Role of Aspiration and Mechanical Thrombectomy in Patients With Acute Myocardial Infarction Undergoing Primary Angioplasty: An Updated Meta-Analysis of Randomized Trials

Study Questions:

What are the clinical outcomes with thrombectomy prior to primary percutaneous coronary intervention (PPCI) compared with conventional PPCI alone?

Methods:

Clinical trials that randomized acute myocardial infarction (AMI) patients to aspiration or mechanical thrombectomy prior to PPCI compared with conventional PPCI alone were included. For all clinical outcomes, an intention-to-treat analysis was utilized. Summary relative risks (RRs) and their corresponding 95% confidence intervals (CIs) were computed for each dichotomous outcome using fixed and random effects (DerSimonian and Laird method) models.

Results:

The weighted mean duration of clinical follow-up was 6 months. Aspiration thrombectomy vs. conventional PPCI (18 trials, n = 3,936): Major adverse cardiac events (MACE) (risk ratio [RR], 0.76; 95% confidence interval [CI], 0.63-0.92; p = 0.006) and all-cause mortality (RR, 0.71; 95% CI, 0.51-0.99; p = 0.049) were significantly reduced with aspiration thrombectomy. Beneficial trends were noted for MI (p = 0.11) and target vessel revascularization (p = 0.06). Final infarct size (p = 0.64) and ejection fraction (p = 0.32) at 1 month were similar. ST-segment resolution (STR) at 60 minutes (RR, 1.31; 95% CI, 1.16-1.48; p < 0.0001) and TIMI blush grade (TBG) 3 post-procedure (RR, 1.37; 95% CI, 1.19-1.59; p < 0.0001) were both improved with aspiration thrombectomy. Mechanical thrombectomy vs. conventional PPCI (seven trials, n = 1,598): There was no difference between the thrombectomy and conventional PPCI arms in the incidence of MACE (RR, 1.10; 95% CI, 0.59-2.05; p = 0.77), mortality (p = 0.57), MI (p = 0.32), target vessel revascularization (p = 0.19), or final infarct size (p = 0.47). A benefit in STR at 60 minutes (RR, 1.25; 95% CI, 1.06-1.47; p = 0.007), but not TBG 3 (RR, 1.09; 95% CI, 0.86-1.38; p = 0.48) was noted.

Conclusions:

The authors concluded that thrombectomy during AMI by manual catheter aspiration, but not mechanically, is beneficial in reducing MACE.

Perspective:

This meta-analysis indicates that as compared with conventional PPCI alone, aspiration thrombectomy is associated with a significant 24% reduction in MACE events, including a 29% reduction in all-cause mortality at 6-month median follow-up. On the other hand, mechanical thrombectomy had a neutral effect on clinical outcomes as compared with conventional PPCI alone, with a trend toward a higher incidence of stroke in all trials evaluated. The current analysis supports the routine use of aspiration thrombectomy devices as adjunctive therapy in ST-segment elevation MI (STEMI) patients undergoing PPCI over conventional primary PCI alone, and justifies the Class IIa recommendation for its use in the American College of Cardiology Foundation/American Heart Association STEMI guidelines. Ongoing large multicenter trials (TASTE and TOTAL) comparing aspiration thrombectomy to conventional PPCI will provide additional insight.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Stable Ischemic Heart Disease, Aortic Surgery, Cardiac Surgery and SIHD

Keywords: Myocardial Infarction, Stroke, Suction, Intracellular Signaling Peptides and Proteins, Catheters, Percutaneous Coronary Intervention, omega-Chloroacetophenone, Thrombectomy, India, Parkinson Disease, Coronary Thrombosis, Confidence Intervals, Pregnancy, Prolonged, United States


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