CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Georgios Sianos, MD, PhD*,
Michail I. Papafaklis, MD,
Joost Daemen, MD,
Sofia Vaina, MD,
Carlos A. van Mieghem, MD,
Ron T. van Domburg, PhD,
Lampros K. Michalis, MD, MRCP and
Patrick W. Serruys, MD, PhD, FACC
* Thoraxcenter Erasmus Medical Center, Dr Molewaterplein 40, Rotterdam, Netherlands, 3015 GD (Email: g.sianos{at}erasmusmc.nl).
We appreciate the interest of Dr. Isaaz for our work (1). In regard to our initial analysis, we did not calculate the flow after the minimal intervention in patients who presented with occluded vessels, but further to this request this parameter was randomly (every second) estimated in one-half (225) of these patients; Thrombolysis In Myocardial Infarction (TIMI) flow grade 1 was restored in 46.6%, TIMI flow grade 2 in 38.8%, and TIMI flow grade 3 in 14.6%.
The imbalances in the baseline characteristics among groups are related to the retrospective nonrandomized nature of our study. Appropriate multivariable statistical analysis was performed to account for these imbalances. For the same reason, established parameters related to clinical outcomes were missing as addressed in the extensive limitations paragraph. The influence of the baseline characteristics imbalances and missing parameters on the results of the study remains speculative. For example, during the review process, we were asked to perform the analysis excluding the patients presenting with stent thrombosis. By doing so, no difference was observed in the resultant independent predictors including large thrombus burden.
By no means could our results support the hypothesis that immediate stenting can probably be avoided in many patients at the acute phase of ST-segment elevation myocardial infarction (STEMI) once flow has been restored using minimal intervention, since all of our patients were stented during the index procedure. Such an approach partly questions the well-established superiority of bare-metal stents compared with balloon angioplasty (2–4), and beyond the questionable efficacy it has logistical and financial implications that would make it quite unlikely to be explored in a randomized fashion. In our view, in a STEMI setting, optimization of all periprocedural parameters, including thrombus management by pharmacologic and mechanical means, is the appropriate way to go forward.
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References
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- 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]
- Suryapranata H, van’t Hof AW, Hoorntje JC, de Boer MJ, Zijlstra F. Randomized comparison of coronary stenting with balloon angioplasty in selected patients with acute myocardial infarction Circulation 1998;97:2502-2505.[Abstract/Free Full Text]
- Grines CL, Cox DA, Stone GW, et al. Coronary angioplasty with or without stent implantation for acute myocardial infarction. Stent primary angioplasty in myocardial infarction study group. N Engl J Med 1999;341:1949-1956.[Abstract/Free Full Text]
- Stone GW, Grines CL, Cox DA, et al. CADILLAC Investigators Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction N Engl J Med 2002;346:957-966.[Abstract/Free Full Text]
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Role of Percutaneous Coronary Minimalist Intervention in the Management of Acute ST-Segment Elevation Myocardial Infarction
- Karl Isaaz
J. Am. Coll. Cardiol. 2008 51: 1046-1047.
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