CORRESPONDENCE: LETTER TO THE EDITOR
Adjunctive Thrombectomy in Acute Myocardial Infarction: For Some but Not for All
Massimo Napodano, MD*,
Angelo Ramondo, MD and
Sabino Iliceto, MD, FACC
* Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, 2 via Giustiniani, 35128 Padova, Italy (Email: massimo.napodano{at}sanita.padova.it).
We read with interest the report by Silva-Orrego et al. (1) regarding the effects of thrombus aspiration on myocardial reperfusion in the setting of primary angioplasty. The study reported a significant enhancement in myocardial reperfusion by a strategy of manual thrombus aspiration before stenting on top of abciximab administration. However, in our opinion some concerns exist about the results of this study. First, the investigators randomized patients with acute myocardial infarction (MI) to a conventional stent-assisted primary angioplasty versus a strategy applying manual aspiration device before stent, regardless of angiographic appearance of thrombus. Early studies evaluating the feasibility of thrombectomy in the setting of thrombus-containing lesion and acute MI clearly reported on the efficacy of thrombectomy devices in reducing thrombus burden at target lesion, consequently limiting distal embolization and no-reflow phenomenon (2,3).
Unfortunately, Silva-Orrego et al. (1) did not provide data concerning thrombus burden at baseline angiography, nor on thrombus removal after device use. Thus, the reported reduction in distal embolization rate may not be univocally ascribed to the device effect, as other factors may affect this result, such as differences in thrombus burden of culprit lesions.
Second, the researchers found a rate of postprocedural myocardial blush grade (MBG) 2/3 in both arms, which is surprisingly higher than expected, based on Thrombolysis In Myocardial Infarction (TIMI) flow achieved after the intervention, and on time-to-treatment reported in this cohort. In the largest study validating the angiographic reperfusion, MBG was strongly affected by epicardial flow, being that patients showing TIMI flow grade <3 very rarely reached an adequate blush (4). Indeed, it has been shown that the effectiveness of myocardial reperfusion after primary angioplasty, as assessed by ST-segment resolution and MBG is clearly time-dependent (5).
In conclusion, to avoid conflicting results, we believe that future studies evaluating thrombectomy as adjunctive strategy in the setting of primary angioplasty should enroll only patients with angiographically documented thrombus at the lesion site, and that reperfusion findings should be carefully evaluated according to time-to-treatment.
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1. Silva-Orrego P, Colombo P, Bigi R, et al. Thrombus aspiration before primary angioplasty improves myocardial reperfusion in acute myocardial infarction: the DEAR-MI study J Am Coll Cardiol 2006;48:1552-1559.[Abstract/Free Full Text]2. Silva JA, Ramee SR, Choen DJ, et al. Rheolytic thrombectomy during percutaneous revascularization for acute myocardial infarction: experience with the Angiojet catheter Am Heart J 2001;141:353-359.[CrossRef][Web of Science][Medline] 3. Napodano M, Pasquetto G, Saccà S, et al. Intracoronary thrombectomy improves myocardial reperfusion during direct angioplasty for acute myocardial infarction J Am Coll Cardiol 2003;42:1395-1402.[Abstract/Free Full Text] 4. van’t Hof AWJ, Liem A, Suryapranata H, Horntje JCA, de Boer MJ, Zijlstra F, Zwolle Myocardial Infarction Study Group Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infaction: myocardial blush grade Circulation 1998;97:2302-2306.[Abstract/Free Full Text] 5. De Luca G, van’t Hof AW, de Boer MJ, et al. Time-to-treatment significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute myocardial infarction treated by primary angioplasty Eur Heart J 2004;25:1009-1013.[Abstract/Free Full Text]
Related Article
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- Pedro Silva-Orrego, Paola Colombo, and Riccardo Bigi
J. Am. Coll. Cardiol. 2007 49: 1586-1587.
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