|Year : 2014 | Volume
| Issue : 2 | Page : 108-111
Short-term effect of successful aspiration during primary stenting on patients with acute myocardial infarction
Shenghui Lin, Ziyad Abdool Russeed Sondagur, Yunshan Cao, Hui Wang, Li Xinli
Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
|Date of Web Publication||3-Oct-2014|
300 Guangzhou Road, Nanjing - 210 029
Source of Support: None, Conflict of Interest: None
Objective: The aim of the present study was to evaluate the effects of aspiration thrombectomy (AT) using an Aspiration Catheter (INVATEC SPA DIVER C.E. MAX, Italy) during primary stenting in patients with acute myocardial infarction (AMI).
Methods and Results: Our study group consisted of 136 patients. The Aspiration Catheter group included 74 patients treated by direct stenting after AT and the control group included 62 patients treated by primary stenting after balloon predilation without thrombectomy. Measurement of left ventricular ejection fraction (LVEF) by echocardiography was obtained before (acute LVEF) percutaneous coronary intervention (PCI) and 1 week after (late LVEF) the procedure. The number of patients with thrombolysis in myocardial infarction (TIMI) grade 3, myocardial blush grade (MBG) 3 and with full restoration of ST segment elevation following PCI was higher in the aspiration Catheter group compared to the control group (90 vs 68%, P < 0.01), (86 vs 62%, P < 0.01) and (90 vs 64%, P < 0.01) respectively. Minimal change in LVEF was observed in patients between the Aspiration Catheter group and control group at 1 week post procedure.
Conclusion: Combination of AT using Aspiration Catheter (INVATEC SPA DIVER C.E. MAX) with primary stenting can better restore epicardial coronary flow and myocardial perfusion, while left ventricle (LV) function had subtle change in AMI when compared to primary stenting after balloon predilation without thrombectomy.
Keywords: Acute myocardial infarction, aspiration thrombectomy, diver C.E. MAX
|How to cite this article:|
Lin S, Sondagur ZA, Cao Y, Wang H, Xinli L. Short-term effect of successful aspiration during primary stenting on patients with acute myocardial infarction. Nig J Cardiol 2014;11:108-11
|How to cite this URL:|
Lin S, Sondagur ZA, Cao Y, Wang H, Xinli L. Short-term effect of successful aspiration during primary stenting on patients with acute myocardial infarction. Nig J Cardiol [serial online] 2014 [cited 2021 Jun 19];11:108-11. Available from: https://www.nigjcardiol.org/text.asp?2014/11/2/108/142099
| Introduction|| |
Percutaneous coronary intervention (PCI) is an established method for ST-Elevation Myocardial Infarction (STEMI) patients. Nevertheless, it often results in suboptimal restoration of epicardial blood flow and affects prognosis. The principal reason is the presence of thrombus in situ. Nowadays, thrombectomy devices are being commonly used in emergency PCI. In STEMI patients undergoing emergency PCI, the European Society of Cardiology guidelines on myocardial revascularization suggest aspiration thrombectomy (AT) as a Class IIa, with level of evidence-A.  AT is an efficacious adjuvant treatment for patients with STEMI.  Abnormal myocardial perfusion is common in acute myocardian infarction (AMI) patients following PCI despite restoration of blood flow.  Myocardial blush score is useful in assessing prognosis in high risk patients who achieved thrombolysis in myocardial infarction grade 3 (TIMI-3) flow after intervention. , It was shown that full resolution of ST-segment elevation (>70%) in resting electrocardiogram (ECG) indicates restoration of myocardial perfusion. , Adverse cardiac events in patients having defective microperfusion is worse as they have increased mortality rate, permanent myocardial damage, and risk of heart failure.  One of the chief reason of insufficient myocardial reperfusion regardless of reestablishment of epicardial flow in the affected vessel is distal embolization.  AT during PCI in AMI (TAPAS) trial  showed amelioration of myocardial reperfusion from usual application of manual AT before employment of balloon or stent in the coronary artery. Follow-up of patients for 1 year from TAPAS trial showed a decrease in mortality with AT.  A meta-analysis of TAPAS and many other trials ended with same results. Application of AT in AMI helps decrease mortality in contrast to PCI alone. ,, The present trial was planned to assess the safety and effectiveness of aspiration catheters (DIVER C.E. MAX) in primary PCI with stenting for AMI.
| Materials and methods|| |
Our study involved 136 patients from January 2012 to December 2013 in whom revascularization therapy was carried out within 24 h of onset of AMI. Criteria for study inclusion were (1) First anterior AMI, (2) within 24 h of onset and (3) a proximal lesion of the left anterior descending artery (LAD). Exclusion criteria were (1) Patients who underwent thrombolytic therapy before PCI, (2) sudden restoration of coronary flow before PCI (initial angiography showed TIMI-2 or 3 flow), (3) Killip class IV and lastly (4) atrial fibrillation. Patients were separated in two groups according to the time periods in which the 2 different interventions were performed. The control group involved 62 consecutive patients treated by primary stenting. The experimental group consisted of 74 consecutive patients treated by primary stenting after aspiration with DIVER C.E. MAX. Written informed consent was obtained from all patients. We compared the parameters of initial TIMI grade, final TIMI grade, blush score, time from chest pain to reperfusion, rate of ST segment resolution, acute left ventricular ejection fraction (LVEF), late LVEF and also the rate of no-flow development between the AT group and the control group.
All patients received 300 mg of aspirin and clopidogrel orally and 100 U/kg heparin intravenously before coronary angiography. During the procedure, additional heparin was given to keep the clotting time at 250 s or above. Standard treatment was continued following stent implantation. In the aspiration group, suction was performed both before and after stenting. According to the judgment of the operator, aspiration was also carried out in other vessels in which embolization have occurred. In cases where the aspiration catheter or stent could not be advanced through the lesion, pre-dilatation was first performed using balloons with smaller diameter to prevent dislodgement of thrombi to the periphery followed by advancement of the device. In the control group, primary PCI was performed. In cases of slow flow phenomenon, intra-arterial nitrate was administered. LVEF was estimated at the time of admission and at 1 week post procedure using echocardiography.
Statistical analyses were performed using the echocardiography test for categorical variables such as genetic distribution, risk factors, target lesion characteristics, initial and final TIMI grade, and blush scores. Unpaired Student's t-test was used for the analysis of continuous variables. A P value of less than 0.05 was regarded as indicating a statistically significant difference.
| Results|| |
Stents were successfully placed in all 136 patients; complete resolution of ST elevation was seen in 90% of patients in aspiration group compared to 64% in control group (P < 0.01). Baseline clinical and procedural characteristics of the study group have been tabulated [Table 1]. There were no differences between the two groups in sex, age, coronary risk factors, culprit coronary artery, and door to balloon time or initial TIMI grade and ejection fraction. For the final TIMI grade, the rate of achieving TIMI 3 was 90% in the aspiration group and 68% in the control group [Table 2]. Measurement of LVEF showed no significant differences between the two groups in acute LVEF or late LVEF. Concerning blush score, the rate of myocardial blush grade 3 was significantly more in the aspiration group (90%) than in the control group (64%). The rate of no-flow was only 2% in the aspiration group in contrast to 40% in the control group (P < 0.01).
|Table 1: Baseline clinical and procedural characteristics of the study patients|
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| Discussion|| |
Platelets rich thrombi are usually seen in patients with STEMI. ,, Platelets have an essential role in distal embolism and microvascular dysfunction. , Recently, the Diver C.E.MAX aspiration catheter was brought in clinical practice. In STEMI patients subjected to emergency PCI, Diver C.E. catheter has demonstrated its safety and effectiveness to establish TIMI grade 3 flow in the culprit artery. , As has been demonstrated in Polish-Italian-Hungarian RAndomized ThrombEctomy (PIHRATE) trial,  our study has also confirmed that AT followed by direct stent implantation is superior to standard balloon pre-dilatation followed by stent implantation. Whether thrombectomy can influence LVEF should be confirmed by new studies and long-term clinical follow-up in patients with STEMI. Favorable clinical impact of AT in STEMI patients is expected. When considerable thrombus is present, AT may not be efficacious as rheolytic thrombectomy and might result in incomplete thrombus removal, no-reflow, and/or distal emboli.  No flow was present in two and 40 of the study and control group respectively No-reflow results in sustained myocardial ischemia after brief obstruction and reperfusion of an epicardial artery during PCI after AMI and affects prognosis.  Many interventional cardiologists encountered one or more drawback from AT such as left main thrombus emerging from target vessel, left main dissection, other vessel dissection and stroke.  Some clinical trials has proved the importance of AT in preventing angiographic no-reflow but additional studies are needed. Utilization of manual AT catheters is faster, cheaper than and as efficacious as other thrombectomy devices. , In a recent study, AT was found to decrease major adverse cardiac events, MI and target vessel revascularization except mortality in comparison to standard PCI and no advantages were seen in mechanical thrombectomy.  In the absence of anatomical contraindication, AT should commonly be used during STEMI PCI. 
| Conclusion|| |
Combination of AT using Aspiration Catheter (INVATEC SPA DIVER C.E. MAX) with primary stenting can better restore epicardial coronary flow and myocardial perfusion, while LV function had subtle change in AMI when compared to primary stenting after balloon predilation without thrombectomy.
| References|| |
|1.||Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), European Association for Percutaneous Cardiovascular Interventions (EAPCI). Wijns W, Kolh P, Danchin N, Di Mario C, Falk V, Folliguet T, et al. Guidelines on myocardial revascularization. Eur Heart J 2010;31:2501-55. |
|2.||De Luca G, Suryapranata H, Stone GW, Antoniucci D, Neumann FJ, Chiariello M. Adjunctive mechanical devices to prevent distal embolization in patients undergoing mechanical revascularization for acute myocardial infarction: A meta-analysis of randomized trials. Am Heart J 2007;153:343-53. |
|3.||Dudek D, Mielecki W, Dziewierz A, Legutko J, Dubiel JS. The role of thrombectomy and embolic protection devices. Eur Heart J Suppl 2005;7:I15-20. |
|4.||Stone GW, Peterson MA, Lansky AJ, Dangas G, Mehran R, Leon MB. Impact of normalized myocardial perfusion after successful angioplasty in acute myocardial infarction. J Am Coll Cardiol 2002;39:591-7. |
|5.||van′t Hof AW, Liem A, Suryapranata H, Hoorntje JC, de Boer MJ, Zijlstra F. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction: Myocardial blush grade. Zwolle Myocardial Infarction Study Group. Circulation 1998;97:2302-6. |
|6.||Dong J, Ndrepepa G, Schmitt C, Mehilli J, Schmieder S, Schwaiger M, et al. Early resolution of ST-segment elevation correlates with myocardial salvage assessed by Tc-99m sestamibi scintigraphy in patients with acute myocardial infarction after mechanical or thrombolytic reperfusion therapy. Circulation 2002;105:2946-9. |
|7.||Cura FA, Roffi M, Pasca N, Wolski KE, Lincoff AM, Topol EJ, et al.; Global Use of Strategies to Open Occluded Arteries V investigators. ST-segment resolution 60 minutes after combination treatment of abciximab with reteplase or reteplase alone for acute myocardial infarction (30-day mortality results from the resolution of ST-segment after reperfusion therapy substudy). Am J Cardiol 2004;94:859-63. |
|8.||Morishima I, Sone T, Okumura K, Tsuboi H, Kondo J, Mukawa H, et al. Angiographic no-reflow phenomenon as a predictor of adverse long-term outcome in patients treated with percutaneous transluminal coronary angioplasty for first acute myocardial infarction. J Am Coll Cardiol 2000;36:1202-9. |
|9.||Eeckhout E, Kern MJ. The coronary no-reflow phenomenon: A review of mechanisms and therapies. Eur Heart J 2001;22:729-39. |
|10.||Svilaas T, Vlaar PJ, van der Horst IC, Diercks GF, de Smet BJ, van den Heuvel AF, et al. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med 2008;358:557-67. |
|11.||Vlaar PJ, Svilaas T, van der Horst IC, Diercks GF, Fokkema ML, de Smet BJ, et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): A 1-year follow-up study. Lancet 2008;371:1915-20. |
|12.||Bavry AA, Kumbhani DJ, Bhatt DL. Role of adjunctive thrombectomy and embolic protection devices in acute myocardial infarction: A comprehensive meta-analysis of randomized trials. Eur Heart J 2008;29:2989-3001. |
|13.||Burzotta F, De Vita M, Gu YL, Isshiki T, Lefevre T, Kaltoft A, et al. Clinical impact of thrombectomy in acute ST-elevation myocardial infarction: An individual patient-data pooled analysis of 11 trials. Eur Heart J 2009;30:2193-203. |
|14.||Ueda Y, Asakura M, Hirayama A, Komamura K, Hori M, Komada K. Intracoronary morphology of culprit lesions after reperfusion in acute myocardial infarction: Serial angioscopic observations. J Am Coll Cardiol 1996;27:606-10. |
|15.||Rittersma SZ, van der Wal AC, Koch KT, Piek JJ, Henriques JP, Mulder KJ, et al. Plaque instability frequently occurs days or weeks before occlusive coronary thrombosis: A pathological thrombectomy study in primary percutaneous coronary intervention. Circulation 2005;111:1160-5. |
|16.||Kotani J, Nanto S, Mintz GS, Kitakaze M, Ohara T, Morozumi T, et al. Plaque gruel of atheromatous coronary lesion may contribute to the no-reflow phenomenon in patients with acute coronary syndrome. Circulation 2002;106:1672-7. |
|17.||Limbruno U, De Carlo M, Pistolesi S, Micheli A, Petronio AS, Camacci T, et al. Distal embolization during primary angioplasty: Histopathologic features and predictability. Am Heart J 2005;150:102-8. |
|18.||Topol EJ, Yadav JS. Recognition of the importance of embolization in atherosclerotic vascular disease. Circulation 2000;101:570-80. |
|19.||Lian H, Yang JQ, Chen ZJ. Influences of different aspiration results by aspiration thrombectomy catheter in emergent percutaneous coronary intervention for patents with acute myocardial infarction. Zhonghua Yi Xue Za Zhi 2011;91:2845-8. |
|20.||Zhao HJ, Yan HB, Wang J, Song L, Li QX, Li SY, et al. Comparison of Diver CE and ZEEK manual aspiration catheters for thrombectomy in ST-segment elevation myocardial infarction. Chin Med J (Engl) 2009;122:648-54. |
|21.||Dudek D, Mielecki W, Burzotta F, Gasior M, Witkowski A, Horvath IG, et al. Thrombus aspiration followed by direct stenting: A novel strategy of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. Results of the Polish-Italian-Hungarian RAndomized ThrombEctomy Trial (PIHRATE Trial). Am Heart J 2010;160:966-72. |
|22.||Navarese EP, Tarantini G, Musumeci G, Napodano M, Rossini R, Kowalewski M, et al. Manual vs mechanical thrombectomy during PCI for STEMI: A comprehensive direct and adjusted indirect meta-analysis of randomized trials. Am J Cardiovasc Dis 2013;3:146-57. |
|23.||Russo JJ, Dzavik V, Cairns JA, Widimsky P, Rao SV, Eskola M, et al. Use of aspiration thrombectomy and practice patterns during primary PCI for STEMI: Results of an international survey. Circulation 2010;122:A10994. |
|24.||Tarsia G, De Michele M, Polosa D, Biondi-Zoccai G, Costantino F, Del Prete G, et al. Manual versus nonmanual thrombectomy in primary and rescue percutaneous coronary angioplasty. Heart Vessels 2010;25:275-81. |
|25.||Vink MA, Patterson MS, van Etten J, Ijsselmuiden AJ, Dirksen MT, Amoroso G, et al. A randomized comparison of manual versus mechanical thrombus removal in primary percutaneous coronary intervention in the treatment of ST-segment elevation myocardial infarction (TREAT-MI). Catheter Cardiovasc Interv 2011;78:14-9. |
|26.||Yan Q, Jihong W, Nie SP, Xin D, Yin Z, Changqi J, et al. Updated meta-analysis of prospective randomized controlled trials evaluating adjunctive thrombectomy in primary percutaneous coronary intervention for st-elevation myocardial infarction. J Am Coll Cardiol. 2014;63(12_S). |
|27.||De Luca G, Dudek D, Sardella G, Marino P, Chevalier B, Zijlstra F. Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: A meta-analysis of randomized trials. Eur Heart J 2008;29:3002-10. |
[Table 1], [Table 2]