CORRESPONDENCE: LETTER TO THE EDITOR
Role of Percutaneous Coronary Minimalist Intervention in the Management of Acute ST-Segment Elevation Myocardial Infarction
Karl Isaaz, MD, FESC, FACC*
* Division of Cardiology, University of Saint-Etienne, 42000 Saint-Etienne, France (Email: isaaz{at}univ-st-etienne.fr).
In their interesting study, Sianos et al. (1) investigated the impact of thrombus burden on the clinical outcome and angiographic infarct-related artery (IRA) stent thrombosis in patients routinely treated with drug-eluting stent implantation for ST-segment elevation myocardial infarction (STEMI). Intracoronary thrombus burden was angiographically scored before stenting using the classification in 5 grades previously described by Gibson et al. (2). Because a majority of patients suffering an acute STEMI present with an occluded IRA that precludes any thrombus classification, the investigators proposed to reclassify thrombus burden after flow restoration was obtained by a minimal intervention based on the use of a guidewire crossing or small (diameter 1.5 mm) deflated balloon passage or dilation. It would have been interesting to know the level of flow achievement based on Thrombosis In Myocardial Infarction (TIMI) flow grade obtained by minimal intervention among patients with totally occluded IRA in the study of Sianos et al. (1), because similar minimal intervention without immediate stenting has been previously proposed for direct reperfusion of patients with acute STEMI (3). In their study (1), the investigators found that a large thrombus burden is an independent predictor of long-term mortality. Analysis of Table 1 shows (1), however, that when compared with patients with a small thrombus burden, patients with a large thrombus burden had higher rates of use of intra-aortic balloon pump and inotropes, and they more frequently had diabetes mellitus, stent thrombosis at presentation, and pacemaker implantation. Also, although it is widely recognized as a major predictor of clinical outcome in patients with STEMI, left ventricular ejection fraction has not been reported in the study by Sianos et al. (1). Entering all of these additional variables into the multivariate analysis model might have changed the results presented in their Table 3 (1) regarding the independent role of thrombus burden for 2-year mortality. The results of the study by Sianos et al. (1) regarding procedural outcome (Table 4 in their article) support the hypothesis and the data of a previously published work (3), in which it was suggested that immediate stenting should probably be avoided in many patients in the acute phase of STEMI once flow has been restored using minimalist intervention. Therefore, there is a need for a randomized trial in which the classical approach of direct percutaneous intervention with immediate stenting would be compared with stent implantation strategy based on thrombus burden analysis after flow restoration by immediate minimalist intervention.
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1. Sianos G, Papafaklis MI, Daemen J, et al. Angiographic stent thrombosis after routine use of drug-eluting stents in ST-segment elevation myocardial infarction: the importance of thrombus burden J Am Coll Cardiol 2007;50:573-583.[Abstract/Free Full Text]2. Gibson CM, de Lemos JA, Murphy SA, et al. Combination therapy with abciximab reduces angiographically evident thrombus in acute myocardial infarction. A TIMI 14 substudy. Circulation 2001;103:2550-2554.[Abstract/Free Full Text] 3. Isaaz K, Robin C, Cerisier A, et al. A new approach of primary angioplasty for ST-elevation acute myocardial infarction based on minimalist immediate mechanical intervention Coron Artery Dis 2006;17:261-269.[CrossRef][Medline]
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