In general, thrombus aspiration in acute myocardial infarction (AMI) has not been shown beneficial by large studies. It could even be prejudicial, since it has been associated with stroke. However, there are certain scenarios where the presence of a significant number of these prevents us from reaching adequate TIMI flow 3, or is associated with no reflow, which in turn increases mortality.
In this context, thrombus aspiration might be useful, even though it has not yet been shown as such by large randomized studies.
A subanalysis of the TOTAL trial was carried out including 2689 patients meeting all criteria, 62 receiving OCT.
Patients were divided into two groups: those presenting a large residual thrombus (LrTB), grade≥3, and a small residual thrombus (SrTB) after balloon predilation. The first group included 1014 patients (35%) and the second 1855 (65%).
Primary end point was cardiovascular death, repeat MI, cardiovascular shock, cardiac failure and y new or worsening functional class withing 4 to 180 días.
The LrTB group presented more hypertension, prior MI, prior PCI and Killip class III on presentation but less likely to have Killip class I.
62 patients received OCT. Patients with SrTB presented smaller angiographic absolute thrombus volume, as well as higher TIMI 3 flow and more presence of myocardial blush grade 3.
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Primary end point resulted in favor of the SrTB group (8.6% versus 4.6%; adjusted HR [aHR], 1.83 [95% CI, 1.34–2.48]; P<0.001). Patients with LrTB exhibited higher cardiovascular mortality, cardiogenic shock, presence of functional class IV and cardiac failure. TVR, stroke and stent thrombosis rates were similar. Most events took place within 30 days.
The use of GP IIb/IIIa and the presence of major bleeding was higher in the LrTB group.
Conclusion
The presence of LrTB is common in primary PCI and is associated to increased adverse cardiovascular events, including cardiovascular death. Future technology should offer better removal than current devices, reduction and even elimination of residual thrombosis risk. This could potentially change strategy options in future clinical trials.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Prognostic Role of Residual Thrombus Burden Following Thrombectomy: Insights From the TOTAL Trial. Mohammad Alkhali, et al. eCirc Cardiovasc Interv.
Reference: 2022;15:e011336.DOI:10.1161/CIRCINTERVENTIONS.121.011336.
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