TOTAL: Manual Thrombectomy During PCI Not Shown to Improve Outcomes in STEMI Patients
In patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), a strategy of routine manual thrombectomy did not reduce the risk of cardiovascular death, recurrent myocardial infarction, cardiogenic shock or class IV heart failure within 180 days, as compared to PCI alone with only bailout thrombectomy, according to results of the TOTAL trial presented Monday, March 16 as a part of ACC.15 and simultaneously published in the New England Journal of Medicine.
A total of 10,732 STEMI patients were divided in to two groups, the first of which underwent PCI with manual thrombectomy and the second group received PCI alone. Both groups were monitored for death due to cardiovascular causes within 180 days.
The results indicated that neither strategy was statistically superior after 180 days, as shown by a 6.9 percent rate of mortality in the thrombectomy group versus 7.0 percent in those who received PCI alone. The rates of cardiovascular death and revascularization were also similar in both groups.
“The improvements in ST-segment resolution and distal embolization that were observed with manual thrombectomy in our trial did not translate into clinical benefits,” said Sanjit S. Jolly, MD, the lead author of the study. “This finding cautions against changing practice on the basis of trials showing an improvement in surrogate outcomes.”
However, in a corresponding article, Filippo Crea, MD, FACC, emphasizes that the problem of revascularization in small blood vessels among STEMI patients remains unsolved and the medical community must find a solution.
“An integrated and personalized approach addressing all mechanisms in different time windows is needed in order to reduce the strikingly increased risk conferred by coronary microvascular obstruction,” said Crea. “The time has come to turn our attention to the development of treatments that address the continuum of STEMI care, from symptom onset through return to the community.”
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