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

doi:10.4103/0189-7969.142099

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ORIGINAL ARTICLE

Year : 2014 | Volume : 11 | 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

Correspondence Address:
Li Xinli
300 Guangzhou Road, Nanjing - 210 029
China

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0189-7969.142099

Abstract

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 2023 Mar 26];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. ^[1] AT is an efficacious adjuvant treatment for patients with STEMI. ^[2] Abnormal myocardial perfusion is common in acute myocardian infarction (AMI) patients following PCI despite restoration of blood flow. ^[3] 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. ^[4],[5] It was shown that full resolution of ST-segment elevation (>70%) in resting electrocardiogram (ECG) indicates restoration of myocardial perfusion. ^[6],[7] Adverse cardiac events in patients having defective microperfusion is worse as they have increased mortality rate, permanent myocardial damage, and risk of heart failure. ^[8] One of the chief reason of insufficient myocardial reperfusion regardless of reestablishment of epicardial flow in the affected vessel is distal embolization. ^[9] AT during PCI in AMI (TAPAS) trial ^[10] 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. ^[11] 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. ^{[11],[12],[13]} 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.

Protocol

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.

Statistics

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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Table 2: Parameter of study patients in each group

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Discussion

Platelets rich thrombi are usually seen in patients with STEMI. ^{[14],[15],[16]} Platelets have an essential role in distal embolism and microvascular dysfunction. ^[17],[18] 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. ^[19],[20] As has been demonstrated in Polish-Italian-Hungarian RAndomized ThrombEctomy (PIHRATE) trial, ^[21] 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. ^[22] 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. ^[9] 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. ^[23] 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. ^[24],[25] 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. ^[26] In the absence of anatomical contraindication, AT should commonly be used during STEMI PCI. ^[27]

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.

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