35%) with well-developed collateralization (Rentrop grade 2 or 3). In comparison, patients with well-developed collateralization had a smaller area of microvascular obstruction (2.1 ± 3.8 vs. 4.5 ± 4.9% of left ventriclular mass (%LV), p = 0.03) and infarct size (27.9 ± 11.7 vs. 34.8 ± 17.2% LV, p = 0.047) on magnetic resonance imaging. Further, mortality at 4-years follow-up was lower (6% Rentrop grade 2 or 3 vs. 25% Rentrop grade 0 or 1, p = 0.02). Poor collateralization was an independent predictor of long-term mortality on multivariate Cox regression analyses in addition to cardiogenic shock and unsuccessful PCI during the index procedure.Conclusion
Sufficient coronary collateralization has a positive impact on microvascular obstruction, infarct size and long-term mortality in STEMI patients presenting between 12 and 48 h after symptom onset.
The incidence of late presentation of myocardial infarction varies between 8.5% and 40%. Late revascularization of an infarct-related artery may limit infarct size and remodeling, reduce electrical instability, and may provide supplemental blood supply to that area via collaterals. Randomized clinical trials have shown a benefit of revascularization in symptomatic and hemodynamically unstable latecomers. Image stress testing can be beneficial to guide management of asymptomatic late presenters. Higher rates of myocardial infarction complications occur with late presentations, so a high level of suspicion is required for early diagnosis. Surgical repair remains the gold standard for management of mechanical complications.
