Thrombus Aspiration in Primary Percutaneous Coronary Intervention Improves the Early Myocardial Reperfusion in Patients with ST-segment Elevation Myocardial Infarction Even Without Upstream Use of Glycoprotein IIb/IIIa Inhibitor
Sanggye Paik Hospital, Inje University, Seoul, Korea (Republic of)
J.H. Kim, B.O. Kim, K.S. Kim, C.W. Goh, Y.S. Byun, S.H. Kang, K.M. Park, K.J. Rhee
Background: Both platelet glycoprotein IIb/IIIa inhibitor (GPI) and thrombus aspiration (TA) can reduce microembolic and atherothrombotic incidence in primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI), especially with heavy thrombotic burden. However, the additive role of TA combined with early use of GPI is unclear. We performed a prospective, randomized study to compare the upstream versus bail-out use of GPI with the selective combination of TA.
Methods: A total of 73 patients with STEMI were randomly assigned to the upstream use of GPI abciximab (n=37) versus the bail-out use (n=36) before undergoing coronary angiography. TA was performed using Thrombuster II (Kaneka Corp. Japan) according to the following angiographic features: infarct related artery (IRA) diameter กร2.5 mm; thrombotic occlusion or evidence of thrombi. Primary endpoint was the flow restoration of the IRA using TIMI grade. Secondary endpoint was the myocardial perfusion assessment using TMP grade, ST-segment resolution on electrocardiogram, and the release pattern of serum cardiac marker. Major adverse cardiac event (MACE) was defined as cardiac death, nonfatal myocardial infarction, diabling stroke, and target lesion revascularization.
Results: Baseline characteristics of both groups were similar. Bail-out use of GPI was associated with significantly worse initial TIMI flow compared with upstream use (TIMI grade 0; 70% vs. 43%, p<0.01), without significant difference in ST-segment resolution (complete or partial resolution; bail-out vs upstream; 88% vs. 92%, p=0.50), final TIMI (grade 3; 88% vs. 95%, p=0.32) or TMP (grade 3; 61% vs. 65%, p=0.36). Although 8 patients from bail-out group (8/36, 22%) were crossed over to the late use of GPI, they achieved significantly lower rate of final TIMI grade compared with upstream use and no use of GPI patients (63 % vs. 95% vs. 96%, p<0.01), but showed similar TMP grade and ST-segment resolution. TA was added in large portion of patients (55/73, 75%). TA showed the tendency of being used more frequently in bail-out group (including all but one patients given late GPI) than upstream group (83% vs. 68%, p=0.09), to overcome the worse initial TIMI flow. TA significantly shortened the time to reach the peak CK-MB level after PCI compared with no TA group (average 5.7 vs. 8.6 hrs, p<0.05) with similar peak CK-MB level, ST-segment resolution, final TIMI and TMP grade. There were no significant differences in MACE rate between upstream and bail-out group at 1 and 9 months.
Conclusion: Upstream use of GPI before primary PCI for STEMI is associated with better initial TIMI flow and shows the tendency to decrease the necessity of TA. Although TA is usually performed in selected cases with heavy thrombotic burden, it significantly shortens the time to reach the peak CK-MB level implying early myocardial reperfusion, and contributes to achieving comparable angiographic outcome regardless of GPI use, even in patients with worse initial TIMI flow.
